Risk and Protective Factors for Suicide Risk and Protective Factors for Suicide and Suicidal Behavior and Suicidal Behavior - PDF Document

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  1. Fact  Sheet  Prepared  by  Section  VII           September,  2012   FACT SHEET PREPARED BY SECTION VII UPDATED JUNE, 2012 PAGE 1 OF 7 DIVERSITY FACT SHEET Risk and Protective Factors for Suicide Risk and Protective Factors for Suicide and Suicidal Behavior and Suicidal Behavior The Nature of Risk and Protective Factors   A suicide risk factor is a variable (characteristic, attribute …) that is associated with an increased risk of morbidity (e.g., suicide attempt) or mortality (death by suicide). The association is correlational, hence not necessarily causal. Risk factors for suicide can be demographic, biological, psychological, social, and cultural. They also can be chronic (associated with elevated lifetime risk) or acute (associated with near- term risk). Many chronic risk factors are static or unchangeable (e.g., a history of a suicide attempt or a history of violence), but others may be modifiable or dynamic (e.g., a mental disorder that can be treated effectively or limitations in coping ability that can be improved with intervention). Acute risk factors are most often dynamic and changeable. morbidity or mortality. Protective factors may provide a counterweight to risk factors, but how risk factors and protective factors may interact is not always clear. No evidence-based system exists that informs clinicians about how much weight to assign any given risk or protective factor or any given combination of risk or protective factors. The co-occurrence of certain risk factors may be additive (i.e., equal to the sum of the risk associated with each factor), sub-additive (i.e., equal to a risk greater than that with one factor, but not equal to the sum of the two), or synergistic (i.e., the combined risk may be greater than the simple sum of the risk associated with each factor). A protective factor is a variable that is associated with a decreased risk of The Uses of Risk and Protective Factors in Suicide Risk Assessment   A listing of risk factors and protective factors for suicide (such as that provided below) should be regarded as an aide-memoire for the clinician; i.e., it is a listing of factors that can be reviewed in a particular case as the clinician attempts to arrive at a formulation or judgment about the level or degree of risk of suicide or suicidal behavior for the individual in question. In other words, a review of risk and protective factors should never be mistaken for a risk assessment in which these factors may be reviewed as part of a more complete case formulation. Moreover, it should be noted that, although the clinician should make all efforts to arrive at an evidence-based or

  2. Fact  Sheet  Prepared  by  Section  VII           September,  2012   evidence informed risk formulation, the clinical formulation of suicide risk is ultimately a clinical judgment. factors may provide a foundation for the risk evaluation, but particular attention should be given to acute risk factors and protective factors. In the violence risk assessment literature, research has suggested that acute and dynamic risk factors contribute appreciably to assessments of short-term risk (McNiel, Gregory, Lam, Sullivan, & Binder, 2003). It seems plausible that the case may be similar with the assessment of short-term risk for suicide. In assessing for acute or short-term risk for suicide, chronic or static risk The listing of factors below is not exhaustive since there have been literally hundreds of identified risk factors for suicide. It is a listing of factors that are individually evidence-based and regarded as important factors to consider by the Section VII/Division 12 Working Group when a clinician evaluates a potentially suicidal individual. For the most part, the factors apply to all age groups. The presence of risk factors for suicide should alert the clinician to the possibility that the individual is at risk. It should be noted, however, that the presence of one or more risk factors does not necessarily mean that a patient or client is actively suicidal. Alternatively, the presence of one or two very serious risk factors (e.g., a recent, near lethal suicide attempt with strong intent to die) can elevate the estimate of risk. Again, and as mentioned above, the clinician’s decision about suicide risk should be based on a review of risk and protective factors in the context of a more complete clinical evaluation and a carefully considered case formulation. In considering the dynamic balance of risk and protective factors, it should be borne in mind that, in the face of overwhelming acute and chronic risk factors, protective factors are unlikely to be effective in preventing suicidal behavior. Plans for management or treatment of a suicidal individual may benefit from a review of those dynamic and acute risk factors that can be modified through intervention and those protective factors that might be introduced or strengthened. In arriving at a case formulation for suicide risk, it is wise, if possible, to seek a consultation with a peer who is not necessarily a friend or close colleague. In addition, it is important to document your formulation of the level of risk, the observations that inform that formulation, your rationale for your formulation, your treatment plan based on your formulation, and the risks and benefits of your plan for management.

  3. Fact  Sheet  Prepared  by  Section  VII           September,  2012   Selected Chronic Risk Factors, Acute Risk Factors, and Protective Factors   Chronic  Risk  Factors     Demographic  factors   Male  gender   White  or  Native  American  race/ethnicity   Divorced,  widowed  (particularly  at  a  young  age),  separated,  single     Age  (35-­‐64;  75-­‐85+)  (based  on  2009  official  U.S.  suicide  data)     Past  Self-­‐Injurious  and  Suicidal  Behavior   Past  suicidal  ideation/plans*   Past  suicide  attempts*   Past  self-­‐injurious  behavior     Past  Impulsive  or  Violent  Behavior   Past  impulsive  behavior   Past  reckless  and  self-­‐endangering  behaviors   Past  violent  behavior       Cognitive/Psychological  Features  or  Traits   Absolutistic  thinking   Tunnel  vision   Limited  coping/problem  solving  ability   Limited  capacity  for  self-­‐soothing   Perfectionism            

  4. Fact  Sheet  Prepared  by  Section  VII           September,  2012   Family/Peer  Group  Factors   History  of  sexual  or  physical  abuse/trauma  as  child/adolescent   Family  history  of  suicide  or  suicide  attempts   Family  history  of  violence,  substance  abuse,  or  psychiatric  disorders            requiring  hospitalization   Family/Self  rejection  of  sexual  orientation     Parental  Divorce  as  a  young  child     Socioeconomic  factors   Barriers  to  accessing  mental  health  care   Stigma  related  to  accessing  mental  health  care       Easy  access  to  lethal  methods  (particularly  firearms)     Guns  in  the  home   Hoarding  of  medications     Mental  Disorders   Mood  Disorders  (including  Major  Depressive  Disorder  and  Bipolar     Disorder,  Depressed)   Substance  Use  Disorder  (particularly  Alcohol  Abuse/Dependence,     Cocaine  Abuse,  and  Nicotine  dependence/smoking)     Schizophrenia     PTSD  (particularly  combat-­‐related  PTSD)   Anxiety  Disorder   Personality  Disorder  (particularly  Borderline  or  Antisocial)   Eating  Disorders   Body  Dysmorphic  Disorder   Conduct  Disorder  (in  adolescents)  

  5. Fact  Sheet  Prepared  by  Section  VII           September,  2012   Co-­‐Morbid    Disorders  (e.g.,  Depression  and  Anxiety;  Alcohol  Abuse  and     Depression;  Schizophrenia  and  Depression;  PTSD  and  Alcohol     Abuse;  Borderline  Personality  Disorder  and  Depression)       Medical  Illness     Cancer  (risk  greater  in  first  year  after  diagnosis)   HIV/AIDS  (risk  greater  with  progression  of  disease)   End  Stage  Renal  Disease  (risk  greater  when  age  >  60)   Spinal  Cord  Injury/Disease  (risk  greater  in  first  2-­‐5  yrs  after  injury)   Neurological  Disorders     Traumatic  Brain  Injury  (risk  greater  with  cerebral  contusions)   Epilepsy  (risk  greater  for  women)       Stroke  (risk  greater  when  age  <  50)   Multiple  Sclerosis  (risk  greater  in  first  year  after  diagnosis)   Huntington’s  Disease  (risk  greater  just  prior  to  diagnosis  and  with     decreased  functioning)   Co-­‐Morbid  Axis  III  and  Axis  I  Disorders  (e.g.,  Axis  III  Disorder  and  Depression  or  Alcohol   Abuse)     Acute  Risk  Factors     Suicide  ideation/behavior     Current  suicidal  ideation**   Current  suicidal  plan**   Current  suicidal  plan  includes  very  lethal  means   Preparation  for  suicide  (e.g.,  giving  away  valued  possessions;     rehearsal  behaviors)   Recent  suicide  attempt  (with  no  wish  to  be  saved  or  expressed   regret  that  death  did  not  occur)  

  6. Fact  Sheet  Prepared  by  Section  VII           September,  2012   Acute  symptoms  of  mental  disorder   Acute  depression   Active  abuse  of  alcohol  (particularly  an  increased  use  relative  to     historical  pattern)   Depression  following  cocaine  use   Rapid  mood  cycling  in  bipolar  disorder   Command  hallucinations  (to  commit  suicide  or  harm  self)   Insomnia;  persistent  nightmares     Acute  co-­‐morbid  mental  disorders     Acute  depression  and  anxiety  or  panic  symptoms     Acute  depression  and  agitation   Alcohol  abuse  and  acute  depression     Schizophrenia  and  depressed  mood     PTSD  and  active  alcohol  abuse     Borderline  Personality  Disorder  and  depressed  mood         Physical  Illness  and  Acute  Emotional  Distress   Physical  illness  (particularly  as  noted  in  Section  I.I.)  and  depression   Burdensomeness  of  multiple  physical  illnesses   Unremitting  and  disabling  pain       Cognitive/Psychological  features   Feelings  of  hopelessness   Severe  anhedonia  and  depressed  mood   Global  insomnia  and  depressed  mood   Decreased  self-­‐esteem  

  7. Fact  Sheet  Prepared  by  Section  VII           September,  2012   Feelings  of  shame  or  humiliation   Feelings  of  intolerable  aloneness   Few  or  no  reasons  for  living;  feeling  loss  of  purpose  or  meaning       Feelings  of  being  trapped     Behavioral  features   Increased  impulsive  behavior  or  recklessness   Increased  anger  and/or  aggression;  seeking  revenge   Recent  violent  behavior   Final  act  behaviors  (e.g.,  making  last  will,  giving  possessions  away)   Evidence  of  stalking  and/or  preparations  for  murder-­‐suicide       Non-­‐suicidal  self-­‐injury     Psychosocial  issues   Recent  loss  or  disruption  of  a  relationship  (separation,  divorce)   Lack  of  social  support   Recent  discharge  from  psychiatric  hospitalization   Unemployment   Financial  Strain   Loss  of  socioeconomic  status   Suicide  cluster  (contagion)  (particularly  with  adolescents)   Pending  legal  issues  or  criminal  charges     Exposure  to  suicide  of  a  peer  or  of  someone  admired       Dramatic  media  coverage  of  a  suicide   Victim  of  bullying  (particularly  in  children  and  adolescents)      

  8. Fact  Sheet  Prepared  by  Section  VII           September,  2012   Protective  Factors  for  Suicide         Good  (available,  accessible,  and  responsive)  social  support  (including  a  positive  therapeutic  alliance)     Family  cohesion  and  involvement  (for  adolescents)       Involvement  in  school  activities  (for  adolescents)     Easy  access  to  mental  health  care  and  substance  abuse  treatment     Good  problem  solving  skills/ability  to  consider  options     Children  under  18  in  the  home     Pregnancy     Multiple  reasons  for  living     Cultural  and  religious  beliefs  that  provide  meaning  and  discourage  suicide     Restriction  of  access  to  highly  lethal  weapons/methods  of  suicide           *  The  absence  of  past  suicidal  ideation/attempts  cannot  be  taken  as  an  indicator  of  lower  risk.  It  is   estimated  that  >  60%  of  suicides  occur  on  the  first  attempt.       **  An  individual’s  denial  of  current  suicide  ideation  or  plan  should  not  be  taken  to  mean  that  there  is  no   suicide  risk.  Also,  both  active  suicide  ideation  and  passive  suicide  ideation    (e.g.,  wish  to  die  without   thoughts  of  killing  oneself)  confer  increased  risk.     Document  prepared  by  the  Section  on  Clinical  Emergencies  and  Crises  (Section  VII)  of  the  Society  of   Clinical  Psychology,  American  Psychological  Association  Working  Group  on  Suicide  Risk  Assessment   Resources:  Phillip  Kleespies  (Co-­‐Chair),  Marc  Hillbrand  (Co-­‐Chair),  Lanny  Berman,  David  Drummond,  and   Lisa  Firestone.