The utility of MMPI-2 suicide items for assessing suicidal potential: development of a Suicidal Potential Scale.

The assessment of suicidal potential is one of the most challenging and stress-inducing tasks facing clinicians. Studies that have attempted to identify specific MMPI codetypes, scales, or individual items predictive of completed suicide have produced inconsistent findings. This study focused on the relationship between the six most direct MMPI-2 suicide items (Items 150, 303, 506, 520, 524, and 530) and verbally reported history of suicidal ideation and behavior among a sample of psychotherapy outpatients (n =116). These six MMPI-2 suicide items provided valuable information regarding suicidal ideation and behavior above and beyond that of verbal self-report. These items were grouped together to create a single scale, the Suicidal Potential Scale (SPS) that manifested strong internal consistency. The SPS provides the clinician with a reliable method of assessing for self-reported suicidal ideation and behavior.

Codetype base rates for the "I Mean Business" suicide items on the MMPI-2.

This study focused on the frequency with which two MMPI-2 suicide items (506 and 520) were endorsed. These two items can be referred to as the "I Mean Business" items, for there is no denying that the client is reporting the recent contemplation of actively taking his or her life. A large sample (N = 23,646) of well-defined MMPI-2 codetypes was examined from the Caldwell (1997) data set. The frequencies with which individuals within a particular codetype endorsed Item 506, Item 520, or both are provided by gender. Results provide information that is consistent with the clinical lore concerning suicidal ideation/intent and codetypes. Unexpected findings are also noted. The implications of these base rates in psychotherapy are discussed from clinical and risk management perspectives.

The role of objective personality inventories in suicide risk assessment: an evaluation and proposal.

Objective personality assessment instruments offer a comparatively underutilized source of clinical data in attempts to evaluate and predict risk for suicide. In contrast to focal suicide risk measures, global personality inventories may be useful in identification of long-standing styles that predispose persons to eventual suicidal behavior. This article reviews the empirical literature regarding the efficacy of established personality inventories in predicting suicidality. The authors offer several recommendations for future research with these measures and conclude that such objective personality instruments offer only marginal utility as sources of clinical information in comprehensive suicide risk evaluations. Personality inventories may offer greatest utility in long-term assessment of suicide risk.

Toward a standard of care for treating suicidal outpatients: a survey of social workers' beliefs about appropriate treatment behaviors.

This study attempts to establish what reasonable, prudent professionals, named in the standard of care, believe is appropriate treatment for suicidal outpatients. We hope to move toward establishing a standard of care based on actuarial data, rather than after the fact evaluation by experts, judges, and lawyers. Previously, Greaney (1995, doctoral dissertation, Pacific Graduate School, Palo Alto, CA) empirically examined the beliefs of psychologists in appropriately treating suicidal outpatients. Our goal is to broaden the perspective of existing empirical data by examining the beliefs of clinical social workers in treating suicidal outpatients.

Hopelessness and suicidal ideation in older adults.

This study examined the role that hopelessness plays in geriatric suicidal ideation. Sixty institutionalized elderly males were recruited. Multiple regression analyses revealed that while hopelessness was strongly related to suicidal ideation, the relationship between hopelessness and suicidal ideation was dependent on level of depression. Participants who reported moderate or higher levels of depressive symptoms were more likely to have suicidal ideation with increasing hopelessness, whereas hopelessness had little effect on level of ideation at mild or lower depressive symptom levels. Unlike previous studies in younger adults, hopelessness did not predict suicidal ideation better than depressive symptoms, although the relationship between depression and suicidal ideation was stronger within higher levels of hopelessness. These findings highlight the importance of considering depression and hopelessness simultaneously when assessing and treating geriatric suicidal ideation.

Suicidality in borderline personality disorder.

Recent research on the relationship between borderline personality disorder (BPD) and suicidal behavior is reviewed. Risk factors for attempted and completed suicide as well as the effect of the comorbidity of BPD with other Axis I and II disorders are considered. Explanations for suicidality in BPD are discussed. General assessment strategies are offered, along with treatment recommendations. Specifically, research has shown that borderline patients improve in the long-term, decreasing in suicidality, self-destructiveness, and interpersonal maladjustment, if survival is effectively managed during the turbulent years of youth. Clinical lore at times can lead clinicians to disregard the danger of suicide completion among chronically parasuicidal patients, which can prevent effective intervention during suicidal crises and result in unfortunate outcomes.

Psychosocial consequences of bone marrow transplantation in donor and nondonor siblings.

We investigated the psychosocial effects of bone marrow transplantation (BMT) on siblings of transplant recipients. We asked how donor siblings compared with nondonor siblings on quantitative measures of behavior, psychological distress, and sense of self. Participants included 44 siblings (21 donors and 23 nondonors, ages 6-18 yr) of surviving pediatric BMT patients. On self-report measures, donors reported significantly more anxiety and lower self-esteem than nondonors. On teacher-rated scales, donors showed significantly more adaptive skills in school. On these same scales, nondonors showed significantly more school problems than donors. One-third of the siblings in each group reported a moderate level of post-traumatic stress reaction. Exploratory multiple regression analyses point to factors that might influence sibling adjustment and suggest counseling strategies and avenues for future research.

Suicide in San Francisco, CA: a comparison of Caucasian and Asian groups, 1987-1994.

Completed suicides in the city of San Francisco, California, were examined across all ages in the racial groups of Caucasians (n = 798) and Asians (n = 124) from 1987 to 1994. A comparison of Caucasians and Asians showed that there were differences between them in their rates across all age groups. The major findings are: (1) Caucasians predominantly used gunshot to complete suicide whereas Asians predominantly used hanging to complete suicide, (2) Asian women over the age of 85 have the highest rates across both groups and genders, (3) Asians, as compared to Caucasians, used fewer drugs and alcohol at time of death. Theoretical connections between differences in suicide and definition of the self, as influenced by culture, are discussed.

Essential clinical and legal issues when working with the suicidal patient.

The legal and clinical literatures on the standards of care for adult suicidal patients are reviewed. We discuss the components of an effective risk management approach that balances the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. Through a review of legal theories and an overview of the clinical literature, we detail the essential guidelines for sound assessment, intervention, and postvention procedures.

Inpatient standards of care and the suicidal patient. Part II: An integration with clinical risk management.

The authors elaborate on the standards of care for the assessment, management, and treatment of hospitalized suicidal patients. The authors attempt to synthesize the concepts of the minimal standard of care with clinical risk management and clinical judgment. They point out the areas of overlap and where optimum care diverges from legal standards of care. Case examples are provided to illustrate major areas of concern. Alleged failures of omission and commission are discussed. Tables are provided that differentiate duties and responsibilities between and among clinicians, hospital staff, and hospital administration.

Inpatient standards of care and the suicidal patient. Part I: General clinical formulations and legal considerations.

The most common legal action involving psychiatric care is the failure to reasonably protect patients from harming themselves. In this regard it is critical to understand that courts have tended to impose much stricter standards on inpatient than on outpatient care; that at the present time, most malpractice actions involve clinical activities related to inpatient care (negligent admission, treatment, supervision, discharge, etc.). This article reviews the current climate in the legal and clinical formulation of standards of care for hospitalized adult suicidal patients. It suggests general guidelines for effective assessment, management, and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. The authors specifically discuss court cases that show common failure situations in inpatient care, discharge planning, and follow-up (e.g., problems in pharmacotherapy, the decision to hospitalize, the assessment of imminence and lethality, etc.). The paper also emphasizes the crucial element of clinical judgment in developing any inpatient standard of care.

Consultation and the suicidal patient.

This paper presents an argument for a paradigm shift in the way that mental health professionals approach their work with psychiatric patients in the midst of a suicidal crisis and suggests that the time has come to discuss a standard of care based on integration of detected risk factors, effective education and training in suicidology, and most importantly, the routine use of consultation and teamwork. Also proposed is a workable model for the use of consultation that has a number of major components: quality education in suicidology, the training and availability of appropriate consultants, clinical teamwork, and the recognition by training programs and clinical institutions that it is necessary to routinely consider a consultative risk management approach for work with suicidal patients.

Outpatient standards of care and the suicidal patient.

This article is a review of the legal and clinical literature on standards of care for nonhospitalized adult suicidal patients. The authors discuss effective assessment, management and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court-determined and statutory standards. Through a review of malpractice claims data and through an examination of the clinical literature we detail the essential guidelines for sound assessment, intervention, and management procedures. The authors specifically discuss common failure situations in outpatient care (e.g., problems in pharmacotherapy, the decision to hospitalize, inappropriate and dual relationships, the assessment of imminence and lethality, and so on). Details regarding practical considerations in developing an outpatient standard of care are provided, as are suggestions that such a standard of care must include an ongoing assessment of the therapeutic alliance.

Provocation of pseudoseizures by psychiatric interview during EEG and video monitoring.

OBJECTIVE: This paper discusses a new technique for diagnosing pseudoseizures. The technique consists of an intensive psychiatric interview designed to provoke a pseudoseizure during EEG and video monitoring. We wished to determine the overall efficacy of the technique and learn how our patients felt about having undergone the procedure. We were also interested in whether their seizures persisted approximately three years later. METHOD: We reviewed medical records and conducted telephone interviews with thirty of thirty-two patients who had previously undergone the procedure as part of an evaluation for unusual or intractable seizures. All evaluations had been performed on a university hospital neurology service. The patients were consecutive referrals to the consultative psychiatry service for suspicion of pseudoseizures. RESULTS: Nineteen of the thirty-two patients interviewed had a pseudoseizure under EEG and video monitoring. Of the thirty reached by telephone for follow-up, twenty-two recalled the procedure as helpful or benign. None regarded the overall psychiatric consultation negatively. Among the patients who had exhibited pseudoseizures there was a variety of psychiatric diagnoses with a preponderance of personality disorders. Two thirds of those patients without coexisting epilepsy stopped having seizures or rarely had seizures following their evaluations. CONCLUSIONS: The diagnostic technique described here is useful in patients with possible pseudoseizures. It does not appear to be harmful when employed as part of a comprehensive psychiatric consultation. How it may compare with other methods of pseudoseizure diagnosis will have to be determined by further study.

Clinical psychology graduate education in the study of suicide: availability, resources, and importance.

Psychologists run the risk of losing a patient to suicide and of experiencing the traumatic impact of this event. The present study examines current levels of training in the study of suicide in the member-departments of the National Council of Schools of Professional Psychology (NCSPP--N = 33), comparing these findings with the level of training in member-departments (N = 115) of the Council of University Directors of Clinical Psychology programs (CUDCP). Eighty percent of the CUDCP departments (N = 92) responded, and of these, only 35% offer formal training in the study of suicide; whereas in the 76% of the NCSPP programs that responded, 56% offer formal training. Although the NCSPP programs seem attitudinally more receptive and supportive of formal training (graduate and postgraduate) in the study of suicide, the NCSPP programs do not significantly differ from their CUDCP counterparts in the actual availability of such formal training. Even when all training efforts of the CUDCP and NCSPP programs are combined, only 40% of all graduate programs in clinical psychology offer formal training in the study of suicide.

Repetitive suicidal crises: characteristics of repeating versus nonrepeating suicidal visitors to a psychiatric emergency service.

The present study involves a retrospective chart review of all patients who visited the Emergency Mental Health Service during the period of July 1, 1985 to June, 30, 1986 (total visits = 2,772). It compares those 'suicidal' patients seen only once during the index year with those seen multiple times (comparison of first visit only for both 'one-timers' and 'repeaters'). The 'repeaters' were generally found to be older and were more likely to have a diagnosis of schizophrenia and personality disorder. Unlike previous studies, substance abuse and affective disorder did not significantly differentiate the two groups. The 'repeaters' were also more likely to be taking antipsychotic and antiparkinson medications, have histories of past psychiatric hospitalizations in the public sector, be living alone, and most importantly, to have made a previous suicide attempt.

Navane versus Haldol. Treatment of acute organic mental syndromes in the general hospital.

A single blind study design was used to evaluate the efficacy and safety of Navane versus Haldol in acute organic mental syndromes in a general hospital setting. Seventeen patients were entered into the study; only 14 remained in the study long enough to complete the protocol. Most patients treated with either neuroleptic agent improved. Only one patient was worse. Improvement occurred rapidly (2-3 days), and few significant side effects were observed. There was a trend toward lower BPRS scores in patients treated with Navane (thiothixene).

Regional use of violent suicide methods: an analysis of suicide attempts in Houston, Texas.

A number of changes in the demographics of suicide and suicide attempters have occurred in the last 10 to 15 years. To assess some of the factors that may be involved in these changes, this study examines a group of suicide attempters in Houston, Texas, where a large percentage of the attempts were violent. These violent attempters are compared with nonviolent attempters, and the entire population of attempters is compared with suicide attempters in New Haven, Connecticut. Finally, the two attempter populations are compared with the underlying general population demographics of two regions (Houston and New Haven). Several differences emerged between attempters in Houston and in New Haven, including larger proportions of violent attempters, male attempters, and married attempters in Houston. Demographic factors in the general populations for the two regions are different, but these differences are not directly reflected in the nature of the attempter populations. Reasons for observed differences are discussed.