Nice article on risk assessment

A colleague pointed me to a nice article on suicide risk assessment written by David J. Muzina, MD in the September issue of Current Psychiatry Online.   The article is well-written and well-organized.  The stepwise approach described can be quite helpful.  I wish the article included more on documentation (there is only one sample note, and I'm not sure how helpful it is).   The article also pays scant attention to families.  But otherwise this is a really solid general reference on the subject.

Related Posts:

Where’s the Family?

At the crossroads of family therapy and suicide prevention

Presentation to Board of Wynne Center for Family Research


I presented at the Wynne Center for Family Research (WCFR) board meeting today. I presented about our clinical services and about my work in suicide risk assessment, including how it grew out of experiences with suicidal patients in couples and families. The Center board and the faculty of the WCFR were present.


The Board is unbelievable--a real dream team for family systems fans:



Barbara Fiese, Ph.D., Syracuse University
Nadine Kaslow, Ph.D., Emory University
William Pinsof, Ph.D., Northwestern University
Harry Reis, Ph.D., University of Rochester (Liaison)
Frederick S. Wamboldt, M.D., National Jewish Medical Center
Karen Weihs, M.D., University of Arizona

Given the stature and brilliance of this audience, I was both nervous and eager to get their feedback about our clinical service and about the work that has grown out of it. Here are my notes, and some reflections, from the discussion that followed my presentation:


-- One board member shared an experience she had many years ago working with a prominent family therapist as her supervisor. She recounted the following experience:
She worked with the family of an adolescent who had attempted suicide. She wanted to do a suicide risk assessment as part of her session with the family. Her supervisor, at first, discouraged her because it wasn't "systemic." She persisted and ultimately prevailed by offering to do a suicide assessment for each person present (not just the child) and to invite others present to provide input on the others' assessment! The supervisor allowed this as sufficiently systemic.

Reflection: This is a fascinating story that highlights the tension inherent in melding an activity that has traditionally been part of an individualistic medical model with a family systems view of people, their problems, and their strengths. I think few family therapy supervisors nowadays would advise against suicide risk assessment. Suicide risk assessment is taught (with a range of how much) in every family therapy training program. But I'm not sure if we've developed a lot further in terms of the actual how-to. My impression is that most of the time, there continues to be a one-dimensional linear approach to training suicide assessment that implicitly assumes individual therapy and interviewing.


-- Other thoughts:  One key to resolving the potential tension is to think about suicide as residing in a family system. This view goes beyond thinking about family members a "collateral informants", which is how family involvement is often described in the suicide literature. Instead, we need to develop conceptual AND CLINICAL models for assessing risk through the lens of interactions, relationships, roles, and family myths. For example, how does the hopeless that registers in the individual grow out of family roles and interactions...or from a strength-based approach how might shifts in the family give greater hope to the individual experiencing suicidality.  It is not that this is never talked about, it's just that the focus on individual psychopathology and personality often overshadows this dimension--and perhaps more so than with other behaviors we assess and intervene with because the act of suicide is ultimately unilateral and done when alone.


-- One member asked about me "sharing" what I'm working on. This is an important question to me on several levels:




  1. Blog. This blog is one mechanism I'm using to share thoughts and discoveries.

  2. Planned publications. I am on the cusp of conducting an evaluation of my risk assessment workshop and plan to publish the results. I am also working on another publication in which I'm collaborating with two faculty members of the Deaf-Wellness Center.

  3. Career Direction. If what I'm doing turns out to be helpful to clinicians and to families, I want to share it widely. That brings up interesting questions about how I spend my time professionally. Given the range of my interests (in terms of content (peds primary care, suicide) and professional activities (teaching, writing, clinical work), it is hard to know the right direction. A career in research is appealing in ways it hasn't been in the past. This is probably a dilemma many of my readers (especially those in academia) are familiar with. I'll be focusing on discerning this over the next year or so.


-- After I talked about this blog, a board member recommended using it as a way of helping to disseminate science to general audience. I have done this a little (such as here), but could probably do more.


-- A board member suggested that, in light of how heavy it is to focus on suicide (an adverse outcome), it would be advisable for our clinical service to also gather stories and data about positive outcomes of family therapy. This is a perceptive and appreciated comment because prevention of a bad outcome does have a peculiar emotional tone for an individual or group. I named this blog "Commitment to living" in part to cast this work in a positive direction. This comment is a good reminder to do that kind of thing in many ways also at a system level.


All of that in 30 minutes! I appreciated the opportunity to consult with such bright and experienced senior experts in our field.

eMJA: The effect of Web 2.0 on the future of medical practice and education: Darwikinian evolution or folksonomic revolution?

CTL added to PsychNews

Commitment to Living has been added as a news source to PsychNews, a site that aggregates psychology news from a range of sources.   PsychNews has a nice-looking interface and plans to offer RSS syndication soon, which will be good for those who want a breadth of psych news coverage in a single feed.

Related posts:  Commitment to Living featured on PsychSplash

Conversation with Paul Quinnett, Founder/CEO of QPR

I talked yesterday with Paul Quinnett, Ph.D. Founder and CEO of the QPR Institute. He has been working in the field of suicide prevention for decades and has developed an excellent set of tools for clinicians. I enjoyed the conversation because Dr. Quinnett is bright, experienced, and passionate about his work, and also because of the conceptual overlaps I observed through our conversation. Here are a few from my notes:

Technology Transfer. Dr. Quinnett’s interest is technology transfer, i.e. taking what is known from the literature and clinical experience giving it legs for the working clinician and healthcare system. This the primary thrust of my evolving work, as well. I also have an interest finding the most efficient and effective pedagogical method for transferring information.  This is where my interest in mapping and other forms of visual representations comes in (see my previous mapping posts). This topic is also part of what has interested me when I heard Wendi Cross speak (see my post reflecting on Organizational factors that support care of suicidal person).


Family involvement. I’ve posted several times (see Where’s the Family?, and At the crossroads of family therapy and suicide prevention) about the conundrum that family involvement presents for suicide risk assessment: we don’t have good models for talking about suicide with family members present, we don’t have clear ideas about how to incorporate families in the assessment process, AND in many cases it is impossible to imagine performing a worthwhile assessment and management plan without family input.  Dr. Quinnett has been working on this very issue from two interesting perspectives. The first is what he called “the cost of data collection.” That is, he is curious about how clinicians perceive the cost of collecting information from 3rd parties. The second is that he is working on developing a protocol of the key questions and info one should ask/gather from family members to guide clinicians in their interviews. Dr. Quinnett has been working on this with Sergio Perez Barrero, MD, a psychiatrist in Cuba who founded the Suicidology Section of World Psychiatry Association and also the World Suicidology Net.Dr. Perez Barrero is a QPR trainer, who has translated the materials in to Spanish.


Drawing on experience in other fields that do risk assessment.  In a previous post, (Reflecting on Intersections with Knowledge Management, Dave Snowden, and Singapore’s Risk Assessment and Horizon Scanning System), I shared my reactions to Dave Snowden’s work on detecting terrorist threats. Dr. Quinnett was struck in a similar way by Gavin deBecker’s work in threat assessment. I had not heard of deBecker but apparently his California firm, Gavin deBecker and Associates works with high-profile clients (including Hollywood celebrities) to analyzing potential threats to their safety. He has written a book called “The Gift of Fear,” which I plan to read on Dr. Quinnett’s recommendation.

Along similar lines, I have consulted with a forensic psychologist and friend, Daniel Murrie, Ph.D., who co-authored a book (with Mary Alice Conroy) coming out this fall about assessment of risk for violence, “Forensic Assessment of Violence Risk: A Guide for Risk Assessment and Risk Management.” This book, which I’ve seen excerpts of, presents an approach to assessment of risk for violence that is clear and accessible to clinicians and retains the richness and clinical complexity that appropriate to the challenging work of predicting an individual’s risk of being violent. The approach that Conroy and Murrie take has potential applicability for suicide risk assessment, for which we’ve never quite had such a clear model for conducting and writing assessments.

I guess the intersection here relates to seeing potential for developments in threat and violence prediction work to help our efforts to improve detection of suicide risk.

Desire to understand the clinician’s state of mind when faced with risk assessment. I have noted before (see my post on Visual maps and guides in high stress situations) that I’m interested in learning what the cognitive science would be related to how people best access information for decision making in high arousal situations. Similarly, Dr. Quinnett mentioned that he would like to test clinician perceptions about information gathering in risk assessment. What kind of cost/benefit appraisals do they make about asking questions and gathering collateral info?

In my view, the clinician’s state of mind/emotion and cognitive heuristics are underappreciated in most approaches to training about suicide risk. As I noted in my post about clinician anxiety (Clinician anxiety–what’s it about?), what we believe about the most pressing concerns for clinicians will influence what and how we teach. Likewise, understanding how clinicians learn best is important for modes of dissemination (for example, see my post on How clinicians learn: Web 2.0 Opportunities?).

Summary: “Needs Development.” This is another post I’ll tag “needs development” because much of this raises more questions than it answers.   But reflecting on these conceptual intersections helps me to see how much is not known about how to approach training in suicide risk assessment.   Really, there is a “basic science” set of questions about learning and the clinician mind that gets skipped over when we do the necessary and important work of evaluating educational interventions (which, of course, we don’t do enough of either!).

Unintended consequences of antidepressant black box warning?

An article by Charles Nemeroff and colleagues in the Archives of General Psychiatry this month reports reports on the "Impact of Publicity Concerning Pediatric Suicidality Data on Physician Practice Patterns in the United States." (If you don't have access to the journal, you can read a report on the article here.)   The authors show that antidepressant prescription rates for children and adolescents have declined and there has been a shift in proscriber patterns from "generalists" (PCPs) to "specialists" (generally psychiatrists) since the FDA placed a black box warning related to suicide risk.  The warning includes the following statement: "Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders."  You can read the entire warning in a .pdf here).

The study does not study who is not getting medication that might have in the past--just that fewer kids are getting the medicine.  Whether that is ultimately good or bad remains to be seen.

Kelly Posner, who headed the FDA/Columbia Reclassification study, spoke at our Department Grand Rounds last month and lead a seminar with a smaller group of us about the reclassification scheme.  (The reclassification project looked in detail at reported adverse events that started this controversy.)   She clearly thought the consequences of the warning would be mostly negative.   She shared her concern (which has been stated by others as well) that the unintended consequence of the black box warning will be fewer youth treated for depression and more deaths by suicide, as a result.  From what I have read, that remains an empirical question and one that will require careful interpretation of data before inferring causality. What is clear is that the black box warning was probably based more on political and emotional concerns than on science (see also Marshall, Posner, and Greenhill, 2006), and that the risk of untreated depression is probably greater than the risk of adverse events from treatment.

[mounting soapbox]  That said...when this discussion comes up I think it is important to add psychotherapy and counseling to the landscape.  Untreated depression can be deadly, but that doesn't mean the treatment has to be medication.  [coming down off soapbox]

What are the implications for risk assessment?   I'm still trying to understand that.  How I am guiding our clinicians at this point is this:   When conducting a risk assessment of an adolescent or young adult in the first weeks following initiation of antidepressants, we need to note that antidepressants have been recently started.  But rather than name this as a "risk factor" we would do better to note how the medication response will be monitored and indicate the risk-related symptoms that are being targeted by the medication.  That is, connect the medication to the risk factors it is designed to reduce, more than to the risk it might carry.

References




  1. Marshall, R. D., Posner, K., & Greenhill, L. (2006). Risk Perception Research and the Black Box Warning for SSRIs in Children. Journal of the American Academy of Child & Adolescent Psychiatry, 45(7), 765.

  2.  Nemeroff, C.B. et al. (2007. Impact of Publicity Concerning Pediatric Suicidality Data on Physician Practice Patterns in the United States.  Archives of General Psychiatry, 64:466-472.

How clinicians learn: Web 2.0 Opportunities?

A thoughtful colleague of mine observed yesterday that, although there is a range of ways clinicians get clinical information about suicide (articles, workshops, books, practice manuals), a lot of clinical learning takes place informally--by doing the work and by talking with other clinicians. That is probably especially true for the busiest front-line clinicians.

I later reflected about what this could mean in terms of Web 2.0 opportunities to change clinician behavior. First, the narrative, personal feel of blogs might appeal to clinicians in a way that practice manuals and official websites don't.   Second, the conversational opportunities of wiki (Wiki in wikipedia, Using Wiki in Education), RSS feeds, podcasts, and other Web 2.0 venues also have potential to reach people in a fresh way.

Would a front-line clinician who does not regularly read research journals subscribe to a weekly 10 minute podcast conversation between a suicide researcher and a clinician who works with high-risk patients? Maybe. It's mostly an empirical question at this point, but there are several experiments going on in the field, some of which are on my blogroll.