Risk management with suicidal patients

Chronic mild stress leads to anxiety-like behavior and decreased p70 S6K1 activity in the hippocampus of male mice

Major affective disorders are highly prevalent, however, current treatments are limited in their effectiveness due to a lack of understanding of underlying molecular mechanisms. Recent studies have shown that reduced activity of p70 S6 kinase 1 (S6K1), a downstream target of the mechanistic target of rapamycin complex 1 (mTORC1), is linked to anxiety-like behavior in both humans and rodents. The purpose of this study was to investigate the relationship between S6K1 and anxiety-like behavior following chronic mild stress (CMS) and drug-induced inhibition of S6K1. Following CMS, anxiety-like behavior was evaluated using an open field (OF) and elevated plus maze (EPM) in adult male C57/Bl6 mice. After behavior analysis, samples of the hippocampus were harvested for quantification of S6K1, S6 ribosomal protein, glycogen synthase kinase-3 β (GSK3β), and beta tubulin via western blot. Our results demonstrate that CMS mice exhibit anxiety-like behavior in the OF and EPM and reduced activity of S6K1 in the hippocampus (HPC). We measured phosphorylation levels of GSK3β and found that GSK3β phosphorylation was also reduced following CMS compared to control mice. Furthermore, pharmacological inhibition of S6K1 with PF-4708671 in male mice was sufficient to produce anxiety-like behavior in the OF and EPM. These results further support the significant role of S6K1 in the pathogenesis of anxiety and affective disorders.

Development and Evaluation of a Pragmatic Measure of Adherence to Dialectical Behavior Therapy: The DBT Adherence Checklist for Individual Therapy

This paper presents two studies conducted to develop and evaluate a new pragmatic measure of therapist adherence to Dialectical Behavior Therapy (DBT): the DBT Adherence Checklist for Individual Therapy (DBT AC-I). Study 1 used item response analysis to select items from the gold standard DBT Adherence Coding Scale (DBT ACS) using archival data from 1271 DBT sessions. Items were then iteratively refined based on feedback from 33 target end-users to ensure relevance, usability, and understandability. Study 2 examined the psychometric properties of the DBT AC-I as a therapist self-report and observer-rated measure in 100 sessions from 50 therapist-client dyads, while also evaluating predictors of therapist accuracy in self-rated adherence. When used as a therapist self-report measure, concordance between therapist and observer ratings was at least moderate (AC1 ≥ 0.41) for all DBT AC-I items but overall concordance (ICC = 0.09) as well as convergent (r = 0.05) and criterion validity (AUC = 0.54) with the DBT ACS were poor. Higher therapist accuracy was predicted by greater DBT knowledge and adherence as well as more severe client suicidal ideation. When used by trained observers, the DBT AC-I had excellent interrater reliability (ICC = 0.93), convergent validity (r = 0.90), and criterion validity (AUC = 0.94). While therapists' self-rated adherence on the DBT AC-I should not be assumed to reflect their actual adherence, some therapists may self-rate accurately. The DBT AC-I offers an effective and relatively efficient method of evaluating adherence to DBT when used by trained observers.

Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients

Suicide is the 10th leading cause of death in the United States and the second cause of death among those ages 15-24 years. The current standard of care for suicidality management often involves an involuntary hospitalization deemed necessary by the attending psychiatrist. The purpose of this article is to reexamine the ethical tradeoffs inherent in the current practice of involuntary psychiatric hospitalization for suicidal patients, calling attention to the often-neglected harms inherent in this practice and proposing a path for future research. With accumulating evidence of the harms inherent in civil commitment, we propose that the relative value of this intervention needs to be reevaluated and more efficacious alternatives researched. Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive hospitalization of suicidal individuals to those who lack decision-making capacity.

Cognitive behavioral therapy for suicide prevention (CBT-SP): Implications for meeting standard of care expectations with suicidal patients

Accumulating evidence supports the efficacy of cognitive behavioral therapy for suicide prevention (CBT-SP) as an empirically supported treatment approach for suicidal patients. In light of these findings, several procedures pulled from CBT-SP have been recommended for standard care with suicidal patients. The present article provides an overview of the procedures used in CBT-SP and discusses how these procedures meet, or even exceed, standard of care expectations for outpatient mental healthcare clinicians. Finally, the relevance of clinician fidelity to the CBT-SP model when evaluating standard of care expectations is discussed.

Differentiating Single and Multiple Suicide Attempters: What Nightmares Can Tell Us That Other Predictors Cannot

STUDY OBJECTIVES

Although nightmares have been associated with suicidal behavior beyond well-known risk factors, the association between nightmares and multiple suicide attempts remains largely unexplored. This study addressed this gap in the literature by examining whether nightmares differentiated between individuals who reported single versus multiple suicide attempts. The individual contributions of nightmare frequency, distress/severity, and chronicity were also investigated to determine which variable contributed the most variance.

METHODS

Participants (n = 225) were recruited as part of a larger data collection through Amazon Mechanical Turk, an online crowdsourcing venue. Participants reported attempting suicide once (n = 107 individuals), multiple times (n = 118), or never (n = 791). Nightmare frequency, distress, and chronicity were assessed with the Disturbing Dreams and Nightmares Severity Index.

RESULTS

Nightmare frequency differentiated multiple from single suicide attempters, even after controlling for symptoms of depression, posttraumatic stress disorder, insomnia, nightmare severity/distress, nightmare chronicity, and age (P = .019). Comparison participants, those not reporting suicide attempts, reported a significantly lower level of nightmare frequency than those reporting single or multiple suicide attempts.

CONCLUSIONS

Inconsistent with past research, this study showed that nightmare frequency, and not nightmare chronicity or severity/distress, differentiated between single and multiple suicide attempters. This outcome suggests that the number of nightmares experienced may be more pertinent in predicting repeat suicide attempts than their duration or perceived severity. Study limitations include a cross-sectional design, a convenience sampling approach, a lack of control for previous treatment or length of time since last attempt, and a retrospective nightmare measure.

Evaluating a Multimedia Tool for Suicide Risk Assessment and Management: The Linehan Suicide Safety Net

OBJECTIVE

The present study examined the usability and effectiveness of the Linehan Suicide Safety Net (LSSN), a web-based, multimedia tool designed to support clinicians working with individuals who are suicidal. The core feature of LSSN is the Linehan Risk Assessment and Management Protocol (LRAMP), an empirically derived protocol that provides a structured checklist for assessing, managing, and documenting suicide risk.

METHOD

Mental health professionals (N = 44) completed assessments at baseline and monthly during a 3-month evaluation period.

RESULTS

The LSSN was rated as acceptable and highly usable. Use of the LSSN was associated with a significant increase in confidence in conducting suicide risk assessment and management and a decrease in concerns related to treating suicidal clients.

CONCLUSION

The LSSN appears to be a promising tool for clinicians working with suicidal clients.

A review of suicide risk assessment instruments and approaches

Introduction:

Conducting an accurate suicide risk assessment (SRA) is no simple task as there are a number of factors that influence an individual's level of suicidality and his/her willingness to share this information. Therefore, it is imperative that practitioners adopt a systematic approach to conducting and documenting the foreseeability that a patient will commit suicide.

Methods

PubMed was used to search for articles published in MEDLINE journals using the following keywords: suicide, risk assessment, measure, scale. Randomized trials and pilot, proof-of-concept publications investigating the use of specific SRA measurements were included in the review. The scales are described based on the prevailing opinions in psychiatry from the American Psychiatric Association's Textbook of Suicide Assessment and Management (2nd ed., 2012).

Results

Although various SRA scales exist, experts in the field have repeatedly concluded that there is not any one scale that can predict who will commit suicide to any useful degree. However, when used along with the clinical interview, standardized suicide risk factor components of clinical and research scales remain crucial to gaining information often omitted by patients regarding thoughts and preparation for suicide. A summary of the most widely cited scales and approaches used in SRA is provided.

Discussion

SRA remains a challenge largely due to the fact that suicidal behavior is multifactorial. As a result, risk formulation is a process that should involve both standardized measures and detailed clinical interviews repeated over time.

Risk factors for suicide among 34,671 patients with psychotic and non-psychotic severe depression

BACKGROUND

Severe unipolar depression is associated with increased risk of suicide, but it remains unknown whether the same risk factors are present in the non-psychotic (non-PD) and psychotic (PD) subtypes respectively. Therefore, this study aimed to identify risk factors for suicide in non-PD and PD separately, and to investigate if the presence of psychotic symptoms is an independent risk factor for suicide in severe depression.

METHODS

This register-based, nationwide, historical prospective cohort study used logistic regression analyses to ascertain risk factors for suicide among all adults diagnosed with severe depression at Danish psychiatric hospitals between January 1, 1994 and December 31, 2010. The risk for suicide was expressed as adjusted odds ratios (AOR).

RESULTS

A total of 34,671 individuals with severe depression (non-PD: n=26,106 and PD: n=12,101) were included in the study. Of these, 755 completed suicide during follow up. PD was not found to be an independent risk factor for suicide in severe depression (AOR=0.97 [0.83-1.15]). Older age (non-PD AOR=1.05 [per year], PD AOR=1.04 [per year]), male sex (non-PD AOR=1.89, PD AOR=1.98), and a previous incident of self-harm (non-PD AOR=5.02, PD AOR=5.17) were significant risk factors for both groups.

LIMITATIONS

As the study population was comprised only of patients with contact to psychiatric hospitals, the results cannot be extrapolated to the primary care setting.

CONCLUSION

The following risk factors for non-PD and PD were identified: older age, male gender and previous incidents of self-harm. In suicide prevention efforts, equal attention should be paid to non-PD and PD patients.

Clinical risk management in mental health: a qualitative study of main risks and related organizational management practices

Background

A scientific understanding of clinical risk management (CRM) in mental health care is essential for building safer health systems and for improving patient safety. While evidence on patient safety and CRM in physical health care has increased, there is limited research on these issues in mental health care. This qualitative study provides an overview of the most important clinical risks in mental health and related organizational management practices.

Methods

We conducted in-depth expert interviews with professionals responsible for CRM in psychiatric hospitals. Interviews were transcribed and analyzed applying qualitative content analysis to thematically sort the identified risks.

Results

The main concerns for CRM in mental health are a) violence and self-destructive behavior (i.e. protecting patients and staff from other patients, and patients from themselves), b) treatment errors, especially in the process of therapy, and c) risks associated with mental illnesses (e.g. psychosis or depression). This study identified critical differences to CRM in hospitals for physical disorder and challenges specific to CRM in mental health. Firstly, many psychiatric patients do not believe that they are ill and are therefore in hospital against their will. Secondly, staff safety is a much more prominent theme for CRM in mental health care as it is directly related to the specifics of mental illnesses.

Conclusions

The current study contributes to the understanding of patient safety and raises awareness for CRM in mental health. The mental health specific overview of central risks and related organizational management practices offers a valuable basis for CRM development in mental health and an addition to CRM in general.

Behavioural therapy of suicidality

Suicidal behaviour is a serious public health issue. Suicidal behaviour includes completed suicide, suicide attempts, suicidal intent and/or plans and suicide ideation. Two prominent mechanisms, behavioural deficits, in particular poor problem-solving skills, and a certain cognitive style with overgeneralization, distortion and lack of positive expectations, have been identified in suicidal patients so far. Besides general therapy strategies, including the diagnostic process and a collaborative, confident relationship and strengthening of protective factors, specific behavioural strategies should aim at the modification of the behavioural repertoire and of cognitive strategies. The modification of the behavioural repertoire includes the direct modification of the behaviour, acquiring techniques for stress reduction and learning problem-solving strategies. Applied cognitive techniques comprise such as thought-stopping, examining options and alternatives, fantasizing consequences, externalizing inner voices, and reattribution. Psychotherapy with suicidal patients has a specific feature: It requires high activity of the therapist in terms of motivation and guidance of the patient. Regular assessment of the suicide risk at every session is a must. Nevertheless, the therapist should always be aware that it is impossible to prevent all suicidal acts.

Promoting positive risk management: evaluation of a risk management panel

The purpose of this study was to evaluate whether a National Health Service Trust risk management panel (RMP) service was effective in promoting positive risk management by supporting mental health clinicians/teams in their management of people with mental health problems who presented with high risk of harm to themselves or to others. Fifteen mental health workers completed a questionnaire regarding their experience of the RMP. Content analysis revealed several themes. The majority of participants found the RMP helpful because of the support provided by shared case discussion and collective responsibility for risk management offered by the RMP. Medical records of the 23 individuals referred into the RMP were also examined. Trends in diagnoses, risks and RMP recommendations were identified. This study points to the importance of the organization's role alongside the individual clinician's in positive risk management and in supporting people with mental health problems using the recovery model. Improvements in developing a RMP are suggested.

Solution-focused therapy for families coping with suicide

Solution-focused therapy is proposed as a model for families coping with suicide. The nature and incidence of suicide is described along with a consideration of the effects that suicide has on families and prevailing treatment approaches. Three case examples illustrate the application. Implications are discussed pertaining to the theory, practice, and research of solution-focused therapy for families coping with suicide.