Presented by: Carmen Loucks, BScPhm Candidate

HOW TO SAVE A LIFE:SUICIDE PREVENTION IN PHARMACY

Why You Should Care• http://www.youtube.com/watch?v=2199PPD8fRw

Why I Chose This Topic

What would you do…?• Conducting a MedsCheck with Mr. ST

Outline •Why pharmacist should play a role

• Assess the risk of a suicidal patient

• Intervene appropriately with a suicidal patient

• Identify available resources

WHY PHARMACISTS SHOULD PLAY A ROLE

Why Pharmacists?• Accessible, available, knowledgeable

• “Gatekeepers”

• Trusted by patients

• Frequent monitoring

• Nonadherence to antidepressants

• Method of choice = drugs

ASSESS THE RISK OF A SUICIDAL PATIENT

True or False• The majority of people who commit suicide have a

mental disorder..

TRUE

About 90% of suicidal patients have a diagnosable mental disorder.

Risk Factors•Depression•Previous suicide attempt• Alcoholism• Schizophrenia• Painful and chronic conditionsEpilepsySpinal or head injuries and strokeCancerHIV/AIDSOther (ie. diabetes, MS)Difficulty walking, seeing and hearing

Who is at higher risk?

Patient A (Male) or Patient B (Female)

Who is at higher risk?

Patient A (Elderly) or Patient B (Young)

Who is at higher risk?

Patient A (Married) or Patient B (Single)

What to Look ForBehavioural Clues:

What to Look ForVerbal Clues:“I want to kill myself” “I want to die”

“I’ll never get out of it”

“They’d be better off without me”

“I have made my will”

Protective Factors • Children at home

• Pregnancy

• Religious faith

• Employment

• Social support system

INTERVENE APPROPRIATELY WITH SUICIDAL PATIENTS

True or False• People who attempt suicide do not want to

talk about it.

FALSEThe best way to find out if your patient has suicidal thoughts is to ask them!

Initial Contact• Step #1 – Find a private place

• Step #2 – Allocate the necessary time

•Step #3 – Listen!!!

What to AskTo determine their current mental state:

• “Do you feel sad?”

• “Have you ever felt that life was not worth living?”

• “Did you ever wish you could go to sleep and just not wake up?”

• “Have things ever reached the point that you’ve thought of harming yourself?”

What to AskTo determine their plan:

• “How likely do you think it is that you will act on them in the future?”

• “Have you made a specific plan to harm or kill yourself?” (If so, what does the plan include?)

• “Is the means readily available to you?”

• “When are you planning to do it?”

What to Ask…To determine what their support system is:

• “What things would lead you to feel more (or less) hopeful about the future?”

• “What things in your life make you want to go on living?”

Risk Level

Low

• Some ideation• No plan

Mod

• Ideation• Vague plan but no immediate plans

High

• Ideation• Specific plan and timeframe established

Suicide Risk Assessment Scales• No evidence to support using only summary scores to determine acute risk

• Predictive value is low BUT the actual content covered by the questions is important

• Useful for pharmacists:SAD PERSONSTASR (Tool for Assessment of Suicide Risk)

Back to Mr. ST• 46-year-old male• Married 23 years• 3 kids at home

• Major depressive disorder, Hypertension• No previous suicide attempts• No suicidal plans• Celexa 20mg daily, Apo-Hydro 25mg

daily, Altace 10mg daily• Lost his job• Struggling financially

• “I don’t know what to do, I don’t think I’ll ever get out of it”

Risk Factors• Male• Major depressive disorder• Job loss• Verbal clues

Protective Factors• Married• Kids at home• No previous suicide attempts

Mr. ST’s Risk

How to Manage Low Risk PatientOffer emotional support

Encourage the person to talk openly in order to resolve suicidal feelings

Cast doubt

Refer the person to a mental health professional or a doctor

Meet at regular intervals

Mr. ST Returns• 1 year later• Divorced, not living with his children• Celexa increased dose• Still unemployed• Drinks 4-5 drinks/day

• Came to the pharmacy to get his medications, asking you to dispense a larger quantity• After probing, admits he will use the

drugs to kill himself• Timeframe <48h

• “The world is better off without me If you don’t give the meds to me, I have rope at my house..”

Mr. ST’s Risk

How to Manage a High Risk Patient Stay with the person

Gently talk to the person and remove the means of suicide (ie. pills, knife, rope etc.)

Make a suicide prevention or “no-harm” contract

Contact a mental health professional or doctor immediately

Arrange for ambulance and hospitalization

Inform the family and enlist support

IDENTIFY AVAILABLE RESOURCES

Crisis Lines• Distress Centre: Distress line, 24/7 Crisis Line

Canadian Mental Health Association/Waterloo Region Branch

• Ontario Association of Distress Centreswww.dcontario.org

• Ontario Suicide Prevention Network

www.ontariosuicidepreventionnetwork.ca

Useful Resources INTERNATIONAL• World Health Organization (WHO)

http://www.who.int/mental_health/prevention/suicide/suicidepreve

nt/en/index.html

Guidelines for Primary Health Care Workers 2009

NATIONAL• Canadian Association for Suicide Prevention (CASP)

www.suicideprevention.ca

Guidelines September 2009• Centre for Suicide Prevention (Alberta)

http://suicideinfo.ca/Library/Resources.aspx• Canadian Patient Safety Institute (CPSI) and Ontario Hospital Association

http://www.patientsafetyinstitute.ca/English/toolsResources/SuicideRisk/Documents/Suicide%20Risk%20Assessment%20Guide.pdf

Suicide Risk Assessment Guide 2011

LOCAL

Waterloo Region Suicide Prevention Strategy 2006-2011

True or False•Doctors, pharmacists and veterinarians have higher than average suicide rates.

TRUE

Professionals Health Program• Offer advice, help, and support to physicians, pharmacists and veterinarians and members of their families who may have substance abuse disorders and/or psychiatric disorders

• OPA Website Membership Support

Please Visit My Website Ever wondered…

• What you would do if you received a prescription for a lethal dose of secobarbital

• About medications used to treat suicide

• What a suicide cluster is and what can be done about it

http://www.howtosaveapatientlife.weebly.com

Summary• Pharmacists frequently come in contact with the public and are ideally positioned to monitor for depression and nonadherence to antidepressants

• Important to be able to identify individuals at risk of suicide

• Use probing questions to determine whether the individual is low, moderate or high risk

•Remember that most patients contemplating suicide WANT to talk about it!!!

References • Vincent, P. (2013, January 10). Suicide Prevention in Pharmacy. Powerpoint

lecture presented at Professional Development Week in Montreal.• World Health Organization (2000). Prevention Suicide: A Resource for Primary

Health Care Workers. Geneva, SZ. • Perlman CM, Neufeld E, Martin L, Goy M, & Hirdes JP (2011). Suicide Risk

Assessment Inventory: A Resource Guide for Canadian Health care Organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute.

• Ontario Association of Distress Centres. www.dcontario.org.• Ontario Suicide Prevention Network. www.ontariosuicidepreventionnetwork.ca• Centre for Suicide Prevention (Alberta)

http://suicideinfo.ca/Library/Resources.aspx• http://www.psychpage.com/learning/library/counseling/suicide.html• Lenard, H. (2006). Waterloo Region Suicide Prevention Strategy. Waterloo, ON:

Waterloo Region Suicide Prevention Strategy Planning Group. • Professionals Health Program. http://php.oma.org/• OPA Website. http://www.opatoday.com/index.php/membership/support-

services.html