I’ve had a nice response to the brief commentary I posted in conjunction with a link to the NY Times article about means restriction.  In light of that, I thought I’d post a link to the a site called Means Matter, which is published by the Harvard Injury Control Research Center.   The site has summary pages called “Taking Action” for families, communities, and clinicians.

The talking action page for clinicians is worth reading for any clinician, and could be especially useful to primary care providers.  I’m thinking a lot about primary care right now because (a) primary care psychology has beeen a focus of my career and I have a deep respect for the breadth of responsibility primary care providers carry, including in suicide prevention (b) I’m still pondering the recent question I considered about self-trasport and (c) I’m presenting a talk titled “Tips for Suicide Risk Assessment and Response in Primary Care” next month at the Highland Family Medicine center here in Rochester.

I have mentioned quite a few NY Times articles in this blog because I think they cover suicide really well.   Last month they published a piece in the NY Times Magazine that I keep recommending to people in informal and clinical discussions, so I thought I’d link to it here.   Many thanks to my colleague Bill Watson for first alerting me to the article.

The Urge To End It, by Scott Anderson, is a stunning piece.  Well-written, and well-researched, it challenges the stereotype that suicide is always well thought out, carefully planned, and the result of a conscious and un-ambivalent decision.   He focuses on the impulsivity and momentary desperation involved in many suicide attempts, and raises awareness about means restriction as a potent intervention.

For clinicians, there are several important take-home points and cautions:

• Expressed suicidal ideation is only one part of an assessment of risk for suicide;  impulsivity, high intensity stressors, and agitated emotional pain signal as much about risk as suicidal ideation.
• We need to ask about available means and seek to disable lethal means whenever possible.
• We need to advocate for public policy that promotes means restriction–this may save the life of someone in our care (or in our lives).
• Ambivelance runs deep.   Even in the moment of jumping, survivors report feeling regret, not wanting to die.  We are built for living, and those who help distressed individuals have a powerful force on our side.
• We need to ask about how bad the pain is and how intense the desire for escape, even (especially) with individuals who have not previously expressed suicidal ideation.

There are probably other lessons from Anderson’s excellent article, including understanding more about the subjective experience of someone who attempts suicide.   The article is not short, but you’ll be rewarded for the time spent to read it all the way through.

A colleague  forwarded me the following excellent question posted to a listserv:

One question that has been raised is how to handle an individual who reports willingness to voluntarily go to the ER for psychiatric assessment.  Since trusting a questionably unstable and suicidal individual to present for treatment opens our agency and the patient up to considerable risk, I wanted to get input on this issue from professionals in the field.

My questions are: What is the process that you use when you genuinely believe an adult patient will voluntarily present her/him self for possible commitment/assessment?  How do you manage patient risk and your own liability in this instance? (e.g . requiring family members to be involved; or requiring a signed written contract to present at the hospital, etc) What do you do to ensure/confirm that they do indeed go to the hospital? What do you do when they do not go to the hospital, as agreed?

I’m looking for both a description of specific steps that you take and what variables you take into consideration as you decide what to do in this case.

This is an excellent question for several reasons:

• the writer wants to support patient agency, preferring in principle to go with the patients voluntary wishes, rather than become unnecessarily coercive.
• the writer is correctly concerned about putting all eggs in the self-report basket.   A person at risk who is not stable may not be able to follow through with intentions to get help.   It is central to both really listen people in our care AND understand that self-report has limitations and has to be considered in context
• the writer has shared honestly her concern about both patient safety and his/her own liability—almost everyone who works with individuals at risk has these dual concerns and needs to think openly about how to balance them.

This is such a good question that I wish I had put it on my docket of questions to blog about.  And it relates as a follow-up question to one that is on that docket, “When it comes to hospitalizing isn’t it always best to “err on the side of caution”?

Here is my attempt to offer some principles for the assessment and documentation of a patient’s agreement to voluntary actions:

• Document assessment of reliability of self-report.  When assessing and documenting self-report the following should be considered and noted:
  • past experience, if any with the patient as a reliable reporter or not.   “Pt. has reliably followed through on medical decisions and plans in the past.”
  • evidence of psychosis, thought disorder, intoxication, extreme agitation or other factor that would put the person’s capacity to make decisions in question.   If not, “Pt’s thinking is logical, coherent, and reasonable.  Judgment is intact.   No indication of impaired capacity to make decisions and follow through with them.”
  • degree of patient cooperation.  Explicitly note that the person volunteered information, though s/he didn’t have to.   “The patient has been open, cooperative, and collaborative in the assessment and planning process.  There is little reason to doubt his/her sincerity in agreeing to seek help and additional evaluation.”
  • impulsivity.   The greatest risk here would be that the person would all of a sudden feel overwhelmed with pain and impulsively kill him/herself.  If there is not strong evidence of that kind of impulsivity (even if there has been some in the past) note that.  “The patient has a past history of mild impulsive behavior, however, this was several years ago and under very different circumstances…”
• Show your reasoning.  The key to great documentation is to state each of the factors considered, then show that the plan came as a result of synthesizing these factors.  This can come in a statement like “In light of these factors, the plan for voluntary self-transport seems reasonable and prudent.”
• Say what you didn’t do.  Related to the previous point, it as as important to document the road NOT taken.   This shows that you took the situation seriously and considered the full range of options.
  • A corollary to this principle is to note risks associated with alternative courses of action.   “Involuntary transport has potential of violating the patient’s rights and of harming the patient’s opportunity to benefit from hospitalization.   The risk associated with involuntary transport outweigh the relatively small risk that the patient will precipitously abandon our plan and harm him/herself.”
• Document consultation.   Much more consultation occurs in primary care than is ever documented.   This would be a time to do it.  One line is sufficient:  “Discussed case with Dr. X who concurred with the plan.”

Note that each of these points needs only a sentence or bullet-point, and not all will be applicable in every circumstance.

I’d be interested in feedback and ideas from who employs these principles in their documentation.  I would also be interested in reading comments with other ideas about how to address the situation the questioner described.

I’ve returned from a fascinating series of trips to two New York State psychiatric facilities (St. Lawrence Psychiatric and Pilgrim Psychiatric), as part of a project I’m working on with the Office of Mental Health.  I learned a great deal from talking about suicide risk with over 500 clinicians from a variety of disciplines and settings–psychologists, RNs, case managers, social workers, psychiatrists, mobile crisis clinicians, family therapists and others.   It would be hard to find a group of professionals with more experience working with individuals at-risk, and the questions, comments, and concerns the participants contributed matched that level of experience.

I have made some notes about issues that were raised by clinicians, and plan to blog my thoughts about these in coming months as I get pockets of time to reflect on my travels.   As I have stated before, I think it’s important for educational initiatives to map closely onto the real-life concerns of clinicians, rather than simply reflecting content that experts deem important.   Here are a few concerns and questions that I hope to think more about when I have time:/

• When it comes to hospitalizing isn’t it always best to “err on the side of caution?”
• Why are we focusing on suicide so much when the people we work with have so many other problems?
• Why are we focusing on suicide when it’s so rare and most people who die by suicide weren’t in treatment when they die?
• How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?
• Does doing a better job with risk for suicide always mean more work and writing?
• Is there anyone for whom it is not indicated to ask about suicidal thoughts?
• How often should we do a risk assessment?
• What kinds of lawsuits have and have not been successful against clinicians in cases of completed suicide?
• Even if we do everything right, can suicide really be prevented?

Along the lines of that last question, several clinicians shared moving stories about ways in which suicide has touched their lives, personally and professionally.   It is always so sad to hear about these deaths, and so encouraging to hear that some of the ideas I brought for discussion felt relevant to these experiences.

A big thanks to the professionals at OMH, St. Lawrence, and Pilgrim who supported and hosted me during these trips.   And to the clinicians at both facilities who made these trainings so stimulating and enjoyable.

The small island of Nantucket, MA has seen 3 teen suicides in a short period of time, according to the New York Times.  Very sad.   Statistically, three suicides in a high school of 400 represents a meaningful cluster, and a possible contagion effect.   Whether it is or it isn’t contagion in Nantucket (it is impossible to know for sure and the article suggests some disagreement in this case), the key thing for clinicians to know is that vulnerability to contagion has been documented in adolescents.  Clinicians working with adolescents at risk at the time of a public or peer suicide should consider reassessing their clients’ risk for suicide when news of a peer death becomes public.

Eric Caine, the chair of our Psychiatry department and co-director of the Center for the Study and Prevention of Suicide, was quoted in a N.Y. Times article last week chronicling an increase in midlife suicides.

N.Y. Times has done it again.  A nice article taking a step back from the current flurry of news and discovery about the relationship between anti-depressants and suicide.

A friend pointed me to an article (found via a post at Think Christian) titled, “The Web Is The Worst Place to Grieve.” The article, published in a conservative-libertarian magazine, describes several examples of real and feigned suicides that have been blogged on the web.   Blogging had made possible public suicide notes.  The article is a good reminder of the dark side of Web 2.0 whose opportunities and possibilities I’ve explored here in the past (see posts in Blogging category).

We’re seeing more public awareness of the nuances in the research about suicide and antidepressants, which I’ve posted about before.  This NEW YORK TIMES article is an example.

Caution, Not Panic, Seen After Drug Warnings

The New York Times does a good job raising public awareness about suicide prevention.   Today, they’ve published an article bout suicide in older adults.   Read the full article here.