Core principles in treating suicidal patients

James Fowler does it again. He has just published another terrific and useful paper, "Core principles in treating suicidal patients." This makes a terrific companion piece to his previous paper describing "guidelines for imperfect assessments" which I have raved about and recommend all the time. The current paper is elegant and straightforward. Dr. Fowler provides a rationale, evidence, and a treatment example for three core principles:

  • alliance building
  • enhancing curiosity about the function of suicidal thoughts and urge
  • enhancing experience and epxression of intense emotions

Voila! What more do you want? You have to put Dr. Fowler's name on your search engine alert list! I just added it to the reference list that I will distribute at my next Commitment to Living workshop.

Fowler, James Christopher. (2013). Core principles in treating suicidal patients. Psychotherapy, 50(3), 268-272. doi: 10.1037/a0032030

Health Affairs: Dr. Ashley Clayton reflects on care she received as a teenager

If my recent post on Patient and Family Centered Responses to Suicide Risk interested you–or if it didn't–I highly recommend an article by Dr. Ashley Clayton published this month in Health Affairs:  How ‘Person-Centered’ Care Helped Guide Me Toward Recovery From Mental Illness.

Thanks to Dr. Yeates Conwell for pointing me to the article.

NY Times article based on Nock study causing a stir

The New York Times published an article this week that readers of this blog should be aware of. The article is titled, Study Questions Effectiveness of Therapy for Suicidal Teenagers. The article reports on results from a study published in JAMA Psychiatry (the new name for Archives of General Psychiatry) by Matthew Nock and a team of outstanding scientists. The NYT headline is based mostly on the finding that:

...suicidal adolescents typically enter treatment before rather than after the onset of suicidal behaviors. This means that mental health professionals are not simply meeting with adolescents in response to their suicidal thoughts or behaviors, but that adolescents who are clinically severe enough to become suicidal more typically enter treatment before the onset of suicidal behaviors. There is no way to know from the NCS-A data how often this early intervention prevents the occurrence of suicidal behaviors that would otherwise have occurred but were not observed in our data. It is clear, though, that treatment does not always succeed in this way because the adolescents in the NCS-A who received treatment prior to their first attempt went on to make an attempt anyway. This finding is consistent with recent data highlighting the difficulty of reducing suicidal thoughts and behaviors among adolescents.  (Nock et al, (2013) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents, JAMA Psychiatry, ePub ahead of print, p. E9)
The Nock article is hefty and I have not yet fully digested it. So I will withhold judgement about the article's conclusions, and about whether the NYT article reported them fairly and accurately. However, I am pleased about the discussions that this study and the Times article have the potential to stimulate. One conversation is about how to improve the quality and effectiveness of treatment for at-risk adolescents. This is not a new conversation, but continues to be an important one. Another conversation I hope this NYT article will stimulate relates to broadening our view of what suicide prevention is. With some important exceptions (including some here in New York State), the dominant strategy in suicide prevention has been to identify youth who are suicidal and get them into treatment. As my mentor, Peter Wyman has demonstrated (Wyman et al, 2008) and this Nock article brings to the surface, these 'identify and refer' strategies are limited by a number of factors, including availability and acceptability of services, the length of time adolescents remain in services, the effectiveness of therapy, and adolescents' tendency not to disclose suicide concerns to adults (Pisani et al 2012). While I am committed as ever to improving the quality of screening, assessment, and treatment for at-risk adolescents (and help to train hundreds of clinicians each year), I do not expect that treatment services alone will be sufficient for reducing suicide in the population. For this reason, in my research I am pursuing youth suicide prevention strategies aimed at addressing risk and protective processes further "upstream" (a term I learned from Dr. Wyman). In an article soon to be published, I argue that we need new interventions that can flexibly reach a broader population of adolescents further upstream and that these will require making use of new delivery systems, designs, and technologies.
I look forward to studying the Nock article and to participating a discussion that could help stimulate the field to re-examine what "prevention" really means. Substance abuse prevention does not start with finding kids who are already taking drugs. Fire prevention doesn't start with the fire department. We need great fire departments and well-trained fire fighters, but fire protection engineering and public education make major conflagrations rare. Likewise, youth suicide prevention must focus more broadly then on adolescents who are already suicidal.

Pragmatic guidelines for imperfect assessments

I love the title of J. Christopher Fowler's article that was published in the current issue (vol 49, issue 1) of Psychotherapy, "Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments." This practice review is thorough and wise. Fowler strikes just the balance between encouraging completeness and responsibility, and acknowledging the limits inherent in assessments of risk. Dr. Fowler also masterfully weaves in the importance of self-awareness on the part of the clinician, and gives constant attention to maintaining a caring, compassionate stance. Some selected quotations to whet your appetite for this article:

"Knowing that patients frequently deny suicidal thoughts before suicide attempt and death, clinicians should remain appropriately circumspect regarding declarations of safety when a patient recently expressed suicidal ideation, feelings of hopeless, desperation, and/or affective flooding. This does not mean we should adopt a suspicious or adversarial stance—on the contrary, curiosity, concern, and calm acceptance of the patient’s emotional and cognitive states may serve to enhance the therapeu- tic alliance, encourage the patient to directly explore her or his current distress, and aid in the accurate evaluation of current functioning."
"Before conducting a formal suicide assessment, clinicians should conduct an introspective review of recent stressful life events facing the patient, including recent ruptures in the thera- peutic alliance, and disturbances in social relationships (Truscott, Evans, & Knish, 1999). Maintaining a therapeutic stance of curiosity and concern (while simultaneously remaining open to the possibility that an alliance rupture may be a precipitant to the crisis) is difficult to sustain when anxieties are running high; however, communicating genuine curiosity and concern about the causes for their unbearable suffering is critical."
"When clinicians face a potential suicide crisis, they are multi- tasking and are usually in a state of heightened alert and anxiety. Under such stressful circumstances, it is easy to get swept up in personal emotional reactions and lose sight of the patient’s suffering and their efforts to communicate distress."

My only critique involves the absence of family system context. I would have liked to see some attention to the positive role that family members can play in the assessment process. The article does mention that the quality of family relationships is an important modifiable risk factor, which should be considered and may be the focus of clinical intervention. But most of the article, and the clinical approach advocated, has a decidedly individualistic bent. The article doesn't address how to involve friends and family members in the interview process, how to build their participation into the decision-making process, how the relational context influences decisions about how to respond to identified risk. For me this is an important gap, and a contribution that is still needed.

This gap notwithstanding, this article will instantly join the Bryan et al. means restriction article on my Top 10 Most-recommended List. In fact, the Fowler article could become my primary go-to reference when clinicians ask for reading on the subject.

Fowler, J. C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49(1), 81–90. doi:10.1037/a0026148

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.

Clinician response to violation of the "social contract"

I had a stimulating conversation with a senior colleague in the CSPS yesterday. One part of the conversation centered around what happens for us, as clinicians, when the patient does not fulfill his/her end of the "social contract" that is implied when someone goes to a mental health professional. The assumed contract is that the professional gets to ask all kinds of personal questions, make recommendations about intimate details of a person's life, and the patient is expected to accurately, honestly, and completely answer our questions, cooperate with recommendations, and be appreciative in the process.

In a previous post about risk and patient Choice, I offered ideas about how to approach a particular instance of patient patient choice (sometime known as "noncompliance"), including some initial documentation suggestions. But that post didn't address how to handle the emotions that accompany working with a patient who exercises his/her freedom by not answering our questions or by refusing our help.

Clinicians experience a range of emotions in these situations under these circumstances. Helplessness, anger, and fear come to mind first. From a family therapy perspective, this calls for what Murray Bowen (1978) called "differentiation"--the ability to remain engaged, present, and available while not becoming reactive, defensive, or distant. Easier said than done! Especially hard when clinicians often feel a duty to protect patients from harm.

The first step is to name what is going on. "This person is violating the 'social contract' and it is making me angry. I'm also afraid that this person could die while in treatment with me." Next is some cognitive work: "This person did not give up the right to direct his life, keep his privacy, and make choices when he sought professional help." Along with that, your best friend is good old fashion consultation. I plan to post more in the future about how to get consultation from colleagues about suicide risk, but for now, I think the main thing is for us, as clinicians, to explicitly frame the consultation in term of our emotions. "I am afraid and angry because a person I am working with, who has high risk of suicide, is not cooperating with my attempts to assess and intervene." That frames the consultation discussion as being about "how am I going to work with this person given my emotions?," rather than "how can I get this person to do what I want, given how difficult he is."

As always, there is much more to say about this. This discussion of the therapeutic social contract and patient choice is not specific to patients with suicide risk. But it deserves special attention in the context of suicide risk because the stakes are high, the issue is loaded, and medical-legal preoccupations kick in and complicate everything. More to come...

References

Bowen, M. (1978). Family Therapy in Clinical Practice. New York: Aronson Publishers.

Clinician anxiety--what's it about?

When the "S" word comes up, many clinicians feel on edge. I'm sure that more than one factor (and different factors for different people) that contributes to the anxiety, but they are different enough that it affects how we would target training. Here are some possibilities:

  1. Uncomfortable with the pain and despair of another.

  2. Squemish about suicide and it's morbid implications.

  3. Unsure of having the right skills to assess and treat.

  4. Worried about medical-legal implications of losing a patient to suicide.

  5. Concerned that suicidality will "hijack" the treatment.

  6. Incredulous that someone consider destroying him/herself.

  7. Fearful of losing a person the therapist cares about.

  8. Worried about not being able to help.


As I said, the source of anxiety probably varies, but I think it's worth asking which is the most prominent so that we can (a) address it in ourselves and (b) target clinician education at the right set of issues.

Post from AAS/SPRC Workshop-Thoughts about staying therapeutic

I'm in Ohio this week at a "train the trainer" workshop developed by the American Association for Suicidology (AAS) and the Suicide Prevention Resource Center (SPRC). The workshop is called “Assessing and Managing Suicide Risk: Core competencies for mental health professionals.” The training has been excellent so far.

The material focuses a lot on the therapeutic stance and alliance, including some excellent video of a master clinician interviewing a suicidal patient. It reminded me of something I've been emphasizing in the trainings I do: that a good therapist is a good therapist....the skill set is not radically different for the suicidal person. The problem is that many of us have been trained (by formal training or by our anxiety) to go into a some other mode when we encounter a person with suicidal ideation: we throw our best therapeutic skills out the window and become the suicide police. We often deprive people of our best skills because we feel we have to focus on nothing but their immediate safety. It is an unfortunate tendency because in the midst of deperation is when people most need compassion, empathy, and humanity--and a therapist who is as interested as they are in relieving the psychache.

So the challenge in developing and delivering training is to give equal weight to two important messages that are in some tension with one another:

"You must have a knowledge, training, and competencies specific to suicide. You must ask about it, document about it, and pay special attention to it."

and

"Don't get stuck on the suicidality or go into some different interpersonal mode. Compassionately tend to the person, the pain, and the problem, just as you always you."

I think the training today did a good job of striking that balance. I hope my presentations and clinical work do too.