Suicide Risk Assessment: Identifying & Evaluating Suicidal Thoughts & Behaviors, Lecture notes of Psychiatry

Download Suicide Risk Assessment: Identifying & Evaluating Suicidal Thoughts & Behaviors and more Lecture notes Psychiatry in PDF only on Docsity! 1 Comorbidity Guidelines Training Program Session Three Handouts Assessment of Mental State Appearance (How does the client look?) − Posture – slumped, tense, bizarre. − Grooming – dishevelled, poor personal hygiene (nails, hair etc.). − Clothing – bizarre, inappropriate, dirty. − Nutritional status – weight loss, not eating properly. − Evidence of AOD use – intoxicated, flushed, dilated/pinpoint pupils, track marks. Behaviour (How is the client behaving?) − Motor activity – immobile, pacing, restless, hyperventilating. − Abnormal movements – tremor, jerky or slow movements, abnormal walk. − Bizarre/odd/unpredictable actions. Attitude (How is the client reacting to the current situation and worker?) − Angry/hostile towards interviewer/others. − Unco-operative. − Withdrawn. − Over familiar/inappropriate/seductive. − Fearful, guarded, hypervigilant. Speech (How is the client talking?) − Rate – rapid, uninterruptible, slow, mute. − Tone/volume – loud, angry, quiet, whispering. − Quality – clear, slurred. − Anything unusual about the client’s speech? Language (How does the client express himself/herself?) − Incoherent/illogical thinking (word salad: communication is disorganised and senseless and the main ideas cannot be understood). − Derailment (unrelated, unconnected or loosely connected ideas, shifting from one subject to another). − Tangentiality/loosening of associations (replies to questions are irrelevant or may refer to the appropriate topic but fail to give a complete answer). − Absence/retardation of, or excessive thought and rate of production. − Thought blocking (abrupt interruption to flow of thinking so that thoughts are completely absent for a few seconds or irretrievable). Mood (How does the client describe his/her emotional state?) − Down/depressed; angry/irritable; anxious/fearful; high/elevated. Affect (What do you observe about the client’s emotional state?) − Depressed – flat, restricted, tearful, downcast. − Anxious – agitated, distressed, fearful. − Irritable, hostile. 2 − Labile – rapidly changing. − Inappropriate – inconsistent with content − High/elevated – excessively happy or animated. Thought Content (What is the client thinking about?) − Delusional thoughts (e.g., bizarre, grandiose, persecutory, self-referential). − Preoccupations: paranoid/depressive/anxious/obsessional thoughts; overvalued ideas. − Thoughts of harm to the self or others. − Does the client believe that his/her thoughts are being broadcast to others or that someone/thing is disrupting or inserting his/her own thoughts? Perception (Is the client experiencing any misinterpretations of sensory stimuli?) − Does the client report auditory, visual, olfactory or somatic hallucinations? Illusions? − Are they likely to act on these hallucinations? − Do you observe the client responding to unheard sounds/voices/unseen people/ objects? − Any other perceptual disturbances (e.g., derealisation, depersonalisation, heightened/ dulled perception)? Cognition: Level of consciousness − Is the client alert and oriented? − Is the client attentive during the interview (drowsy, stupor, distracted)? − Does the client’s attention fluctuate during the interview? − Does the client present as confused? − Is the client’s concentration impaired? (can he/she count from 100 or say the months of the year backwards?) Orientation − Does the client know: - Who he/she is? - Who you are? - Where he/she is? - Why he/she is with you now? - The day of the week, the date, the month and the year? Memory − Can the client remember: - Why he/she is with you? (Immediate) - What he/she had for breakfast? (Recent) - What he/she was doing around this time last year? (Remote) − Are they able to recall recent events (memory and simple tasks e.g., calculation)? Insight and Judgment − How aware is the client of what others consider to be his/her current difficulty? − Is the client aware of any symptoms that appear weird/bizarre or strange? − Is the client able to make judgments about his/her situation? 5 SAMPLE MENTAL STATE EXAMINATION REPORT Name: ADAM JONES (fictional person) D.O.B. 1/1/89 Date: 22/1/10 Appearance 21 year old Adam Jones presented to the service in the company of his mother. Adam sat slumped in a chair. He appeared unshaven with unkempt hair. His clothes were clean and ironed. Adam appeared to be underweight for his height. (Adam’s mother reported that he has recently lost weight). Behaviour Adam made very little eye-contact during the assessment interview. He appeared quite withdrawn and gave minimal or no responses to the questions asked. He remained slumped in the chair throughout the interview. Speech Adam said very little during the interview. When he did speak it was barely audible. The rate of his speech was slow. Language (form of thought) Although Adam said very little during the interview, he did at times respond appropriately to some questions. For example, when asked about what he liked about smoking cannabis, Adam responded with “It makes me feel relaxed, it helps me to sleep”. Later in the interview Adam appeared to be crying and stated “I feel like I’ve made a mess of things”. Mood and affect When asked how he was feeling, Adam shrugged his shoulders and stated “I dunno. Sort of nothing”. His affect was flat and congruent with his mood. Thought content Adam did not appear to be paranoid or delusional. When assessed for suicidal thoughts, Adam stated “I just want to go to sleep and not wake up”. He denies having a plan to commit suicide or to self-harm. Adam also has no thoughts of harming others. He stated towards the end of the interview “I know mum’s worried about me. I don’t want to hurt her.”. 6 Perception Adam denied hearing voices or any other perceptual disturbance. Cognition Adam remained conscious throughout the interview. Adam had difficulty answering questions at times. Twice he asked the interviewer to repeat the question. He appeared to be oriented to time, place and person. Insight and judgement Adam showed some insight into his situation when he stated “I just want to feel better”. His concern about worrying his mother was also noted. Adam did agree to return in the near future to talk further about his use of cannabis and the possibility of making a change. He wants to return to his TAFE course at some time. 7 TRAUMA SCREENING QUESTIONNAIRE (TSQ) Please consider the following reactions which sometimes occur after a traumatic event. This questionnaire is concerned with your personal reactions to the traumatic event which happened to you. Please indicate (Yes/No) whether or not you have experienced any of the following at least twice in the past week. 1. Upsetting thoughts or memories about the event that have come into your mind against your will □ No □ Yes 2. Upsetting dreams about the event □ No □ Yes 3. Acting or feeling as though the event were happening again □ No □ Yes 4. Feeling upset by reminders of the event □ No □ Yes 5. Bodily reactions (such as fast heartbeat, stomach churning, sweatiness, dizziness) when reminded of the event □ No □ Yes 6. Difficulty falling or staying asleep □ No □ Yes 7. Irritability or outbursts of anger □ No □ Yes 8. Difficulty concentrating □ No □ Yes 9. Heightened awareness of potential dangers to yourself and others □ No □ Yes 10. Being jumpy or being startled at something unexpected □ No □ Yes Source: Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C., Turner, S. & Foa, E. B. (2002) Brief screening instrument for post-traumatic stress disorder. British Journal of Psychiatry, 181, 158-162. 10 Assessment of Suicide Risk Level Level of risk Suggested response Non-existent: No identifiable suicidal thoughts, plans or intent • Monitor risk periodically or when indicated Mild/Low: Suicidal thoughts of limited frequency, intensity and duration. No plans or intent, mild dysphoria, no prior attempts, good self-control (i.e., subjective or objective), few risk factors, identifiable protective factors • Review frequently • Identify potential supports/contacts and provide contact details • Contract with client to seek immediate assistance if fleeting thoughts become more serious or depression deepens Moderate: Frequent suicidal thoughts with limited intensity and duration, some plans but no intent (or some intent but no plans), limited dysphoria, some risk factors present, but also some protective factors • Request permission to organise a specialist MHS assessment as soon as possible • Continue contract as above • Review daily Severe/High: Frequent, intense and enduring suicidal thoughts. Specific plans, some intent, method is available/accessible, some limited preparatory behaviour, evidence of impaired self-control, severe dysphoria, multiple risk factors present, few if any protective factors, previous attempts • If risk is high and the client has an immediate intention to act, contact the mental health crisis team immediately and ensure that the client is not left alone • Call an ambulance/police if the client will not accept a specialist assessment, or the crisis team is not available • Consult with a colleague or supervisor for guidance and support Extreme/Very high: Frequent, intense, enduring suicidal thoughts and clear intent, specific/well thought out plans, access/available method, denies social support and sees no hope for future, impaired self-control, severe dysphoria, previous attempts, many risk factors, and no protective factors Adapted from: Lee N, Jenner L, Kay-Lambkin F, Hall K, Dann F, Roeg S, et al. PsyCheck: Responding to mental health issues within alcohol and drug treatment. Canberra: Commonwealth of Australia; 2007; Rudd MD, Joiner T, Rajab MH. Treating Suicidal Behaviour: An effective, time-limited approach. New York: Guilford Press; 2001. Schwartz RC, Rogers JR. Suicide assessment and evaluation strategies: A primer for counselling psychologists. Counselling Psychology Quarterly. 2004; 17(1):89-97. 11 Standardised Screening Tools Kessler – 10 (K-10) Name...........................................Date................. For all questions, please circle the answer most commonly related to you. Questions 3 and 6 automatically receive a score of one if the proceeding question was “none of the time”. In the past four weeks: None of the time A little of the time Some of the time Most of the time All of the time 1. About how often did you feel tired out for no good reason? 1 2 3 4 5 2. About how often did you feel nervous? 1 2 3 4 5 3. About how often did you feel so nervous that nothing could calm you down? 1 2 3 4 5 4. About how often did you feel hopeless? 1 2 3 4 5 5. About how often did you feel restless or fidgety? 1 2 3 4 5 6. About how often did you feel so restless you could not sit still? 1 2 3 4 5 7. About how often did you feel depressed? 1 2 3 4 5 8. About how often did you feel that everything is an effort? 1 2 3 4 5 9. About how often did you feel so sad that nothing could cheer you up? 1 2 3 4 5 10. About how often did you feel worthless? 1 2 3 4 5 Total: Test: Kessler, R.C. (1996). Kessler's 10 Psychological Distress Scale. Harvard Medical School: Boston, MA. Normative data: National Survey of Mental Health and Well-being, Australian Bureau of Statistics 1997. 12 PsyCheck Screening Tool Client’s Name: DOB: Service: UR: Mental health services assessment required? □ No □ Yes Suicide/self-harm risk (please circle): High Moderate Low Date: Screen completed by: Clinician use only Complete this section when all components of the PsyCheck have been administered. Summary Section 1 Past history of mental health problems □ No □ Yes Section 2 Suicide risk completed and action taken □ No □ Yes Section 3 SRQ score □ 0 □ 1-4 □ 5+ Interpretation/score – Self-Reporting Questionnaire (SRQ) Score of 0* on the SRQ No symptoms of depression, anxiety and/or somatic complaints indicated at this time. Action: Re-screen using the PsyCheck Screening Tool after four weeks if indicated by past mental health questions or other information. Otherwise monitor as required. Score of 1-4* on the SRQ Some symptoms of depression, anxiety and/or somatic complaints indicated at this time. Action: Give the first session of the PsyCheck Intervention and screen again in four weeks. Score of 5+* on the SRQ Considerable symptoms of depression, anxiety and/or somatic complaints indicated at this time. Action: Offer sessions 1–4 of the PsyCheck Intervention. Re-screen using the PsyCheck Screening Tool at the conclusion of four sessions. If no improvement in scores evident after re-screening, consider referral. 15 Psycheck Self-reporting questionnaire Client or clinician to complete this section First: Please tick the “Yes” box if you have had this symptom in the last 30 days. Second: Look back over the questions you have ticked. For every one you answered “Yes”, please put a tick in the circle if you had that problem at a time when you were NOT using alcohol or other drugs. 1. Do you often have headaches? □ No □Yes   2. Is your appetite poor? □ No □Yes   3. Do you sleep badly? □ No □Yes   4. Are you easily frightened? □ No □Yes   5. Do your hands shake? □ No □Yes   6. Do you feel nervous? □ No □Yes   7. Is your digestion poor? □ No □Yes   8. Do you have trouble thinking clearly? □ No □Yes   9. Do you feel unhappy? □ No □Yes   10. Do you cry more than usual? □ No □Yes   11. Do you find it difficult to enjoy your daily activities? □ No □Yes   12. Do you find it difficult to make decisions? □ No □Yes   13. Is your daily work suffering? □ No □Yes   14. Are you unable to play a useful part in life? □ No □Yes   15. Have you lost interest in things? □ No □Yes   16. Do you feel that you are a worthless person? □ No □Yes   17. Has the thought of ending your life been on your mind? □ No □Yes   18. Do you feel tired all the time? □ No □Yes   19. Do you have uncomfortable feelings in the stomach? □ No □Yes   20. Are you easily tired? □ No □Yes   Total score (add circles): 16 DEPRESSION ANXIETY STRESS SCALE – DASS 21 Name: Date: The rating scale is as follows: Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time 1 I found it hard to wind down 0 1 2 3 2 I was aware of dryness of my mouth 0 1 2 3 3 I couldn't seem to experience any positive feeling at all 0 1 2 3 4 I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the absence of physical exertion) 0 1 2 3 5 I found it difficult to work up the initiative to do things 0 1 2 3 6 I tended to overreact to situations 0 1 2 3 7 I experienced trembling (e.g., in the hands) 0 1 2 3 8 I felt that I was using a lot of nervous energy 0 1 2 3 9 I was worried about situations in which I might panic and make a fool of myself 0 1 2 3 10 I felt that I had nothing to look forward to 0 1 2 3 11 I found myself getting agitated 0 1 2 3 12 I found it difficult to relax 0 1 2 3 13 I felt down-hearted and blue 0 1 2 3 14 I was intolerant of anything that kept me from getting on with what I was doing 0 1 2 3 15 I felt I was close to panic 0 1 2 3 16 I was unable to become enthusiastic about anything 0 1 2 3 17 I felt I wasn't worth much as a person 0 1 2 3 18 I felt that I was rather touchy 0 1 2 3 19 I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate increase, heart missing a beat) 0 1 2 3 20 I felt scared without any good reason 0 1 2 3 21 I felt that life was meaningless 0 1 2 3 Source: Lovibond, S.H. & Lovibond, P.F. (1995) Manual for the Depression Anxiety Stress Scales. 2nd edition. Sydney: Psychology Foundation. Page | 17 THE PRIMARY CARE PTSD SCREEN (PC-PTSD) In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: 1. Have had nightmares about it or thought about it when you did not want to? □ No □ Yes 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? □ No □ Yes 3. Were constantly on guard, watchful, or easily startled? □ No □ Yes 4. Felt numb or detached from others, activities, or your surroundings? □ No □ Yes Source: Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2004). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9, 9-14. Page | 20 Page | 21 Integrated Motivational Assessment Tool Motivation regarding AOD treatment M ot iv at io n re ga rd in g ps yc hi at ri c tr ea tm en t Pre- contemplation Contemplation Preparation / Determination Action Maintenance Pre- contemplation Contemplation Preparation / Determination Action Maintenance