Hi, good morning, everybody. We want to welcome you to today's webinar on Suicide Assessment and Prevention of Early Psychosis by Dr. Tara Needham. I am Judith Doberman. I'm the Program Manager for PetNet at Stanford University School of Medicine. And with us today is Dr. Kate Hardy, who is a Clinical Psychologist and a Clinical Associate Professor in Psychiatry and Behavioral Sciences in the Stanford School of Medicine. And also joining us today is Dr. Steven Adelsheim, who is a Clinical Professor at the Stanford Department of Psychiatry and Behavioral Sciences, the Associate Chair for Community Partnerships, and the Director for the Center, Stanford Center for Youth Mental Health and Well-Being. And both Dr. Hardy and Dr. Adelsheim will be co-facilitating with Dr. Tara Needham your questions for today. Today's webinar is brought to you as a partnership between PetNet and SMI Advisor, which is a SAMHSA-funded initiative implemented by the American Psychiatric Association. And now I'd like to turn this over to Dr. Kate Hardy to introduce Dr. Needham. Thank you. Hello, and good morning or afternoon to everyone, depending on where you're located. So we are delighted to have Tara Needham with us here today to do the presentation. I just want to highlight her impressive bio. So Dr. Needham is an Associate Professor in Psychiatry at the University of California, Davis. She completed her PhD in Clinical Psychology at UCLA. And as the Executive Director of the UC Davis Early Psychosis Programs, ADAPT and SACADAPT clinics, Dr. Needham supervises clinical and training activities and coordinates outreach and educational presentations within Sacramento and across California. She certainly brings a wealth of experience with her as she's developed four early psychosis programs in Northern California based on coordinated specialty care models of early psychosis. And overall, her research focuses on proving clinical and functional outcomes for youth with serious mental illness across four key themes. Elucidating factors that contribute to real-world functioning and clinical outcome across psychiatric disorders, evaluating the impact of interventions on outcomes in psychosis, developing technology-enhanced methods to improve identification and enhancement of treatment, and dissemination of best practices for early psychosis care. And through her research and clinical experience, Dr. Needham has developed expertise in the assessment of suicide risk and implementation of evidence-based practices to address such risk in early psychosis populations. And that much-needed topic is what we're going to be hearing about from Dr. Needham today. Just as a reminder, as you're introducing yourselves, please do make sure you're putting questions in there because we will have time for Q&A at the end of this talk. And I will hand over to Dr. Needham now. Thank you, Tara. All right. Thank you so much, Dr. Hardy, for that lovely introduction. I do want to know my disclosures. I'm a founder and shareholder in Safari Health, which is a mobile health technology company, but I won't be discussing any of that during our presentation today. So I'm so pleased to be here and talk about this really important topic with all of you. It's thrilling to see the number growing to almost 400 attendees. This topic is near and dear to my heart. I think that death from suicide is one of the worst outcomes we can experience in our early psychosis clinics. It's something, one, that we've experienced in our clinic, unfortunately. So I'm very pleased that you all have taken the time to join today and to learn about this important topic. I am so excited to see some of the folks who are signing in. Good morning from Russia. I want to give a shout out to Kentucky. That's where I'm from. And again, thank you all for joining. So today what we're going to do is we're going to talk about how to systematically assess suicide risk. So really how to think about suicide risk and then how to use a fantastic tool, the Columbia Risk Scale. So I'll go through how to use that scale. By the end of this, I hope you have a better sense of at least five risk and protective factors that you will look for. I'm going to give you some tools that you can use to keep those in mind. And then at the end, we're going to talk about the safety planning intervention, SPI, which I think is a fantastic way to manage suicide risk in our populations. Again, as Judith and Dr. Hardy mentioned, please put questions in the chat. There are no silly questions. I want to make sure everybody gets what they need from this presentation today. All right. So I think before we begin, I want to start with this really important caveat. And this was a very powerful conversation for me as I talked with individuals who had lived experience with suicide. So people in this webinar have lived experience. They know someone who's died by suicide. They themselves may have experienced suicidal thoughts or behaviors or have a loved one who has. So as we're having our conversation, our Q&A later, as we're putting things in the chat, I just want to remind everybody to keep in mind that we're going to be honest, we're going to be open, but let's also be aware and respectful. And so one of the most important pieces here is to think about our language. We talk a lot about this in our work, and we try to be very mindful. So here is another place where I want to encourage everyone to be mindful and to hold themselves and their colleagues accountable. So we want to avoid terms like committed suicide or killed themselves. Okay. This really harkens back to criminal and immoral views of suicide, that this is a crime. And for those who have had suicidal thoughts or behaviors or have someone die by suicide, it's perceived as very blaming and stigmatizing. So really we want to think about how folks can use language instead that comes from medical terminology. We say that people died from cancer or they died in a car accident. So let's say died by suicide, or it was a suicide death. I do want to own that as we're going through the CSSRS today, you will see some of the more stigmatizing language. The measure was made a while ago, and this is a newer concept. So if in your administration, you choose to shift that language to died by suicide or considered ending your life using suicide, that's fine. So I wanted to kind of give everyone a prep that they will see some of this language, but for us to commit to trying to shift. Okay, great. So for today, I'm going to structure this in two different sections. I want us to really shift our view of suicide management from a reactive stance to a proactive stance. Most of us were trained to maybe minimally ask about suicide if we did it all, or we only waited for folks to bring it up. And that is a surefire way to miss it. And so what we're going to be learning about today is a more proactive stance, how to integrate suicide risk management into your ongoing practice is something that you do regularly. And a proactive intervention, we're really going to try to shift our thinking here. Because if we can take a more proactive stance, you will see that your need to use a reactive stance when someone is in crisis is going to diminish significantly. So I really want to encourage folks to think about this new proactive stance. So Eric, I see your question here, we're trying to ask, do you want to kill yourself? Should we want to say, do you want to die by suicide? I want to say I'm going to come back to that when we get to the CSSRS questions. So if you feel like I don't address it, then please chat again your question, and I'll be sure to address it. Okay. So let's talk about suicide risk in general. All right. In 2017 alone, 1.4 million U.S. adults attempted suicide. And while we may kind of dismiss that number, it's really important to keep in mind that these attempts themselves can be incredibly serious and can result in permanent damage or disability. I've had clients use power tools to try to hurt themselves that have resulted in significant scarring or other damage. So even an attempt, if it doesn't lead to death, is a really important behavior we want to try to prevent and address. It's also really important to note that between a quarter and a third of individuals will make a second suicide attempt in the 10 years following the first attempt with the greatest risk in that two years, that first two years. So for those of us who work in early psychosis care, sometimes it's the suicide attempt that leads the individual to the hospital, which then allows us to identify that they have psychosis or that psychosis may be driving this behavior. And so if your program then starts right after that hospitalization, then that two years that you're serving that client is the highest risk period for a second attempt. So again, just trying to illustrate that for us, this is a really important issue. And someone in the chat made the point that suicide attempts and risks have gone up during the pandemic, and that's exactly right. We have seen a significant increase in ideation and attempts during the pandemic period for both adults and children. Okay, so in general, in mental health populations, we know that serious mental illness is associated with elevated suicide risk. And for all of these disorders, death by suicide can range from 8% to 15%. So that's a very high rate, almost one in 10 individuals who attempt to die by suicide. It's the 10th leading cause of death in the U.S. And again, in 2017, there was one death every 11 minutes. For younger individuals, for teens and young adults, it's the second leading cause of death. And again, these are premature and preventable deaths. So this is an area where we can intervene and have a powerful impact. If we focus on schizophrenia, just specifically schizophrenia, between a quarter and a half of individuals with schizophrenia attempt suicide. Many individuals make repeated attempts, as I've discussed before, and 5% will die by suicide. Highest risk is in that first year of illness, but the risk is ongoing. This is also the case in individuals who are at clinical high risk. So when we look just at reporting suicide ideation, between a third and almost 90% report ideation. It's such a common thought for these youth who are experiencing these attenuated symptoms of psychosis. And 70% or more of individuals with first episode psychosis report suicide ideation. So we're going to talk today about ideation versus behavior. So ideation, these thoughts are very common in first episode and clinical high risk populations. And then the behavior is also, attempt behavior is also fairly common. So these are both things that we want to keep in mind. And I want to encourage you to think about these two things separately, ideation and behavior. So Amy has asked, attenuated me, referring to psychosis. So this is the clinical high risk period. So these are individuals who are showing sub-threshold symptoms of psychosis and indicate that they are at higher clinical risk for going on to develop a full psychotic disorder. So instead of at full psychosis, they hear voices or have paranoia, believe it 100%, it affects their behavior and their functioning. Individuals with attenuated symptoms may have whispers or laughter, hear noises, be unsure of the cause, question it, but may check. And it's upsetting because it's unusual. So there is some distress, but it's not as significant as full psychosis. Same thing with the delusional thoughts, they may question maybe whether someone's watching them, you may see some social withdrawal because of it. And so these are what we call the attenuated symptoms of psychosis. Perhaps this is another webinar that SMI advisor would like to host. So hopefully, Amy, I answered your question. There's a lot of data showing that early intervention in these clinical high risk populations prevents or could prevent the development of the full-blown disorder. All right. So here, I want to come back to suicide and schizophrenia. We do know that longer DUP, so that's that time between the onset of psychotic symptoms and someone being appropriately identified with psychosis and appropriately treated, that period, the duration of untreated psychosis, the longer that gets, the higher their risk for suicide. And I've certainly seen that in my clinic. I've seen youth who when their psychosis started, there was distress, there was various behavioral manifestations of that distress. Family started seeing that something was wrong, but there wasn't an adequate clinical response. Maybe they didn't get treatment. The family didn't understand what was happening. And so they continue to be psychotic in the community for longer and longer. And then the youth escalates. They begin self-harm behaviors. They voice suicidal ideation. They voice ideas to hurt others. It escalates. Their distress is growing, and it leads towards suicide. All right. So really, in our work as individuals who serve these folks, as we're trying to get out into our communities, identify folks early, intervene early, we need to focus on suicide to reduce the rates of attempts as well as death by suicide. Okay. So as all of us likely know on this webinar, for those of us who are clinicians, clinicians in training, this is hard. I'm just impressed upon you how important it is. And it's really hard. So I want to make sure I validate everyone's feelings of challenge around this topic, because there are so many different risk factors. There's biological, psychological, familial, environmental, cultural. We're going to go through all of them. So it can be really challenging to know which key factors you need to assess. Additionally, risk thoughts aren't always predictive of behavior. People can have thoughts and never move on to preparatory behavior or any sort of attempt. And so again, that's why I want you to think about these two things separately so we can assess them separately and monitor them separately. Okay. And while most people who make attempts or die by suicide, they have discussed their suicidal thoughts at some point. Most don't tell anyone before they act. So this is the reason why that reactive stance, that idea that somebody's going to say something before they make an attempt is erroneous. Because people may voice their ideation. They may voice their plans, their motivations. But oftentimes right before they act, they don't tell anyone. So you have to monitor that ideation. You have to know how to consider that in this context and remember that most attempts are impulsive. And so that's why the SPI will be very helpful in giving folks an alternative during those dysregulated, highly impulsive moments of what they can choose instead of suicide. All right. So we're shifting now into these risk factors and thinking about risk factors. And again, at the onset of this presentation, I set out that we hope by the end you can identify at least five of these. So we're going to go through both risk and protective factors because we want to think about this as the overall picture for the individual. Do they have protective factors that balance out their risk factors? A lot of these that we will identify in terms of risk factors are actually modifiable. They can be targets for your intervention. So that's another important piece. We're going to talk about acute risk factors and warning signs. And we're going to try to think about those separately from more chronic ongoing distal risk factors. The goal here, again, is to guide your treatment decisions and your treatment planning. We're going to think about this, about risk is not something that's static. We're going to think about it as something that changes over time. Again, this is that proactive view. This is something I'm going to monitor over time. Okay. As we go through the different tools I'm going to give you today, I want you to always remember that these do not replace your clinical decision making. They enhance your clinical decision making. I cannot tell you how many times in my clinic, my clinicians have been using these proactive tools, the SPI, the CSSRS, and on the page, the client doesn't seem to be at increasing risk, but the clinician is saying, I'm getting that feeling that something is at risk. And that is valuable because you know your clients. And sometimes you can't put your finger on exactly what that is in the moment, but in the end, it usually ends up being right. So I really want to make sure everyone continues to listen to that voice inside their heart that says something is going on with this client. Okay. So let's start thinking about these different groups of risk factors. So here we're going to start in these distal risk factors. So these are things that are longstanding lifetime characteristics, often from someone's background, that we know in the long term can be associated with elevated risk for suicide. Okay. So I've got some examples, you know, demographics, like being male, you know, having a suicide attempt 10 years ago, and a family history of suicide. These are some of the common ones that people tend to think about. So some other ones are listed on the right side of the slide. Impulsivity is a big one. Emotion dysregulation is another, you know, folks who are very reactive, they get upset very quickly and have a hard time regulating, in particular, their negative affect. Cognitive inflexibility and poor decision making. There's actually neuroimaging data that shows the difficulty activating the prefrontal cortex as part of kind of guided attention and decision making is associated with increased suicide risk. And as a clinician, that makes sense. You know, in the moment, you're having a hard time making a decision and thinking flexibly. Okay. I'm going to come back to Paige's question in one second. So head injury, again, that's often impacting cognitive functioning. There's very interesting genetic data looking at stress sensitivity and serotonin functioning, premorbid social adjustment, early abuse and trauma is a very important risk factor, prior suicide attempts, substance use and treatment difficulties. So these are some of those, again, background distal factors. So to Paige's question, why are males more at risk of suicide than females? You know, actually, we see that ideation and attempt is more common in females. It's just men tend to use more lethal means. So more males die by suicide. So there's a difference there that is a pretty consistent pattern, even in schizophrenia. And so why more females, why, you know, men choose, again, to tend to use guns or other things like that. Females tend to use pills or other things where oftentimes someone can intervene. So hopefully, um, I can, I answered that question. Yes. Early loss of a loved one. So death of a parent. Yeah, that's, that's what early loss means. Okay. So now let's, let's think about proximal. So these are more recent factors, clients coming into your office, you're going to do your assessment, you're going to kind of get this idea of what's happening in their background and their past. You're going to start thinking about what's happened more recently, maybe what's bringing them into care, what led them to go to the hospital. That's, that's your more proximal or acute risk factors. Okay. And these are important because they are related to increasing risk. So again, if we think about suicide as something, something, suicide ideation behavior, something that increases and decreases over time, you know, prox, I'm sorry, distal factors can increase your just baseline level. Like you had, um, you know, a family history of death by suicide and then your male. Okay. So your, your baseline is already higher. And now, okay. What are the more proximal factors that are going on? Oh, so there's been a suicide attempt the past three months. They're currently depressed, but you know, their depression could remit and that will take their more proximal factors down. Similar things again, as I mentioned at the beginning, an acute psychotic episode and acute medical illness. Um, that is really important. We see folks who struggle with chronic medical illnesses or significant medical illnesses, higher risk for suicide. They're a stressful life event, loss of a job, death of a loved one, um, a divorce or loss of a significant, you know, partner. Those are very important. Um, now we've got folks who are, you know, losing their homes, any of those stressful life events. I want to also remind people that stressful life events can be positive. Um, getting married, having a baby. Um, those are also really stressful. Um, so just to keep in mind that stressful life events aren't always negative. They can also be positive going off to college. That's another really good one. Poor social support and family conflict. So one of the protective factors we'll see in a second is social support. Um, having your tribe that you can turn to, um, when, when you're struggling, when those stressful life events happen, when you're struggling with depression, um, that's a protective factor. So having the loss of social support or having family conflict is an important risk factor we wanna keep in mind. So acute substance use, this impairs folks' cognition, increases impulsivity, decreases emotion regulation. So some of those distal risk factors, substance use impacts those. So we wanna keep in mind that how substance use can affect things. And then in red, access to lethal means. So we really need to ask our clients if they have access in particular to guns and whether the guns are kept locked up or whether they can remove them from the household. That is really important. Many folks feel uncomfortable asking and counseling people about guns in their home if that it feels like an uncomfortable conversation or if you feel like your own views about gun ownership could impact that conversation. I really encourage you to look to some of the information in particular that has been put out by the Gun Violence Center at UC Davis. And I'm happy to share that with Dr. Hardy and Dr. Adelsheim as well about how to counsel people because really we just want them to be locked up and we want them, if they're having increased risk factors, we want them to feel comfortable giving their guns to somebody else for that time when they're in distress. We're not saying get rid of guns, we're just saying we want people to be safe with guns. So these are some of the more proximal factors. Let's see. So Rodrigo asks, so head injury is a risk factor because it could affect their cognitive flexibility. Yes, so head injury is a risk factor because it impacts folks' cognitive ability. It impacts their ability to problem solve. Thank you, Dr. Adelsheim. So their ability to problem solve, folks can become more impulsive and dysregulated. It's just that cognitive factor of people being able to kind of think through their thoughts and manage their emotions. Access to means can include sharp objects and medications. I think you're gonna know that because perhaps they've either identified that those are the plans that they've considered or they're gonna have a previous attempt by those demands, by those means, or they have non-suicidal self-injurious behavior using sharp objects. Then yes, those would be considered access to means. But oftentimes that might not be what we know at the beginning. That might be something we learn over time or through our assessment. So Caitlin, you're right. We wanna have a broad view of what access to means means. I think here, I just really want to emphasize that death tends to come from guns. And so we wanna make sure we have that safety conversation about firearms at this point. Okay, all right. All right, warning signs. What are the things that are happening right now for a certain person? These are really related to the individual and their history and their coping skills and their symptoms that show you, oh boy, we're headed for the spike. We are now seeing warning signs that this person is at much higher risk for suicide. So some examples here could be increasing ideation or severity of ideation that is similar to what happened before a previous suicide attempt. An increase in substance use, that idea of a recent loss or interpersonal conflict that you know was really important to that person. So I'll give you an example for our clinic. We had a client where there was a breakup with their partner and that was their most important social relationship. And then this person started no showing for appointments, became more socially withdrawn and kind of stopped communicating with everyone. Now that's not an example of escalating outward ideation, but we knew from this client's history that that was the behavior, this isolation and refusal to engage in treatment was this person's warning sign for a suicide attempt. And because that is what had happened before. So this is where you need to know the client and you need to know what their warning signs are that things are escalating. Okay, so some of these things can be alcohol and drugs, increased reckless behavior, isolation, changes in sleep appetite or energy level, preparatory behaviors, visiting or calling people to say goodbye or giving things away, agitation or aggression, reporting discomfort due to their symptoms or due to medication side effects. Things like akathisia, restlessness associated with medications is a very high risk factor for suicide. Things that they may say, hopelessness being very important and then moods that they may show. And so Sian has asked, can we really prevent someone from dying by suicide even if we remove the means? No, they can find other means. And what we know is that the lethality of a suicide attempt by a firearm is much higher. You're more likely to get a death. So that's why we focus on that. Folks will try other things and that's important. That's really important. All right, other considerations. So here we're back to the gender. More males than females die by suicide. Females with psychosis are at higher risk than the general population or other risk groups. So we will have more ideation in females, more attempts in females, but again, males will use more lethal means. We want to pay very close attention to our sexual minority youth, our LGBTQ identifying youth. They are at much higher risk for suicide than their non-minority youth. And for clinicians, what can be particularly challenging here is that you may know that the youth identifies as a sexual minority youth and the parents may not. And so that may be an issue that you're managing in your clinical practice with them. But to keep that in mind that that's a high risk group, we see higher risk in non-Hispanic, Native American, Alaskan Native, as well as non-Hispanic, white or Caucasian groups. So higher rates of suicide in our Native American, American Indian, Alaska Native and our Caucasian populations than other groups. So a suicide attempt is an attempt to seek help. It can be seen that way, and it can be seen as a way to end the pain that one is experiencing. So let's see, certain occupations are associated with higher risk, veterans in the military, definitely construction, the arts, so art, design, entertainment, the food industry has a very high rate of suicide. As well as sports and media. And I think we've seen actually some sad examples of this as individuals have died by suicide that we have seen in media. Any theories as to why American Indian, American Native white populations are at higher risk? I can speculate. Suicide, if we know that familial suicide is an increased risk factor, so there's high rates of suicide in American Indian, Native American populations. And so you already have that higher risk factor in that population. I think we also see in white, yes, they tend to have a family friend or peer who's died or attempted suicide. So it just tends to be more common, which increases everyone's risk in that population. In Caucasian white populations, we tend to see this sense of individualism. And I need to deal with this on my own compared to the more familial approach to help that you may see in other racial or ethnic groups where the family sort of rallies around the person. And there's this sense to step up. Again, just kind of putting this out there. Let's see. Okay. I'm having now a hard time keeping up with the questions. I'll come back to them at the end. I did see that there was a surprise response for food. And here in Sacramento, there's actually been a big group of individuals who've reached out to the food industry and are trying to create sort of a support group around the food industry because there have been so many deaths by suicide within that industry. So definitely a high risk group. Unemployment and lack of meaningful regular activities associated with higher risk. This has been a huge one right now during COVID. People losing their jobs, losing their ability to connect with people like team sports or going to yoga class, or all of these different things, having a job, going to school have been incredibly impactful for people. And so is a contributing factor to increased rates of suicide that we're seeing right now. Single individuals more often die by suicide more than those in relationships. Again, that's that social support factor. That's a protective factor. Feeling like you're not alone. And some important contributing distal factors are poor social functioning and a lack of social support. So if you have somebody come into your clinic, they've struggled always to have friends and to keep friends or to have relationships, this is a risk factor if they're struggling with suicidal ideation. We don't want to discount psychosis symptoms here as something separate. When individuals are bothered by their psychosis, when it's intolerable, I had a young woman who we managed the other week whose the voices were just more than she could bear. And we were monitoring her on a 24-hour basis because we knew that that was a very high risk for suicide. We also want to make sure that psychotic symptoms that are compelling them to act, we consider those. Command hallucinations, thought insertion, delusions that they need to die to protect their family, those are suicide thoughts. And we need to consider them as that and not just psychotic symptoms. And I'll come back to that on the CSSRS. Our highest risk period to monitor folks is three to six months post-hospitalization. And this is most important if they don't go home. So if they end up going into some sort of step-down care or other residential care, that is a very high risk change. So I've highlighted a few of these, potential protective factors, such as feeling connected with others, that's social support. We talked about problem-solving skills, that supportive social environment. We've also talked about the limited access to lethal means. Having access to mental health treatment and a positive attitude towards mental health treatment is very important. So when you're doing your intake or your initial assessment, taking that time to ask about how people's experiences have been with prior mental health is very, very important, particularly if they were involuntarily hospitalized. That can be a very traumatic experience for folks. And so we want to make sure, again, we have that understanding of what their experiences have been so that we can engage them more positively in the treatment that they're getting now to manage their symptoms and their suicide behavior. All right, so one of the things we're gonna send out, I believe Judith said we'll send these out to you via email. After the presentation, I have a bunch of resources that we'll send to you all. One of them is the safety. And I encourage all of my staff to print this out and put it on their desk. So it's like something they can see. You can do this at home if you're working via Zoom. So you'll see here, it talks about a multi-stage assessment process, okay? You're gonna identify those risk factors, protective factors, and then you're gonna do your suicide inquiry, which is the CSSRS. You're gonna determine your risk level and intervention, and then you're gonna document it, okay? So here on the back is this nice little cheat sheet about risk factors, protective factors, the suicide inquiry, and then this really nice little table that helps you think about where they are, what their level of ideation is, and then what you might consider doing, okay? Then down here at the bottom, it's gonna remind you all of the pieces to document. So we'll send this out so that everybody has it. Okay, so now we are going to pivot to assessing that suicide inquiry, okay? So this is the CSSRS. So when we think about suicide assessment, one of the things that I have been continuously struck by as I work in this area is the lack of conceptual clarity about suicide behaviors. And really, we don't have good words. And so today, if you walk away with good words and clear definitions, I am so proud that I have done a good job. You know, some behaviors can be called a variety of things, a threat, a gesture, and oftentimes we add in language that makes it pejorative and is based on incorrect notions about the seriousness of the behavior. Manipulative, non-serious, passive. My staff are not allowed to use the term passive suicidal ideation. I'm sure right now, if I asked you all to put in the chat what your definition of passive suicidal ideation is, I would get a hundred different answers. Example of how we don't have clear terms to communicate with each other. So today, I'm gonna give you those clear terms. And I really encourage you to use these in your clinical practice and train your trainees to use them. So I love the CSSRS. It's the gold standard for assessing suicidal thought and behavior in adolescents and young adults. So really, this is designed for younger populations, but you can use it for all ages. It includes items that are associated with suicide risk. If you do a clinical trial, the FDA requires it. I wanna be clear that this is not designed to assess risk factors, protective factors in detail, supports, or how to respond. Remember, on the safety, this is just one box. That's suicide inquiry. All right, what information can you use? You can use everything. Anything that informs your clinical judgment and allows you to make a meaningful response. And I encourage you to speak to collaterals, to the client, to get records, the spouse. Really, we want to use everything. And this is important because we've seen that clients may avoid talking about a prior event, especially if they've had a prior attempt, or they might not remember. We've seen that too. Really, go beyond just the client to get information. So we're gonna now go through the CSSRS. This is going to, again, be sent to you, and you'll have a copy that you can use going forward. Okay, so it's going to ask you about timeframes. And the one that we're gonna send you is the lifetime or a baseline. You can use a similar version to ask over follow-up. So you're gonna ask about, when you ask about ideation and the intensity of ideation, you're going to talk about when they were feeling the most suicidal ever. Do not try to average it. So the questions are things like the time in your life when you were feeling the most suicidal. Did you wish you were dead? Have thoughts of actually killing yourself, et cetera. So again, here's some of that language we're trying to avoid so you could say, have thoughts of dying by suicide. So you're gonna really focus on that most time. When we talk about behavior, you're gonna capture everything, the total number of attempts. And these may or may not have accompanying ideation. Okay, Steve, I saw your question from anonymous. Could we hold that to the end? I also see, is the safety protocol with the CSSRS as effective as the CSSRS? So the CSSRS is only one component of your overall suicide inquiry. You can do the CSSRS, but the expectation is that you've also assessed risk and protective factors as well as develop the plan. So this is just one part of that inquiry. All right, so you need to do it all. Sorry, and you're welcome. So as we go through ideation, okay, and these are the terms. There's five levels of ideation. As we go through them, these are the words I use. So I don't say, this is often wish to die is what people call passive suicide ideation, but sometimes that's not it. They might have thoughts, but not a plan to act. Please, again, stop using that word or that term. So I say wish to die. Client endorses wish to die. Have you wished you were dead or wished you could go to sleep and not wake up? Lots of people are gonna endorse this because it's common and that's okay. It's meant as a warmup question. The next one is active thoughts of killing oneself. Have you actually had thoughts of killing yourself? So now we're getting into more concrete ideation. So the way the CSSRS, I'm gonna show you in one second, is set up, is if you get a no to both of these, you are finished with ideation. If you get a yes to either one, you continue with the ideation section and then the intensity section, okay? So let's look at what the CSSRS looks like. So this is the top of the first page. So baseline, ask about lifetime. And we also ask about past month. I divided it up this way for my staff to be able to take notes and then check off whether the criteria were met. So wish to be dead. Subject endorses thoughts about a wish to be dead or not alive or a wish to fall asleep and not wake up. Here's the question. I added here ever and in the past month and then a space for you to write. Same thing, nonspecific, active, suicidal thoughts. General, nonspecific thoughts without thoughts of the ways, like the plan, the method, the intent of the plan. So you would describe that here and here. So as you go through, remember what you're trying to do in this assessment is to say, does what this person told me match the definition up here? I'm gonna write that down. And then if it matches the definition, I will say yes or no, okay? And I want you, as you fill this out, and this is the scary thought that we all have, is that a lawyer psychologist is gonna come behind you and look at your notes and look at your assessments and determine whether you were culpable in the death of a patient. So this is how I approach this assessment. So you take notes, you write down in quotes what they said, and you make a determination. Anything that's blank means you didn't ask it. So you always wanna say, client denied, client denied, not reported. And then here's a little bit of if yes, or to one or two, continue. If no, go to behavior. You never skip behavior. Okay, let's keep going. Rufina, I might have to come back to your question just for the sake of time. Then we're gonna go on to the next three. You've got associated thoughts and methods, some intent, and plan and intent. And so you'll see that these are numbered one, two, three, four, five. And that's because these are increasing levels of risk. Okay, so Christine, if they report ideation, you come down to plan or associated thoughts and methods. You just keep going. I wanna remind you all again that suicidal content of psychotic symptoms count as ideation. So if the thoughts say, take your car and drive it off a bridge, and they feel committed, like they need to respond to the voices, that's your intent. Because they may not endorse thoughts or wishes to die, but they're saying, I have to respond to the voices or they're gonna hurt my family. There's your intent. They have a plan. You're at a five. So Christine, you can check yes or no. I would just keep going. I wouldn't get too hung up on that. You could write in the lifetime or the current that they endorse thoughts and plans, see below. That's what I would do. Okay, so here's the bottom part of the page. Active suicidal ideation with any method without intent to act. Thought of at least one method during the assessment period. This is different than a specific plan, place or method details. I thought about taking an overdose, but never made a plan as to when or where, and I would never go through with it. We get a lot of these. I thought about walking out in front of a bus, but I don't think I would go through with it. I thought about drowning myself in the tub, but I wouldn't do it. That's active ideation. They have a thought about what they might do. Now with a four, you have some intent to act. Okay, they have a plan and some intent to act. And so this, I wanna encourage people to be thoughtful of you're asking about now, but also you wanna ask about in the moment when you had that thought. How much did you wanna act? And I like to give them a zero to 10 scale from I would never act to like a 10 would be you acted. So a nine, meaning that, and usually something stopped them. Then active ideation with intent and plan. So these are the different questions, okay? And you go through and you rate them for lifetime and past month. All right, then you go to the intensity of ideation. Where you ask about, again, you're gonna focus on the most of your thoughts. You're gonna ask about frequency, duration. Are they easy to control or not? Were there any deterrence and why? Was it to stop the pain or make someone angry? This is where you're trying to get at something other than death. Like they're doing it for, so my mom would pay attention to me. I wanted to get help. And really stopping the pain is a higher risk factor for actual death by suicide. Okay, so all of these are predictive of death by suicide. For me in my clinic, when I am asking my staff or when I am documenting suicidal ideation, I use those definitions. I use the terms that are here. Client reported for lifetime. Client reported active suicidal ideation with any methods, no plan without intent to act. In March of 2018, client reported whatever their thoughts were, right? Client denied for past month. I am very specific to each of these levels in my documentation and in my communication with my colleagues. Okay, so I'm giving you guys those words that we can all use together to mean the same thing. When I'm making decisions, I'm really looking at the intensity of ideation when the thoughts are more frequent, longer, less controllable, fewer deterrents, and stopping the pain is the reason, that is when we want to pay attention. So I really look at the scores of four and five as points of intervention. So if there is no passive suicidal ideation, does it mean all suicide? No, it does not mean that. You see that here, again, active, active, active, and then you had non-specific active and wish to be dead. So again, don't worry about passive and active, just use these words because they are much more clear about what you are trying to assess for the client. All right. Okay, so now we've talked about ideation. Now we're switching to behavior. Again, we think about these two things separately, right? Suicide behavior is a self-injurious act committed with at least some intent to die as a result of the act, okay? There does not actually have to be any injury or harm, just the potential for injury or harm. So if the gun fails to fire, the rope breaks, doesn't matter, okay? This is really important where you have kids. If you work with kids, they will try to die by smothering themselves with a pillow, by drowning themselves in a bathtub. And so you may be like, and this is where you start to see things like non-lethal. That's not the point, folks. They have an intent to die as a result of an act. So to keep that in mind, because if someone did or something should happen and they stayed in the bathtub, they could die. So just keep these things in mind. Any non-zero intent to die counts. People often have mixed feelings when they attempt suicide. They are ambivalent. It doesn't have to be 100%, but it has to be more than zero. So I will ask people on a scale from 0% you didn't wanna die to 100% you wanted to die, where did you fall? And I have seriously had people say to me 0.001%. That's enough. There was some little piece of them that thought they could die or wanted to die by that act. So that counts. And that can be hard, but it counts. Intent to die and behavior must be linked. So this is where we separate out non-suicidal self-injurious behavior, or NSSIB, S-S-I-B, where folks want to hurt themselves for other reasons, okay? And we'll come back to that in one second. Intent can sometimes be inferred from the behavior of the circumstances. They might deny intent, but they thought the act could be lethal. Intent could be inferred. Well, I thought I might die, but I didn't wanna die when I jumped off the bridge or when I took 10 pills. Also clinically impressive circumstances, any highly lethal act where no other intent can be inferred, gunshot to the head, jumping from a bridge, setting yourself on fire. Those are things where that's the clear outcome. So stopping the pain can be physical pain, emotional pain, doesn't matter. Suicide behavior, an attempt begins with the first act, the first pill to take, this first scratch with the knife. If they stop, they take one pill, they have a handful, they stop after taking one, that's an aborted attempt. If someone comes in and is like, what are you doing? That's an interrupted attempt, but it starts with that first act, okay? Well, you'll see in the CSSRS, it will ask, have you made a suicide attempt? Have you done anything to harm yourself? Have you done anything dangerous where you could have died? Always ask the extra questions here because clients might not consider something a suicide attempt. So I'll give you an example from an intake yesterday. We had a client denied all ideation and we got to behavior and no, never made a suicide attempt. Nope, haven't done anything to harm myself. Have you done anything dangerous? Well, my car accident might count. Well, tell me more about your car accident. Well, the voices told me that I needed to drive my car into the center of the road and crash it or else they wouldn't hurt my family. Right, there's your ideation, but see, they didn't see it as their own. So there's your ideation and there's your attempt. And he did crash his car and it was really a bad accident. So just remember that people might not think of things as suicide attempts and these questions are designed to elicit those other options. So now let's think about non-suicidal self-injurious behavior. So this is behavior that's 100% for other reasons, to feel better, relieve pain or external circumstances, get attention. But even if in that moment, a small percent of the self wishes to die, then it would be an attempt. So you will often see people who have both NSSIB as well as suicide attempts, it's very common. So, okay. I also really, in terms of language, want to encourage people to start using non-suicidal self-injurious behavior in your terminology, instead of cutting, burning, self-mutilation. Non-suicidal self-injurious behavior is a much less stigmatizing term. And we abbreviate it NSSIB. Always ask follow-up why questions in the actual attempt section. Don't just infer, ask them why they did what they did. You're gonna have multiple suicide events sometimes that you have to assess. I really encourage you to keep them organized via dates or numbers. And again, they may have both NSSIB and suicide behavior. So here's what it looks like. Here's the actual attempt, the top of the behavior question. It reminds you, intent does not have to be 100%. Doesn't have to be in the injury in heart. Here are your three key questions. Have you ever made an attempt, done anything to hurt yourself, anything dangerous? What did you do? Here's some of your really nice follow-up questions. Did you crash your car as a way to end your life? Did you wanna die even a little when you crashed your car? Were you trying to end your life when you crashed your car? Did you think it was possible you could have died? This helps you to infer intent. Or did you do it for other reasons? And that helps you to get at the non-suicidal self-injurious behavior. So here's your place to capture that. So Patricia, self-mutilation can also be attempts, but yes, you are right, but you need to have the intent to die. So you can still have somebody cutting on their neck or over their arteries with zero intent to die. So just to keep that in mind as you're trying to separate those two pieces out. Okay. Although if they made a huge gash and no other thing could be inferred but they had intent to die, then you would kind of label it under that. So you're gonna get three types of attempts, an actual attempt where they acted with at least some intent to die, an interrupted where they haven't acted yet, or an aborted attempt where they stopped themselves. And then you have preparatory behavior. You are always gonna query ideation and behavior separately because you will have people who deny ideation but do report behavior. So here's an example, person denies ideation. And then I once impulsively tried to hang myself. So you always go on to behavior. For Brandon, you can give examples for how people may hurt themselves. I think that's totally fine. I'm just saying in our conversations with each other, we should use less stigmatizing terms as well as in our documentation. So two other pieces that I wanna give you all. Folks often ask me if there's good options for some self-reports that people can use in the waiting room as a screener before they come in and do something more significant like the CSSRS as a way to just get a little bit of information. I really like the suicide behavior questionnaire, super short and is a really nice screener, goes down to age 13. I also like the ASQ. This was designed for primary care and other healthcare settings. So it's another really simple, short one that you can use, goes down to age 10. These will also be sent to you in the email that you guys get today, so you can have those. Now we're gonna pivot to intervention. I wanna give a shout out to Yael Holschutz from, she was with OnTrack, wonderful psychiatrist who worked with me to develop this other piece. She's worked with Barbara Stanley on the SPI. And so this is a collaborative piece of work. So we have proactive and reactive. So you're always gonna use the SPI. So here you're gonna do your risk assessment as a standard part of care. I really encourage people to do this at intake as a screener, and then regularly, we do it every six months. And that really helps to reduce the stigma around it. We ask this of everybody and you're gonna be asked it again. And our clients get really used to it. They don't get upset when it's couched in this very regular way. And then we always use it when someone reports increased risk. My staff know to always administer the CSSRS and to use that when they're consulting with me. So there's a number of evidence-based risk reduction strategies. We've talked about means restriction, problem solving and coping skills, social support, emotional context, and even motivational enhancement has been really good. If you feel like you have a population where you're seeing a lot of suicide behaviors or risk behaviors, there's a number of different interventions for suicide that you can use. I will be honest that majority of these have not been tested in populations with psychosis. Our folks are often excluded from clinical trials, which is really unfortunate. But we have integrated a lot of DBT skills into our clinic to help with risk management. All right, so the SPI is really simple. It's a very simple one-page document that you use when you see that a suicidal crisis is emerging. Again, remembering that risk fluctuates over time and you're trying to give them a tool that they can use to manage their feelings and stay safe when something happens. Because more often than not, you're not gonna be there when the thoughts happen. So because most attempts are impulsive, we want them to have a tool. You complete this with the clinician and really you can do it in 15 to 20 minutes. We often do these at intakes and then we update them regularly and keep them in the client charts where everyone can see it. The theory here is that, again, when we're in distress, problem-solving capacity goes down. So we wanna have something that's simple and that's over-practiced that folks can implement in a crisis. So an analogy is stop, drop, and roll for fire safety. That's all been ingrained in us since like kindergarten. It's the same idea. You guys collaborate. And you'll see here that there is a stepwise increase in the level of intervention. It starts with in-self and then builds to emergency room. However, the individual can always skip steps depending on their level of distress. And sometimes my staff likes to link SUDS ratings or subjective units of distress to these different levels. I think it can be really, really helpful. So here, one-pager, here you go. You say who helped complete it? Triggers and stressors. What are some of the things that put you at risk for suicidal thoughts? Warning signs. What are those signs that something is emerging, that there's a crisis that could be impending? And again, that could be like a fight with a loved one or increased depression, social isolation. What are some internal coping strategies? What can you do without contacting anybody? So these are skills. Then step four. All right, skills aren't working. Who can I reach out to for distraction? This is not for help. This is for distraction. Names and where places you can go. Then five. Okay, who are some people I can ask for help? What are their phone numbers? You want contact information here. Okay, that's not working. Who can I call? Now we've got clinicians, pagers. You know, here, you'll get a Word document, so you can update this for your local setting. But these are some of the suicide prevention talk and text lines that are local to us. And then 911 in the local emergency room, making sure they know where that is. And then some of the things we've added is making the environment safe. What are some things that you can do to reduce your risk? Lock up the guns, take away knives, keep my pills. And then what is the one thing that's worth living? Okay. It's not copyrighted, Jane. Use it as you wish. Okay. I want to be clear. This is not a substitute for treatment. This is not. So one of the things I love about the SPI, you go through your suicide risk assessment. You think, okay, I think we can manage this with the safety planning tool. You start going through the safety planning tool. They're not able to come up with coping skills. They refuse to identify people that they can contact for distraction or for help. You start realizing, like, I can't actually come up with a plan. That helps you to get a sense of, wait, now this person has ideation, past behavior, risk factors, and I can't use this plan to manage them outpatient. That's a very helpful point where you start to think about whether actual inpatient treatment is needed now or crisis residential or some other step up of care. Okay. But this is not a way to manage someone who's in imminent danger. Also, no suicide contracts are not an evidence-based practice. You know, this is asking one to promise to stay alive and that's not giving them any help to do so. So really the SPI is trying to give them the tools to manage their ideation and when they should call you and when they should reach out for help. So we use this for all clients beginning treatment. If they mention any ideation or behavior, we always update it when they have increased risk. And then we always make sure when someone's been hospitalized, had an attempted emergency room visit, we update it. There's all sorts of other skills that you can use, training programs, family involvement, medication. Again, you can just follow up with your client more often, see them every day. For a 15 minute check-in, increasing social support in that way can be hugely helpful in decreasing suicide risk. If you have peers or other staff who can reach out and just check in, that is a great intervention to help bring people's risk down. So when you identify that someone's at acute risk, they're having increased ideation, intent and behaviors, maybe increasing psychosis symptoms, they can't use their skills, family and collaterals are not able or available. We are seeing now for a lot of our youth, parents are at work and so we can't monitor in the way they might be able to previously. That's an important thing to know when you're trying to make decisions on acute risk. And just always making sure you know the hospitalization protocol. Again, hospitalization can be very stigmatizing and very traumatizing for our clients. And so the more information you can provide about what the experience is gonna be like really helps clients prepare. I've put some references here. Here's the resource center. There's apps. There's NASHPID information for FEP. Again, here's the template. All of this is freely available. Information on crisis centers. Some of this is local. And then all of the references. All right. I know I am over my hour, but there might still be some questions that I am happy to take a few minutes to answer if people want. Great. Thank you, Dr. Needham. This was a fantastic webinar and extremely informative. So I also want to... These webinars are sponsored in partnership with SMI Advisors. We wanna give a shout out to our partner. If you would like to have a consultation service with them or ask them questions, please do. Thanks, Judith. So Tara, we've just got sort of four or five minutes. And I know there's a lot of questions and a lot of interest. And you did an amazing job of answering questions as we were going. I don't quite know how you did that, but well done. A couple of times people were asking about intrusive thoughts and how that fits with this kind of presentation and how you would conceptualize intrusive thoughts in an assessment. So, you know, it depends on what you mean by intrusive thoughts. So if anyone's still here and wants to give an example in the chat of what they meant by intrusive thoughts, that would help me a lot. So, you know, when I think of intrusive thoughts, that could be delusional thoughts that come in and feel intrusive, or it could be hallucinations that feel intrusive. It could also be thoughts of suicide that just pop into one's head. And those are distressing. Those are just thoughts. And so if they're suicide thoughts, you know, I want to go take all of my pills and die. That's a thought, that's ideation, right? And so you want to see if there's ways in which in the SPI, you can help folks manage those thoughts through distraction or coping skills. You know, there's therapeutic work you can do around those thoughts, but there's still thoughts. So regardless of whether the intrusive thoughts are suicide thoughts or other thoughts that then make the person think death by suicide is an answer, you know, those are some of the thoughts you want to monitor in the safety plan. So those might be warning signs, or those might be triggers at the top, depending on kind of the quality of those thoughts. I think Jacqueline was just trying to clarify what she was meaning by that further up. There's been a lot of chat since, but what you're saying of intrusive thoughts when driving on the freeway of like, I could drive into the central reservation and die right now. Yeah. So when you have that thought, how much did you want to act on it? You know, that's really, it's a thought and you count it as a thought. You know, I think there's, it really then comes down to the ideation, the intent, the, you know, the stress associated, or if it's a passing thought. I mean, we all have those thoughts, like those sort of passing intrusive thoughts, you know, lots of people have. So I think you just want to see how compelling it is. Is it increasing in frequency? Is it distressing to them? Again, those thoughts could be warning signs or triggers, but they're definitely something you want to keep in mind. I know this isn't the focus so much of this presentation and could indeed be a presentation all of its own, but it's something I know you've also thought a lot about and just might be worth very quickly touching on, but supporting staff around their emotional reactions to assessing for suicide and as suicidal behavior increases in their client. What kind of support do you recommend within teams? This is where supervision is so important, right? Like my, because it's overwhelming, it's distressing for our team, we love our clients, we're very worried about them. And so just making sure that they always have someone that they can reach to for supervision and guidance. We always consult, consult, consult, consult. If I'm doing a risk assessment, I will consult with one of my other licensed folks to make sure I feel like I've done a thorough job. Always feeling like you have backup I think is really important. I think if you have a death by suicide in your clinic, that is a whole nother ballgame of making sure that you bring your staff together, give them a space to process. The leadership team has done a thorough review of the procedures to make sure that it was handled appropriately and to allow, to figure out how you may allow the rest of your clinic to know if that client was in groups or known to other folks. And I have additional information that I'm happy to share as well if that would be helpful for folks. And then just final question before I wrap up, someone's asking, can they self-evaluate their own risk of suicide? And what would your recommendations be around that? Self-evaluation of their own risk for suicide. Like a client? I mean, to me, that's where I think the SPI can be a really helpful collaborative assessment. How well does that client think that they can use their skills? Have they demonstrated their ability to use their skills before? How well have they reached out to other people before? I think that is where self-assessment for a client is really important. And the more you can engage them in the process, the better the outcome will be. We want our clients to be able to be good self-assessors of how bad they're feeling and what level of support they need. So I would say encouraging them in that and also recognizing that when folks are really feeling bad, our ability to think clearly breaks down. And that is where having help from loved ones and a clinical team can be really important in making decisions. So I would say there's a partnership. I wanted to hit one question I just saw in the chat from Marcella. Creative ideas to make an environment safe. So this is something that often comes up with our families. Just lock it in the trunk of your car and sleep with your keys. This is what I have my families do when knives and other pills can be a big deal is we give families lock boxes and keep it in your room where you sleep at night so that the youth or individual can't sneak in and get it. And then you can always lock stuff in your car trunk and sleep with your keys. As long as they can't get in your trunk in some other fashion, you should be good to go. But that's a quick way to do it. Thank you so much, Tara. This has been incredibly informative. We still have a lot of people hanging on. So that speaks to how fantastic this was and how much needed this topic is and really how much we needed a whole lot more time to get into this more deeply. Thank you for your generosity and sharing the resources that will be circulated. And thanks to everybody for joining us today. And thanks to Dr. Edelstein for helping to co-facilitate the chat. And thank you Judith for all the behind the scenes making this work. Thank you. Thank you so much. Bye-bye.

Suicide Assessment

Prevention of Early Psychosis

Dr. Tara Needham

Suicide Risk Assessment

Suicidal Thoughts

CSSRS

SPI

Adolescents

Young Adults

Mental Health

Youth