Suicide Risk Management: A Manual for Health Professionals 2e PDF
Preview Suicide Risk Management: A Manual for Health Professionals 2e
Suicide Risk Management Suicide Risk Management A Manual for Health Professionals 2e Sonia Chehil MDFRCPC AssistantProfessorofPsychiatry DalhousieUniversity,Halifax,Canada Stan Kutcher MDFRCPC ProfessorofPsychiatry DalhousieUniversity,Halifax,Canada Thiseditionfirstpublished2012(cid:2)2012byJohnWiley&Sons,Ltd. Wiley-BlackwellisanimprintofJohnWiley&Sons,formedbythemergerof Wiley’sglobalScientific,TechnicalandMedicalbusinesswithBlackwellPublishing. Registeredoffice: JohnWiley&Sons,Ltd,TheAtrium,SouthernGate,Chichester,West Sussex,PO198SQ,UK Editorialoffices: 9600GarsingtonRoad,Oxford,OX42DQ,UK TheAtrium,SouthernGate,Chichester,WestSussex,PO198SQ,UK 111RiverStreet,Hoboken,NJ07030-5774,USA Fordetailsofourglobaleditorialoffices,forcustomerservicesandforinformationabout howtoapplyforpermissiontoreusethecopyrightmaterial inthisbookpleaseseeourwebsiteatwww.wiley.com/wiley-blackwell. Therightoftheauthortobeidentifiedastheauthorofthisworkhasbeen assertedinaccordancewiththeUKCopyright,DesignsandPatentsAct1988. Allrightsreserved.Nopartofthispublicationmaybereproduced,storedina retrievalsystem,ortransmitted,inanyformorbyanymeans,electronic,mechanical, photocopying,recordingorotherwise,exceptaspermittedbytheUKCopyright,Designs andPatentsAct1988,withoutthepriorpermissionofthepublisher. Designationsusedbycompaniestodistinguishtheirproductsareoftenclaimed astrademarks.Allbrandnamesandproductnamesusedinthisbookaretrade names,servicemarks,trademarksorregisteredtrademarksoftheirrespectiveowners.The publisherisnotassociatedwithanyproductorvendormentionedinthisbook. Thispublicationisdesignedtoprovideaccurateandauthoritativeinformationinregardto thesubjectmattercovered.Itissoldontheunderstandingthatthe publisherisnotengagedinrenderingprofessionalservices.Ifprofessionaladvice orotherexpertassistanceisrequired,theservicesofacompetentprofessional shouldbesought. LibraryofCongressCataloging-in-PublicationData Kutcher,StanleyP. Suicideriskmanagement:amanualforhealthprofessionals/StanKutcher, SoniaChehil.–2nded. p.;cm. Includesindex. ISBN978-0-470-97856-6(pbk.) I. Chehil,Sonia. II. Title. [DNLM:1. Suicide–prevention&control. 2. Suicide–psychology. 3. Risk Assessment–methods.WM165] LCclassificationnotassigned 0 616.858445–dc23 2011030220 AcataloguerecordforthisbookisavailablefromtheBritishLibrary. Thisbookispublishedinthefollowingelectronicformats:ePDF9781119953111;Wiley OnlineLibrary:9781119953128;ePub978119954316;Mobi9781119954323 Setin10.5/12.5ptTimesRomanbyThomsonDigital,Noida,India FirstImpression 2012 Contents Introduction, vii Objectives, ix 1 The Importance of Suicide Awareness and Assessment, 1 2 Understanding Suicide Risk, 13 3 Suicide Risk Assessment, 56 4 Putting It All Together: Tool for Assessment of Suicide Risk (TASR), 88 5 Special Topics in Understanding and Evaluating Suicide Risk, 94 6 Suicide Prevention, 110 7 Suicide Intervention, 115 8 Post-suicide Intervention: Caring for Survivors, 123 9 Care for the Carer: Death of a Patient by Suicide, 130 10 Clinical Vignettes for Group or Individual Study, 135 Appendix A Tool for Assessment of Suicide Risk (TASR), 140 Appendix B 6-ITEM Kutcher Adolescent Depression Scale: KADS, 142 Appendix C My Safety Plan, 144 Index, 147 Introduction Understandingsuicideisunachievable.Theunderpinningsofsuicide arediverseandmultifaceted,involvingauniquefusionofbiological, psychosocial and cultural factors for each individual. Suicide is not an event that occurs in a vacuum. It is the ultimate consequence of a process. Formanypeoplewhotakethedecisiontoendtheirownlifewewill neverbeabletoanswerthequestion‘Why?’Forsome,self-inflicted death may be: . an escape from despair and suffering . a relieffrom intractable emotional,psychological or physicalpain . a response to a stigmatizing illness . an escape from feelings of hopelessness . a consequence of acute intoxication . a response to commanding homicidal or self-harm auditory hallucinations . a manifestation of bizarre or grandiose delusions . a declaration of religious devotion . a testimony of nationalist or political allegiance . a means of atonement . a means of reunification with a deceased loved one . a means of rebirth . a method of revenge . a way to protect family honour Thisdoesnotmeanthathealthprofessionalsshouldnotknowhow torecognize,assessandmanagethesuicidalpatient.Indeed,allhealth professionalsshouldbeproficientinthiscorecompetencyasmanyof viii Introduction their patients may face the prospect of suicide at some time in their lives.Manypatientswhoexperiencesuicidalthoughtsormakesuicide planswillchangetheirmindsaboutcommittingsuicide.Manypeople who attempt suicide and are not successful go on to live productive lives.Forsome,asuicideattemptisaneventthatleadstoafirstcontact with a helping professional. Some of these individuals may be sufferingfromamentaldisorderthatwillrespondtoappropriateand effective treatment. Some may be suffering from chronic physical disorders;othersmaybeoverwhelmedbylifestressors.Inanycase, manyoftheseindividualsmayconsidersuicideasaviablesolutionto theirproblemsortheonlymeanstoendingtheirsuffering.Bybeing awareofsuicideriskfactorsandknowinghowtoidentifyandprovide appropriate targeted interventions for suicidal individuals, health professionalscanassistinthepatientchoosingliferatherthandeath. Cultural, religious, geographical and socioeconomic factors all impactontheexpressionofsuicidalityandthecompletionofsuicide. Thus,healthprofessionalsfromvariouscountriesorregionsmayneed toadaptsomeofthematerialinthisbooktoreflectlocalperspectives. However,weallneedtoremember,wheneveraclinicianandasuicidal person interact, that careful, considerate application of suicide risk managementwillneedtobeapplied–regardlessofcontext.Contexts differ but people are similar. Objectives 1 To provide information regarding the epidemiology, risk factors and associated aspects of suicide. 2 To provide information that will assist in the understanding and assessment of suicide risk. 3 Toprovideacontinuousself-studyprogrammepertainingtoclin- icalevaluationofsuicide,usingtheSuicideRiskAssessmentGuide (SRAG). 4 TointroducetheToolforAssessmentofSuicideRisk(TASR)and provide instruction on its appropriate clinical application. Chapter 1 The Importance of Suicide Awareness and Assessment Why is it important to know about suicide? Suicide is a significant public health problem worldwide. Suicide represents 1.4% of the Global Burden of Disease and accounts for nearly half of all violent deaths and almost one million fatalities globallyeachyear.Althoughthesenumbersmayseemalarming,itis widely believed that they are underestimates of the true global prevalence and global burden of suicide. For every life lost to suicide there are many more left in the wake of the tragedy – parents, children, siblings, friends and communities. ‘Foreverysuicidedeaththerearescoresoffamilyandfriendswhose livesaredevastatedemotionally,sociallyandeconomically...Suicide is a tragic global public health problem. Worldwide, more people diefromsuicidethanfromallhomicidesandwarscombined.Thereis anurgentneedforcoordinatedandintensifiedglobalactiontoprevent thisneedlesstoll.’ Dr Catherine Le Gal(cid:2)es-Camus, WHOAssistant-Director General, WorldMentalHealthDay2006 SuicideRiskManagement:AManualforHealthProfessionals,SecondEdition. SoniaChehilandStanKutcher. (cid:2)2012JohnWiley&Sons,Ltd.Published2012byJohnWiley&Sons,Ltd. 2 SuicideRiskManagement Challenges to understanding global suicide rates and suicide risk Estimating suicide prevalence in different countries is problematic. Suicideratesrangesubstantiallybetweencountries (WHO,2009)and thevariabilityofdatacollectionandreportingmakesnationalcompar- isonsdifficultifnotimpossible.Manycountrieslackastandardsurveil- lancesystemthataccuratelycapturessuicidedeath.Wheresurveillance systemsexist,datavaliditycanbeobscuredbyvariabilityintheclassi- fication of suicide deaths, procedures for recording suicide deaths, proceduresforcompletingdeathcertificates,andthebodiesresponsible fordeterminingthe causeofunexpecteddeath.Thestigmaassociated withsuicideisalsoasignificantbarriertoestimatingtrueprevalencerates. Inmanyculturessuicideishiddenbyaffectedfamiliestoavoidshame, disgrace,ridiculeorsocialexclusion.Worldwide,cultural,religiousand social values and beliefs have significantly influenced what has been reportedinofficialdeathrecordsandarebelievedtocontinuetocontribute tothemisclassificationofsuicidedeathsasaccidentalorduetounknown causesinmanycountries.Therefore,‘prevalenceestimates’takenfrom countryrecordsgloballylikelyunderestimateactualsuiciderates. Thepervasivestigma,shameandhumiliationassociatedwithasuicide deathareperpetuatedbylegislationthatcontinuestoclassifysuicideasa criminaloffenceinmanydevelopingcountries.Althoughsuchlawsmay nowrarely,ifever,beenforcedinmostjurisdictions,insome,persons whosurviveasuicideattemptmaybetriedandconvictedincourt.Sotoo mightfamilymembersofasuicidevictimbechargedwithstiffpenalties orbesubjecttosocialhumiliation.Notsurprisingly,reportedprevalence figuresincountrieswheresuchlawsareupheldareconsistentlyreported to be extremely low. Nevertheless, based on available data, globally suicideisbelievedtoaccountforanaverageof10–15deathsforevery 100000 persons each year, and for each completed suicide there are believedtobeupto20failedsuicideattempts. Another compounding issue in understanding global and national suicideratesisthelargejurisdictionalvariationsinreportedsuicides evenwithincountrieswheresuicidedataarerelativelywellcollected. SuicideratesvarywidelyacrossdifferentstatesintheUSAandacross provincesandterritoriesinCanada,forexample.Historically,suicide rates within jurisdictions, countries and regions have demonstrated TheImportanceofSuicideAwarenessandAssessment 3 seculartrendsthatarepoorlyunderstood.Thecomplexityoffactors outsidethesuicidalindividualthatmaycontributetoincreasedriskis substantial.Theunderpinningsofsuicidearediverseandmultifaceted, involving a unique fusion of biological, psychosocial, political, eco- nomicandculturalfactorsforeachindividual.Thesignificanceofeach factor or combination of factors in any location at any one time is difficult to deconstruct. For example, in many developed countries, includingCanadaandtheUSA,historicalprevalencedatademonstrate thatsuicideinyoungadultsandteensstartedincreasinginthe1950s.In thelastdecadeandahalfthislongstandingtrendshifted,withyouth suicide rates in many developed countries decreasing or reaching a plateau.Thisshifthasnotbeenstronglycorrelatedwiththepresenceor absenceofnationalsuicidepreventionstrategiesanditisnotclearwhat factors have been most important in changing this suicide trend in youngpeople,althoughconsiderationshaveincludedthemoreeffec- tive identification and treatment of depression and control of lethal means.Nonetheless,intheUSAandmanyothercountries(particularly inwealthyordevelopedstates),suicidecontinuestobeoneofthethree leadingcausesofdeathinyoungpeoplebetweentheagesof15and24. Themajorityofstudiesonriskfactorsforsuicidehavebeenconducted indevelopedcountriesusingthepsychologicalautopsymethodology. PsychologicalautopsystudiesintheWesthaveconsistentlydemon- strated strong associations between suicide and mental disorder, reporting that 90% of people who die by suicide have one or more diagnosablementalillness.Themostcommondiagnosesfoundtobe associatedwithsuicidedeathincludetheaffective(mood)disorders, anxiety disorders, substance abuse disorders, personality disorders and schizophrenia. These studies have identified the presence of an untreated mental disorder – particularly depression and substance abuse – as the greatest attributable risk factor for suicide. Usingthesametypeofpsychologicalautopsymethodology,studies conductedindevelopingcountrieshavenotdemonstratedasrobustan association betweensuicide and mental disorder as purported inthe West. Undoubtedly there are many factors that may explain this discrepancy. In developing countries, suicide may be less clearly correlatedwithmentaldisorderandmaybemoreofteninfluencedby cultural,religious,social,economicandpoliticalfactors.Thedearth
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