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Alex Raben: [00:00:00] Hello, listeners, this is Alex here. Welcome back to PsychEd for the month of July. Instead of one episode, you'll be getting five. That's because we're going to be doing a special mini series in which we cover clinical skills in psychiatry. So in the past, we've tended to cover specific disorders or illnesses, but these five episodes will focus on approaches and competencies that will help you in your training in psychiatry. We hope that you will enjoy!
Lucy Chen: [00:00:39] Hey there podcast listeners this is PsychEd the podcast for medical learners by medical learners. I'm Lucy Chen and I'm joined by Alex Raben. And today we are officially PGY-5's. Yeah, yeah, we made it through, guys. So today we're going to focus on the clinical skill of suicide risk assessment and we're lucky enough to be joined by DR. Juveria Zaheer again for this topic as she has a great deal of research expertise and clinical expertise in this area. So in terms of the objectives for this episode, we're going to familiarise ourselves with the risk factors and predictors of suicide, as well as protective factors. We're going to learn about the components of a suicide risk assessment, and we're going to learn how to comprehensively document and communicate the risk assessment as well. So without further ado, we'll let Dr. Juveria Zaheer introduce herself and talk a little bit more about her research experience, and then we'll delve right into the episode. We've brought back Dr. Juveria Zaheer. So we already got a little bit of an introduction on her. But Dr. Zaheer, maybe you can refer maybe you can explain a little bit more about your research on this topic.
Dr. Juveria Zaheer: [00:02:12] Absolutely. So suicide risk assessment prevention is a real passion for me. When I was a resident at the University Toronto, I'd completed my master's in the Arthur Sommer Rotenberg Suicide Studies Unit at St Michael's Hospital, and there did a lot of research on suicide, qualitative suicide research. So understanding the experiences of people who have had suicidal behaviour, people who've died by suicide through suicide notes, clinicians, family members who work with suicidal people. In my fellowship here at the Centre for Addiction and Mental Health, I focused on understanding how we can use big data or linked health administrative data to understand how patterns of service utilisation or presentations or risks differ for different populations, for suicide risk. And also another part of my research portfolio is Best Practices in Suicide Risk Management. So recently worked with the Canadian Armed Forces to write their clinical handbook for suicide risk assessment and prevention. So and I'm an emergency psychiatrist, so risk assessment is the bread and butter of what I do on a daily basis. Initially, my suicide risk assessment approach was very similar to what we were taught in residency to use sad persons to understand the risk factors for suicide, which I think is a really, really important place to start. One of the things that I found really challenging is people often told us, and I think they meant to tell us this in a supportive or a way to reduce anxiety, but that it's you can't predict suicide on an individual level.
Dr. Juveria Zaheer: [00:03:40] And so it was very tough to reconcile these pieces that were trained in suicide risk assessment, and we can't predict suicide. And so it was something that I really thought of. I thought about a lot. And I think something that guided my research career in my clinical practice. I think understanding the data, reviewing the literature, doing our own work has shown me that although yes, it's very difficult to predict suicide on an individual level, we have very good epidemiological evidence. We have very good clinical evidence about what is risk, what increases someone's suicide risk. We can also use a suicide risk assessment to better understand a person sitting in front of us. And rather than looking at the suicide risk assessment for me as something that stratifying people's risk arbitrarily, their low, their medium, their high, and often we only link it to whether they're admitted or not. And hospitalisation isn't actually an evidence based intervention for suicidal ideation or suicidal risk. And so what we thought about is how do we understand suicide risk in the way that doing a really good assessment can help guide treatment, can help us manage the risk factors that can be modified, can help people keep people safe, and how can we do it in such a systematic way that we can think about suicide risk prevention as more of a public health concern rather than something that we do clinically?
Lucy Chen: [00:04:55] That's great. So for our learners, where are they going to be expected to perform a risk assessment?
Dr. Juveria Zaheer: [00:05:01] That's a great question. I think that, you know, there's a lot of data on this topic. So, for example, Kelly Posner, who wrote the Columbia Suicide Prevention Suicide Assessment Scale, she said that in every appointment, everybody should be screened for suicidal behaviour, like in suicidal ideation, even in medical settings. And then on the other hand, you have the Canadian-American guidelines that say that suicide screening shouldn't be done regularly in family practice unless there are resources available or unless it's a high risk group. We're psychiatrists, so, or we're training to be psychiatrists. So we should be doing suicide risk assessments because we are sort of by definition, working with a higher risk group, people who have mental health concerns. It's really important to point out that everybody that, you know, in North America, over 90% of people who die by suicide would have had a diagnosable access one or access to mental health concern. But the vast majority of people with mental health concerns don't die by suicide. It's really, really important that there is hope and that there is a way forward for us. We always want to do a suicide risk assessment. If it is a new assessment with somebody, even if they're saying, I don't have any suicidal ideation right now, the act of getting the historical information and the current risk and the acute risk factors is so useful because then you have a baseline for when you see them later. You always want to do it in an emergency department setting. You want to do it if they're expressing to you that they have new or worsening CI or suicidal ideation, thoughts of suicide, you want to do it. If you're repeating an assessment for someone who's at elevated risk for suicide, or if there's concerns from a health care provider or a family member in your clinical practice, if you do a thorough suicide risk assessment on visit one and you're doing CBT with the client you want to screen every time you see them, and if there's no elevated risk, then you wouldn't repeat this whole process.
Alex Raben: [00:06:39] You you were mentioning right at the beginning that we there are ways of knowing what puts people at higher risk for suicide or that we know some of the factors involved in that. We also know that hospital admission is not an evidence based intervention for prevention of suicide. So could you help us understand from your perspective, what are the goals of a suicide risk assessment?
Dr. Juveria Zaheer: [00:07:06] So it's so for me, the goals of a suicide risk assessment are to understand the risk of suicide for that person in the short term and the long term to understand if their risk, their personal risk is changed over time. So is there something that's happening that's changing their risk that needs to be addressed? By doing a thorough risk assessment, we can identify modifiable risk factors. So for example, by understanding if somebody is having suicidal ideation, we can ensure that we're going to do a safety plan with them, which is an evidence based intervention. If somebody is having worsening depressive symptoms or worsening psychotic symptoms that are contributing to their suicidality, then we can make sure that we treat those pieces. So in that case, an inpatient hospitalisation to treat these modifiable risk factors is completely useful and important. If someone tells us that in our suicide risk assessment that they have a specific thought of a specific plan and they have insomnia and they're not sleeping and they're thinking about it all the time and they have access to means we can make sure that the firearm is removed from the home. We can think about Daily Dose prescribing. We can know that compared to their baseline, their risk is higher. So maybe hospitalisation for stabilisation is important.
Lucy Chen: [00:08:14] And I'm wondering if there's a better way to understand are there components of risk or can we break that down?
Dr. Juveria Zaheer: [00:08:19] Absolutely. I think and we always we also often think about risk as a negative thing and they're doing a good risk assessment should also highlight the positive factors, too, and the protective factors and strengthen them. I think we can understand risk in a few ways. So one is somebody is historical risk. So what are things that they have on a population level that would put them on average compared to another person at higher risk for suicide? So those could be sort of demographic risk factors, gender, age, history of family history, of suicidal behaviour, of history, of trauma. We also want to understand suicide specific risk factors. And so those include past attempts, a past history of suicidal ideation, a past history of deliberate self harm, which all, even if there's no intent to die, is an independent risk factor for death by suicide. We also want to understand acutely what's happening that is potentially modifiable. So what are the acute risk factors, whether it's mental illness, substance, medical illness, as well as acute psychosocial risk factors, occupation, marital status, financial stress, immigration, stress. And we also want to understand how the person perceives suicide. What are the psychological risk factors? Are they do they feel a sense of perceived burdensomeness? Do they have a sense of exhaustion? Do they feel alienated? Do they have a lot of cognitive rigidity around this issue? And finally, and most importantly, we want to understand warning signs for suicide. So what is happening in the short term that puts someone at high risk for suicide? Are they engaging in suicidal communication, talking to people about dying by suicide? Are they engaging in preparatory behaviour which might mean making plans for suicide, researching ways to die or the other half is getting one's affairs in order reaching out to people. Have they had any recent attempts? And I think we're probably moving as a field to looking at these suicide specific warning signs to predict suicide death rather than relying solely on sad persons, because a lot of those features are quite static.
Lucy Chen: [00:10:13] Yeah. So can we talk about SAD PERSONS? Because I remember learning this in medical school, this acronym and just memorising it for the sake of memorising it. It's a suicide risk, I suppose other components of a potential suicide risk, that approach that we can take, like maybe we can go through it and then like, what is it? Is it good.
Dr. Juveria Zaheer: [00:10:32] Enough? Yeah. So I think SAD PERSONS is a really important place to start because I think suicide is it's such a tragedy. It affects people and families and communities and health care providers and it can feel very mysterious because it's an outcome that has social and biological and cultural factors. I think that SAD PERSONS is a great tool for learners because it shows us, it sort of illustrates the depth and breadth of risk factors associated with suicide. We also know that suicide is so, so rare that it's very difficult to predict. It's very it's a small signal. So getting epidemiological risk factors are pretty tough. So you need really, really big samples. So that person is sort of a distillation of the evidence as it exists. And so would you like to go through the risk factors?
Lucy Chen: [00:11:15] Yeah, sure. Yeah.
Dr. Juveria Zaheer: [00:11:16] So the essence that person's is for sex. And so in North American constructs as well as in sort of other high ses European countries, Australia, New Zealand women have engaged in suicidal behaviour at a rate of maybe three or 4 to 1, but men die by suicide at a similar rate. So about in Canada it's about I think 3.2 male suicide deaths to every female death by suicide irrespective of this history of behaviour. And then this varies by culture. So until the last decade in China, women actually died by suicide more often than men did. And in several European and several Asian countries, the risk is actually much closer. There's a there's a much lower ratio. As a multi sort of ethnic society, that's really important for us to know. People tend to carry, according to the World Health Organisation, carry their own sort of cultural risk for suicide to their new country for at least two or three generations before it kind of normalises. The second thing that we talk about is age. So I think in general we teach our students that especially for men, the older you are, the higher your risk for suicide. Although, you know, if you look at the Canadian and American census data, I think what we're kind of landing on is that 45 to 64 age is the highest risk, that middle age for both men and women, for men that that risk remains elevated through the course of their lifespan. And, you know, older men are at higher risk than older women, although this isn't a largely Caucasian population.
Dr. Juveria Zaheer: [00:12:42] So older men, middle aged men and women. And then there's the youth and emerging adults factor. And there was a really disturbing and important paper that just came out in JAMA Psych that showed that the rates of suicide are going up in young people. And so males tend to be at higher risk young males than young females. But certainly that's another high risk period. We'll call that emerging adult. The next risk factor is D is for depression. So again, it's really, really important to point out that the vast majority of people who suffer through major depressive disorder and even who have suicidal ideation do not die by suicide. And there are people with other diagnoses other than depression that are at high risk for suicide. But certainly having suicidality, suicidal thoughts is one of the criteria for major depressive disorder. And so if you're having an episodic depression, a major depressive episode is a risk. People who are treatment refractory in particular carry the highest risk. The next one is P for previous attempts. This is the big one. This is the most important risk factor for suicidal behaviour is a past history of suicidal behaviour. People often ask, you know, what are the percent of people who die on their first attempt? And there's a nice there's a nice paper that says it's probably about 40% of people die on our first attempt, 60% have had recurrent attempts.
Dr. Juveria Zaheer: [00:14:00] But again, the vast majority of people, even who've had a suicide attempt or we like to say suicidal behaviour if we can don't die by suicide. The next one is E is ethanol. It's a bit of a stretch, but is ethanol abuse? Alcohol can mitigate the risk for suicide in myriad ways. It's really, really important. So having an alcohol use disorder in and of itself raises your risk for suicide considerably, depending on the study you read here in Toronto. According to coroner's data, I think 30 to 50% of people who die by suicide across coroner studies have alcohol on board. So alcohol, like you think about it in sort of different stratified by different classes, right? So having an alcohol use disorder, it's it can have mood related symptoms which can result in suicidal behaviour. The second piece is that when people are intoxicated they may be more susceptible to co ingestion, they may miss, they may misinterpret risk of self harm behaviour, they may become more impulsive, they may become more emotionally disregulated. They may use alcohol as a way to reduce inhibition. Alcohol withdrawal can potentially make people feel agitated or, in the case of delirium, tremens, sort of do things that they wouldn't normally do. And then the last piece I think is a really important one, right, is an alcohol use disorder can have really serious psychosocial consequences. It can affect your job, can affect your marriage, it can affect your relationships. And I think often that's something that we need to really think about.
Dr. Juveria Zaheer: [00:15:25] The next one is our rational thinking loss. And you know, you want to call it rational thinking loss. We can call it cognitive rigidity. I really like Thomas Joyner's theory; interpersonal theory of suicide, which says that people feel a profound sense of alienation as well as a sense of perceived burdensomeness. The Beck hopelessness scale is a good one. Talking about losing hope, being quite black and white, having a negative view of yourself in the future and the world not being able to problem solve right. Being really in a dark place like thinking of, you know, often when people have unsolvable problems, suicide becomes sort of an awful solution to an unsolvable problem. Even though we know that with appropriate treatment, people's risk can come down considerably and people can live really happy and resilient and well and meaningful lives. I would say the last one is social. The next one is social support lacking, particularly for men being divorced or being socially isolated as a risk factor for suicide. There's some really innovative and interesting work in that area, but when people are alienated, they don't have a lot of social support. Makes it really tough to safety plan. Like if you don't have anyone to call it feels really stressful. And that's something that we can certainly build when we care and work with people who organise suicide plan. So one of my challenges with that persons is this feature here organized suicide plan or p previous attempts on the face of it looks like it has the same weight as something like sex and age, which it certainly doesn't, but.
Dr. Juveria Zaheer: [00:16:58] It is a great way to remember all of these pieces. So that's the caveat and we'll talk about that organized suicide plan at length I think during the session. No spouse, especially for males, as we discussed and asked, is for sickness so chronic or severe? I think there's there's lots of things that are missing from SAD PERSONS, you know, especially in our, you know, 2019. We always want to think about addiction, right? Opioid use. And there's a really growing body of evidence that opioid use disorder would be associated with suicide risk, things like personality disorders. And here, schizophrenia isn't here. All of these illnesses carry risk for suicide. Trauma, I don't think is on this list. And trauma is associated with, at the very least, an increase in suicidal behaviour, you know, things like LGBTQ2s+ or indeed like being Indigenous. Being an indigenous person isn't on this list. That's exactly right. And so, you know, I think it's a useful feature, but we need to maybe move beyond it. And we really need to distinguish between things that put an individual at risk for suicide over the course of their lifetime versus things that put people at risk for suicide in the immediate in the days or weeks or months coming up.
Lucy Chen: [00:18:12] So thanks so much for bringing SAD PERSONS to life. I think it adds a little bit more dimensionality and kind of a context for why this acronym is used. I can actually see many categories of SAD PERSONS within the scope of the components of suicide risk in terms of suicide specific risk factors, mental illness or psychosocial risk factors and psychological risk factors. So I see more as a memory aid, but then kind of to stratify that further in terms of what what components of risk assessment were actually assessing for?
Dr. Juveria Zaheer: [00:18:45] Absolutely. I think it's really difficult to move from not knowing anything about suicide risk assessment to using a formalised template or having a formalised approach without the intermediate step of that person's.
Lucy Chen: [00:18:54] Mm hmm.
Alex Raben: [00:18:55] Sure. So how do we move, then, from SAD PERSONS, which is a great memory aid, and it gives us a foundation of some of the risk factors. How do we move from that to a more fulsome risk assessment?
Dr. Juveria Zaheer: [00:19:08] So I think we want to exactly, as you guys said, use SAD PERSONS as a jumping off point to help us feel comfortable and help us make sure that we don't miss anything. And we want to focus in our suicide risk assessment on a few different areas historical information, current risk, including acute risk factors and warning signs as well as collateral information. So we want to be able to pull everything together. And in our formulation, you know, the you'll hear me talk about this a lot. If you work with me clinically and maybe even today on the podcast. But often medical students and residents are asked by your staff, what is this person's suicide risk? And we say low, medium or high, but we never talk about low, medium or high. Compared to what? Compared to whom? You know, there's no evidence around what makes low, medium or high risk. It doesn't really guide treatment. So doing a suicide risk assessment, that's an evidence based approach with based on understanding someone's risk in the moment and using it not only to come up with low, medium high, which is actually not super useful, but using that information to create a safety and treatment plan. Then we're talking. Then we're actually talking about something that can help people.
Lucy Chen: [00:20:20] Mm hmm. So I guess, you know, the approach to kind of maybe a successful suicide risk assessment, I guess essentially like we have to talk about kind of maybe the space and kind of the environment of a risk assessment and then maybe also the content of a risk assessment. And then we'll move on to kind of maybe formulation of risk assessment.
Dr. Juveria Zaheer: [00:20:39] So this is hard stuff to talk about. And I think for a lot of us who work in this field, I'm sure you've had a loved one or a friend or someone who's on psychiatry say to you, well, or even a family member of a client say, "Well, if you ask about suicide all the time, doesn't it make people feel more suicidal?" And we know from the data that a clinician asking about suicide doesn't actually increase someone's risk for suicide. We've done some work in this area. There's a nice qualitative study about or a survey study, I believe, of people's experiences of being asked about suicide. So I think part of the comfort we want to create a safe and comfortable environment. Part of that safety and comfort is our own safety and comfort. This is hard stuff to talk about and it feels really good. And I know a lot of the people listening to call it feels great when you meet someone and they say, I have no suicidal ideation. And then there's like this feeling of relief because first of all, you care about the person and you obviously don't want anything bad to happen to them. But then the second is like, Oh, now I don't have to go through any of this stuff. It saves me a bit of time. I can think about other things. But you know, if you can do a really good suicide risk assessment early, you create the scaffold for which we can understand this person's risk over time, and we can understand this person better and we can show them that we care. And there's lots of different pieces that we're thinking about.
Lucy Chen: [00:21:51] And maybe diving into the actual assessment. What is historical information? What's a sort of historical what's that that scope? What does that look like? So, you know, I think if.
Dr. Juveria Zaheer: [00:22:02] We don't go through this process, if we just sort of ask about current suicidal ideation intent and plan, then we miss all of this historical information, which is you look at that person's a lot of that is historical information. So this is a way that we can get all that information up front. You get it up front. And even if the person doesn't have active suicidal ideation, you have it. It's always there for the next clinician or for yourself when you're looking at it. So historical information informs the current state risk assessment and provides context for the current presentation. We will always want to ask about the history of suicide attempts. Again, sometimes you'll hear me say suicide attempts. Sometimes you'll only hear me say suicidal behaviour. I tend to prefer suicidal behaviour because we try to move away from the language of attempts or completion because it's maybe potentially unnecessarily stigmatising. So and I think often people aren't really sure either. There's a lot of grey area between deliberate self-harm and suicidal behaviour with intent to die. So if we want to call it suicidal behaviour with intent to die, it's a bit of a mouthful. But in their history and historical information, I usually cut it by the HPI. So if someone comes to you and we talked about this in our last session before the demarcation, so not in the last two months we'll see a number of attempts, most recent attempt method lethality efforts to seclude an emotional reaction to surviving the attempt. And I often ask for contextual factors as well. The second piece is a history of suicidal ideation, intent or plan or preparatory behaviour.
Dr. Juveria Zaheer: [00:23:34] This is something that I think before I started using a really formal approach that I would miss, because if someone's presenting with suicidal ideation now we want to know, have they. We often you see when you see a chart chronic SI (Suicidal Ideation) have you ever seen that all the time. And so chronic aside, does that mean that they've had it one day a week for their entire lives? Does that mean they've had it every day for six months? It's pretty vague, right? So I kind of draw out like you think about the person's life history. We say, I know you've been having suicidal ideation. You told me right now because you get that in your HPI write tell me about your life. When was the first time you ever had thoughts of suicide? When when were they there? Are they always there? Do they come and go? And and someone might say to you, I only ever had suicidal ideation in 2011 in the context of a major depressive episode. And now I'm having it again. It's super valuable information. Another person might say, I had my I had suicidal thoughts for the first time when I was seven. And they kind of come and go depending on if I have stressful things happening in my personal life. That's also really important information, right? We also want to do the same kind of process with intent and plan as well as preparatory behaviour. And we can talk about each of those things in a bit more detail if you would like now or we can do that later.
Lucy Chen: [00:24:47] Yeah, maybe we can elaborate on this topic now. I think preparatory behaviour is something that we're always mindful of, but I guess how to do that robustly or kind of scope.
Dr. Juveria Zaheer: [00:24:57] Yeah, absolutely. So you know, in our little I think there's a handout that you guys will get to that describes preparatory behaviour. I think this is a really, really important concept and we don't talk about it I think nearly often enough. So preparatory behaviour refers to one of two things. One is are there things that we're doing to prepare for death? So are we getting our affairs in order? Are we saying goodbye to people or are we, you know, maybe selling items off that kind of thing? And then the other half preparatory behaviour is are we like researching methods online, are we stockpiling medications or are we doing rehearsing? So I think preparatory behaviour goes as sort of both of those categories as well as suicidal communication. Are we talking more about suicide? More people talk about suicide before death by suicide than not. And I think people think, oh well, you know, they won't necessarily say anything about it, but everybody who has suicidal ideation, you have to remember, is deeply ambivalent. Right, because there's a part of them that is still alive and there's a part of them that's really, really suffering. And it's important to kind of highlight that piece.
Lucy Chen: [00:26:04] And I kind of would like to sometimes see suicidal ideation to intent and to plan and to preparatory behaviour a sort of like a spectrum. So I guess it's a little bit more nuanced sometimes the difference between ideation and intent.
Dr. Juveria Zaheer: [00:26:17] Absolutely. And I think we often think about the really classic presentation. We think somebody gets very depressed, they're functional, they have functional impairment, they start to feel really sad, then they have suicidal thoughts, and then slowly they develop intent and then slowly they engage in preparatory behaviour. And then there's a tragedy that needs to be averted. I think in practice you can think of suicidal ideation as pretty binary in the sense that either you have thoughts of suicide or you don't. And that to me is the biggest jump. You have thoughts or you don't, right? And you think about having suicidal ideation is like going through life with a sunburn. It's like, you know, if you normally take off your shirt, put on your shirt, have someone grab your arm and you don't have a sunburn. It doesn't feel it's fine. That's okay. But when you have suicidal ideation, everything hurts, right? Like you're more sensitive to things and you go, but you cycle between these scales, right? Sometimes you have intent, sometimes you don't. Sometimes you have a plan, sometimes you don't, sometimes like small. And that's why means restriction is so important. Sometimes you can feel so distressed in the context of see that you get closer whether you're intoxicated or you've had, you're feeling isolated. And so thinking about it as less as a continuum and more about like, do they have ideation or not? If they have ideation, getting all of this information and figuring out what makes it better, what makes it worse. Thinking about suicidal ideation is like taking a pain history, frequency, intensity, alleviating factors, associated factors. I think that's probably your best bet.
Lucy Chen: [00:27:42] Okay. And then now delineate delineating kind of between suicidal ideation, intent and plan and then self-harm.
Dr. Juveria Zaheer: [00:27:49] Yeah. So again, I think, you know, when I was training, I always thought that this was so binary. But I think for you guys, when you work with people in our emergency department or you do consultation or people with lived experience will tell you it's not that black and white. There's certainly, you know, we call it deliberate self-harm without intent to die. So and that can be cutting, head banging, hitting. Often we focus a lot in the cutting, but there can be other, other types of behaviours that we might be missing. And so, you know, I ask about both separately and there's this kind of non-specific kind of grey area. I think in the middle when I ask about history of deliberate self-harm, you want to be systematic about it. When did the behaviour start? What is the behaviour looking like? What is the frequency? What is the intensity, what are the triggers and is it changing over time? And you also want to understand the person's explanatory model because they want to. They want you to for two reasons. One is you want to be empathic and understand someone's pain and suffering. And it's a behaviour that can be really stigmatised and can feel really shameful. So an open explanation, exploration is really important. And also most importantly, if you understand the explanatory model, then you can actually figure out how to support them and figure out how to replace the behaviour or reduce their suffering or distress.
Alex Raben: [00:29:06] And then I guess also in the historical information we would get at some of these non-modifiable risk factors that we were kind of going talking about with the SAD PERSONS such as sex and age and those kind of things as well.
Dr. Juveria Zaheer: [00:29:22] Absolutely. And I usually write them all out early and then when I do my risk formulation, I'll always have it in the same place because that's the stuff you can't change. So it's important to know that we think about high, medium and low risk compared to what and compared to whom and compared to when. This is the compared to whom. Right. It's this is this is who is at a stratified risk of suicide that's higher compared to the general population. And it's really important because we would do that in medicine, too. Who are people who have risk factors for cardiac events or for developing diabetes?
Alex Raben: [00:29:55] Right. Subsets of the population that have higher risk?
Dr. Juveria Zaheer: [00:29:58] Exactly.
Alex Raben: [00:29:59] And then I guess we would move more towards the proximal factors that are putting someone at risk.
Dr. Juveria Zaheer: [00:30:05] Absolutely. So we call this current risk, and I usually focus on the HPI. So differentiating your HPI from past history is so important for lots of reasons, especially for suicide risk assessment. So we go through the same process. So on the template, I think I call it suicidal ideation intent plan and preparatory behaviour within the last month, but I think within the last month is useful if you're seeing them or or it can be since the last appointment or it can be like during this episode. But you know, it doesn't matter how you differentiate as long as you differentiate, I think. And then I think about it again, like pain intensity, frequency triggers, alleviating and aggravating factors, associated features. The next step is understanding suicidal behaviour, both attempts and deliberate self-harm since the last visit, within the last month in this time period. And then acute risk factors, worsening depression, presence of psychosis, substance use, relationship breakdown, financial stress. I think we sometimes think of suicide as so related to depression that we don't think about the other things that are happening in someone's life. And suicide is a tragic outcome that's so multifactorial. So you want to make sure that you explore these psychosocial pieces and some of those psychosocial pieces are can be quite modifiable or the target of the target for support or the target for intervention. One of the things that I should have mentioned is you always want to ask about access to firearms in the United States.
Dr. Juveria Zaheer: [00:31:26] Rates of firearm death by suicide are higher than they are in Canada. But you I always ask everybody about firearms because it's a small thing and you don't want to miss it. And I also ask about stockpiling medications or access to medications at home, and then the next one is warning signs. So this is a way you know, this is something that sad person doesn't really get at. Right. This is what is happening now in the in the days or minutes or weeks or, you know, hours before someone is presenting to you, are they more agitated? Do they have worsening insomnia? Really, really important, especially in qualitative explorations of suicide and suicidal behaviour? This insomnia agitation is so important irritability, anxiety, hopelessness, suicidal communication, psychosis including command, hallucinations, planning for carrying out a suicide, a suicide plan, engaging in suicidal behaviour, making arrangements for death, worsening substance use or intoxication. So these are things that you want to take really, really seriously. If you if someone is describing these these behaviours. And then the last thing that I try to focus on and it's something that, you know, it's something that I've had to learn and it's not something that comes very naturally to me, but I think it's really important is suicide narrative is what does suicide mean to them? Is it a function of hopelessness or helplessness? Is it a function of burdensomeness, alienation? What is their explanatory model that's really useful, right? Like if someone is describing all of these things to you and they say, I'm going to do this because I don't think my depression will ever, ever, ever, ever get better then targeting the depression, instilling hope becomes so important if it's because, you know, my wife has left me and I'm going to punish her and I'm going to punish myself, that it might mean that, you know, you might need to bring this person into hospital to stabilise them to do a little bit of family work, because there's something going on here that's really difficult to engage with.
Dr. Juveria Zaheer: [00:33:21] If it's a sense of perceived burdensomeness, then you can do some interesting family work to bring the family there and have the family say that, you know, we really you're really meaning you really mean a lot to us. We had no idea you were suffering, you know, so there's there's kind of ways that you can work with that narrative. And that's how and then I also I think it's really important to stress protective factors. I don't think we think about that nearly often enough. But what are these person's personal characteristics, their social supports, their treat and capability to engage in treatment, their ability to safety plan? What is it about this person that's keeping them with us that we can harness and work with them to create a robust safety plan?
Lucy Chen: [00:33:56] It's sometimes so hard to kind of assign weight to the protective factors and versus sort of the weight of. All of the historical context of suicide attempts or suicidal ideation, self-harm history, and then the current risk and then how we balance all of those features. Yeah.
Dr. Juveria Zaheer: [00:34:15] One of the things that's really helped me is to try to move in my mind, which is a bit challenging as an emergency psychiatrist. Right. But between like, is this person at risk or not? Or do I have to admit them or not? But more moving towards how do I understand the protective factors in the context of safety planning? So rather than assigning them a weight, if I can say that they have tons of suicidal ideation, but they have a loved one who's willing to stay with them. 24 seven They have access to date treatment so they can come into hospital every day. They're willing to start medication treatment. So there are pieces that would and they don't want to come into hospital. It's not really in keeping with their values at the moment. There are pieces that we can definitely work with them to engage in a robust safety planning process and a treatment plan that doesn't necessarily facilitate hospitalisation. But, you know, it's it's a bit of a mind shift. But I'm trying to personally and I think in the teaching that we do try to move beyond like having it be like typing it all into a computer and coming up with like a decision tool. Because I think that's really, really challenging, especially when the decision tool is often around hospitalisation, which again is isn't necessarily the the best proxy for for safety plan. I will also say that like recent hospital discharge or increasing service utilisation is another risk factor for suicide. And we have to whenever excuse me, you see somebody who's being having more admissions or going to the emergency department more, you want to take it seriously and think about breaking that cycle by an admission or another type of treatment modality.
Alex Raben: [00:35:45] So it sounds like the if we shift a little bit in our mind frame, the risk assessment can be thought of more as a layered understanding of someone's relationship with their suicidal ideation and behaviours and the various factors in their lives that affect that. And you know, just hearing you talk about that, you mentioned multiple times that there were interventions you can actually tailor to each of those kind of things. And so having this layered understanding, I imagine, is really helpful in that way.
Dr. Juveria Zaheer: [00:36:20] Absolutely. And there's a lovely paper that I'll send to you guys that gets at exactly this. It's we train so long to understand, to do an assessment, to come up with a metric for risk. And, you know, if we can switch that focus to doing a really robust and thorough assessment that serves three purposes, one that engages the client, the second is that it gives us a benchmark so we can compare risk over time to know when things are going sideways or to adjust our plan. And three, it shows us all of our targets for intervention. I think it's it's it's a much more hopeful process.
Alex Raben: [00:36:57] I think how do we as as learners balance this approach versus what our staff will often ask of us on a call which is kind of like, give us the bottom line in terms of what you think the risk is or what your disposition might be. How do we synthesise all of that to to that point?
Dr. Juveria Zaheer: [00:37:14] And I hope I really do hope that they're sort of mutually they're not mutually exclusive. Right. And so what I would say is, if I'm reviewing with you guys and it's on call and it's four in the morning and you want to you know, I would say two things. So go through the process and tell me what their suicide risk is. But not just high, medium, low, but compared to X and Y. Right. So you can say I've seen Mr. Jones compare to his A, he has this, you know, demographic risk factors, this sort of warning, these clinical risk factors, these warning signs compared to the general population. I think his risk for suicide is elevated compared to psychiatric outpatients. I think his risk for suicide is elevated compared to other psychiatric outpatients of his same demographic group, you know, a 70 year old white male who's divorced. Even compared to that high risk group, his risk is elevated and I think his risk is as elevated as psychiatric inpatients. So I think he merits a psychiatric admission. The second half is I think Mr. Mr. Jones is risk state. His risk compared to himself is the highest it's ever been. He had a major depressive episode 20 years ago, but never had this intensity of suicidal ideation at his baseline.
Dr. Juveria Zaheer: [00:38:20] He doesn't have any suicidal ideation. And so I think his baseline risk is, is that the highest it's ever been because he's engaging in preparatory behaviour, he's had recent average visits or recent hospital discharge and I think that understanding. Mr. what do we call him, Mr. Jones, is risk. Here are my treatment targets. So one is I think he has depression with psychosis. So I think that we should admit and consider ECT, which is an evidence based treatment that's shown potentially to reduce suicide risk. And we can also treat his psychosis with X or Y medication to is I think that he has a firearm in the home. So we need to talk to his family about removing that three. We can talk to his doctor about he's had an overdose recently about daily or weekly dispense versus like giving three month. At a time and for I think he has an alcohol use disorder so we can consider safety talks and naltrexone. So you can sort of look at the risk factors you have. And then the fifth piece is he's having a lot of stressors around sense of burdensomeness. His daughters live elsewhere, but seem to me to be very supportive of him. Maybe as part of the process we can engage in family meetings.
Alex Raben: [00:39:25] So just the same way in which your assessment is very layered, your delivery can also be very layered in terms of what you're putting forward.
Dr. Juveria Zaheer: [00:39:34] Yeah, absolutely. And if you look at the time, it doesn't take that much more time. I think we you know, the last thing we would ever want to do for our learners who are learning how to be psychiatrists is to make them do things that it's going to take a lot of time with no payoff or no benefit, most importantly to the client. But I think this approach doesn't actually take too, too much longer, and it can come up with a treatment plan that I think is more robust. And I think it's something that probably would be we're going to do a study on it to see how people experience various suicide prevention initiatives like qualitatively. So, stay tuned. But I do think that a client is not going to mind going through this process. And we do know that a safety plan which is also included in your materials, there's a lovely paper in JAMA Psychiatry from 2018 in the summer that showed that a safety plan intervention, which doesn't take very long done in an emergency department, reduces suicidal behaviour in the intervening three months by half. So there are, there are reasons to do this kind of stuff.
Alex Raben: [00:40:35] Speaking of the safety plan, like I find that particularly useful for me in especially in an emerge setting to do with someone not only because, as you say, it's an effective intervention, but also I find you get at a lot of this nuanced information because I will often just even give a quick explanation of the safety plan and hand it to someone, have them fill it out while I do some other paperwork and whatnot. And when I come back, I then have all this rich information onon the page and it starts a conversation.
Dr. Juveria Zaheer: [00:41:06] I agree completely. And it shows you who's important to them. It shows what the triggers are. It shows what kind of thoughts they have. It shows you what their reasons for living are. And I think even in addition to what you said, which is so important, it can also serve as a bit of a diagnostic tool. Right. If someone tells you, you know, how many times have you seen somebody who very sadly engaged in suicidal behaviour and was transferred to psychiatry? And they're saying to you, I have, I don't want to do it, I want to go home. But then you give them a safety plan and they can't really tell you anything and they can't really and they're maybe dismissive of it or they're feeling they have they're in so much pain and suffering that they can't really engage with safety or safe living. And I think that to me is maybe an indication that supporting them through hospitalisation might be something that would get them to a place where they feel safer for sure.
Lucy Chen: [00:41:57] I also want to emphasise a really essential component of the safety assessment is collateral information. And so we touched on it and I was hoping you can elaborate further about this component.
Dr. Juveria Zaheer: [00:42:08] Absolutely. I think collateral is super important because people remember that suicide is a social suicidal ideation. Suicidal behaviour or death by suicide is inherently a social act. Right. And so if somebody is expressing worry about someone, you know, it doesn't necessarily mean that you have to do what they say, but you really want to be able to understand where they're coming from. I think especially if you had a loved one who was having suicidal thoughts and you brought them into hospital, you would definitely want to be contacted. You would definitely want to be able to say your piece because when people are in a cognitively rigid or inflexible place, they might not be able to tell you what you need to know and engaging in collateral also improve safety planning because then people are on board, you know, because of that ambivalence around suicidal ideation or behaviour. And I think a pretty profound fear of hospitalisation, which I don't blame people for. People might not or might not be in the place where they can tell you how they feel or, you know, they haven't. If you don't go through this whole process, you might not know that they're okay now. But when they binge drink, which they're planning on doing later, the suicidal ideation ramps right up.
Dr. Juveria Zaheer: [00:43:19] And so I think, you know, you always want to get collateral if the person is risk as such that the collateral is going to make the difference between staying or going, then absolutely. But also, I always ask everybody if I can talk to a loved one and that safety plan is useful. Right. Because then I can say, can you mention that Joe's a support? Can I give you a call? Our child nonetheless. And colleagues do this so well, right? Thinking about people and systems and engaging systems and providing some psychoeducation even for family members about what do you do if I there's a lovely handout. We have one in the military manual that we wrote of. How do you support someone that you love if they're having suicidal ideation? Like how do you give people the tools? So I think for that reason, collateral is really, really key. And also in terms of people's health care team, like with consent or if the risk is so high that you can sort of circumvent consent, you know, if you're someone's. Treating psychiatrists, you'd probably want to know that they came to an emergency department with suicidal ideation.
Lucy Chen: [00:44:09] Yeah, I just want to emphasize this because oftentimes I've encountered an emerged sort of a patient who minimises all of their symptoms or they say there's nothing going on, you know, you know, my I was told to come in, but I really don't see what the big deal is. And then you sort of get some collateral information from their parent or from a loved one. And there's there's a lot of concern like they've they've witnessed some preparatory behaviour.
Dr. Juveria Zaheer: [00:44:31] And this is so important because without that collateral in your assessment you would right patient like no elevated risks, no intent, no plan low risk for suicide and you know, for the person's life is sort of in the balance here. And we want to respect people's autonomy and dignity, but we also want to give them the very best chance to alleviate their suffering and to get treatment for treatable conditions. And I think it's really, really important. And like medical legally, you know, you hate to say it, but medical legally as this is not why we practice and we should never practice because we want to avoid litigation. But, you know, the optics aren't great, right? If you know somebody is at risk and you don't get collateral, the optics aren't great if they've had a suicidal behaviour and then you discharge them and right. Low risk, no intent, no plan.
Lucy Chen: [00:45:16] For sure. Yeah. Like the labelling of those scenarios would be completely different. One case would be sort of not acutely elevated risk at all. And the other case, there's some cognitive rigidity or there are some like lack of ability to engage and we have some more information about preparatory behaviour which would put them at high acute risk.
Dr. Juveria Zaheer: [00:45:34] Absolutely. And you still may not admit that person to hospital, but you could do a robust risk assessment with recommendations and safety planning and follow up that would give them the very best chance to recover rather than sending them out without anything.
Alex Raben: [00:45:47] You very imagine a scenario where in gathering collateral, if the risk is high enough, you may not get consent for that. Could you talk about that a little bit more, just so it's clear for our listeners?
Dr. Juveria Zaheer: [00:45:59] Absolutely. And we should all work within health care systems where confidentiality is treated with utmost respect and our patient's autonomy and dignity is treated with respect. And also people may come from marginalised communities or have trauma and they may not want us to contact specific people who may be perpetrating violence. And you know, it's also interesting because we talk so clinically about suicide risk, but, you know, to reduce risk for suicide as a society, we need means restriction. As a society, we need safe housing, we need freedom from oppression. All of that to say around confidentiality. We want to support people's dignity and their autonomy. At some point, safety trumps confidentiality. And if I'm for my line as an emergency psychiatrist is if I have somebody on a form or who I think about being able to certify or hold and voluntarily, safety has to trump confidentiality. And so in those cases, I'll say, you know, I need to talk to your loved one. And I always remember you can always get information, right? So you don't necessarily have to give information, but you can collect information if someone tries if someone's trying to contact you. And I think people are pretty, you know, of course, imagine being in that situation, being an emergency department, not wanting your partner or your parents to know. And sometimes I'll frame it with people. It's like, I'm not going to call them right now, but I think they're really important for your safety planning. So maybe we'll sleep on it. We'll talk about it tomorrow.
Alex Raben: [00:47:22] And then you mentioned, um, how we communicate the, our risk assessment is very important and you kind of gave the example of someone communicating it very briefly as in something like no change in risk, say to be discharged. How should we be? I imagine I'm guessing the answer is fulsome, but how do we communicate all of this?
Dr. Juveria Zaheer: [00:47:49] Absolutely. So the first thing I would suggest for learners is to get into a habit of like communicating the suicide risk fulsomely for everybody. And I have we were going to distribute some case summaries that show like a way of documenting suicide risk for someone who has no elevated acute risk. And so if you get into that habit, you can see it's like three lines in your chart, but it's so valuable and so important because it creates a baseline. I would say that you don't have to you don't have to write a novel to do this effectively. I usually have one line that is the historical risk. I have two or three lines that are the current risk and the warning signs, and then I have a collateral piece, and then I will say risk status, risk state. So their risk status, their risk compared to general population, peer matched demographic group, psychiatric outpatients, psychiatric and patients. The inpatient thing is really key because if someone is at super elevated risk in hospital, like if they have a history of suicidal behaviour in hospital, their risk of suicide in hospital is elevated over psychiatric inpatients, which means you're going to need a higher level of observation, right? So and then then align that is their risk state. So their risk compared to themselves. And then I have my safety and treatment plan. So here are the things that I'm going to do to alleviate their risk. And that's actually your treatment plan anyway. Like a lot of there's a lot of overlap. Yeah, yeah. Your, your, your plan is going to be to treat depression and so you're going to write that out anyway. So it's a way of kind of considering it all in one place.
Lucy Chen: [00:49:18] And maybe to help our junior learners maybe conceptualise some of these levels of acute risk. Like I guess what would a low acute risk sort of look like? What would moderate acute risk look like? What would high acute risk look like? Just for our learners to have an approach and to how they can best communicate those scenarios.
Dr. Juveria Zaheer: [00:49:37] It's great. We have in our military manual, we have a table that I adapted from the American Armed Forces Manual that I really like, and I sort of use it myself just so my nomenclature is consistent. The challenge in psychiatry, you know, we want words that mean something. We want them to be reliable, meaning that everybody does the same thing and we want them to be valid, meaning that it measures what we say we're going to measure. My concern around this stuff is I don't think that this is particularly reliable or valid unless we all start doing things the same way. But I think you're going to have to use the wording that we use like as a discipline. So I can give you some examples right now. The other thing I would say is just there's one particular pitfall that I think we all fall into residents, staff, medical students is sometimes we reverse engineer our risk assessment. So if we're admitting someone, we say it's moderate or high, and if we're discharging someone, we say it's low. But I would really strongly encourage you to you know, you can discharge people who are at moderate or high risk for suicide with a safety plan and like targeted treatment. And you can admit people who are at low risk for suicide to manage other symptoms, you don't necessarily have to link the two.
Dr. Juveria Zaheer: [00:50:49] But the way that we define it in the manual and in the materials that you have is not acutely elevated, is no suicide, no recent suicidal ideation and no history of suicide-related behaviour. So that's like many of the patients that we see low acute risk is recent suicidal ideation, but no intent or to act can control impulses have not engaged in preparatory behaviour, no previous attempts, limited risk factors and some protective factors. So you ask how I write out my assessments. Sometimes I'll just use one of these terms and I'll write down the things that pertain to that patient from this list. It's pretty useful and it's fast to moderate. Acute risk is current suicidal ideation with no intent to act and no recent attempt and no preparatory behaviour. They have warning signs or risk factors and limited protective factors. The next one is high. Acute risk is persistent suicidal ideation, strong intent to act, or a well developed plan or feel unable to control the impulse to harm themselves. It also refers to those who've had a recent suicide attempt or who have participated in preparatory behaviour. They may also be in acute state of mental disorder or psychiatric symptoms, psychosis, agitation, intoxication or have precipitating events and inadequate protective factors.
Dr. Juveria Zaheer: [00:51:59] And then we always want to talk about the chronically high, acute risk. So these are people who have a history of multiple suicide attempts, acute stressors, including major depressive episodes, substance use or relationship conflict that can increase their risk or recent hospital discharge. And for those people, you want to use an acute on chronic risk assessment model, which is a little bit beyond the scope of what we're doing today, but not really. Right. They have a high risk compared to the general population, but where is the risk compared to themselves? And again, there are going to be times where you are going to discharge someone with high, acute risk because they've had a suicide, they've engaged in suicidal behaviour, they're feeling really depressed. They were intoxicated at the time. They're committed to staying away from alcohol. They really don't want to be hospitalised. They can engage in safety planning. They have follow up within the next three days and the bridging service. They have family who are willing to stay with them. They don't have any psychosis. You could discharge that person safely and in keeping with their values. No prescription drugs in the house, but you just want to document accordingly.
Lucy Chen: [00:53:04] So thanks for that clarification. I think a lot of the times we're often afraid to make these calls, right? Yeah. And hopefully there's a little bit more context now into getting a sense of what's all the information available to us and how we can communicate that and make sense of that and formulate that effectively.
Dr. Juveria Zaheer: [00:53:21] Yeah, that's exactly right. Like we I think sometimes I worry that when people see these materials, they say, oh my goodness, now we have to do so much more work and it's not going to help anybody and it's not predictive of death. And what's the point of any of it? I hope by listening or by engaging with the material, we can say this is actually not going to make the assessment that much longer. It's really going to help me and my colleagues and my client because we'll be able to track the risk better over time, and it's going to facilitate better safety planning and a shared common language. And I think that would be the goal of this kind of work.
Alex Raben: [00:53:57] Make sense.
Lucy Chen: [00:53:58] And maybe with or for early learners or sort of early trainees, any words of wisdom or advice you can give to them on their first psychiatric rotation or their first day emerge with you?
Dr. Juveria Zaheer: [00:54:07] Yeah, so I really like this question or lucky enough in the camera merge to have all of our U of T psychiatry residents now come through. So I think 36 PGY-1s every year we have a big call pool too. We have a lot of our wonderful senior residents like you guys who do call and who come back. What I would say for your first day of psychiatry is to be kind to yourself. This is a big field and you're in it because you care about people and you're going to learn so much from your clients and you're going to learn so much from your staff, and people are going to learn from you. And to remember that your decisions are supported by your staff. And all you can do is gather the information that you can and do the best job that you can. Try to always triangulate your data, try to get information from more than one source and enjoy the process because it's it's a learning process. And we're really happy to have you in the field and it gets easier.
Lucy Chen: [00:55:04] And we've got some tools for you guys, so you'll feel a little bit more sort of relieved or relaxed about having some type of approach.
Alex Raben: [00:55:11] Yeah, exactly.
Lucy Chen: [00:55:13] Okay. So that's it. We'll see you guys in the emerge. Take care!
Speaker4: [00:55:18] PsychEd is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not meant to be representative of either organisation. This episode is part of our mini series on psychiatric skills, which are intended to provide you residents with content directly related to the trustable professional activities or EPAs in our curriculum. Since EPAs are designed to capture core professional psychiatric competencies, we trust our listeners outside. You will still find them entertaining and educational. This episode was produced and hosted by Alex Raben and Lucy Chen. Our theme song is Working Solutions by All Live Music. A special thanks to Dr. Juveria Zaheer for serving as our expert this episode. You can contact us at Info at Select Podcast or visit us at Podcast Talk. Thank you so much for listening. Catch you next time!