Northwestern Memorial Hospital/ Northwestern University Feinberg School of Medicine: Reinventing Inpatient Psychiatry

CHICAGO – A new 29-bed inpatient psychiatric care facility at Northwestern Memorial Hospital’s Stone Institute of Psychiatry was designed with two key elements in mind: the on-stage, off-stage concept, also known as the "Disney concept," and the idea of a treatment mall, said registered nurse Maureen Slade. Above all, the designers wanted patients to feel safe and comfortable, as in a neighborhood.

Photo Richard Hyer/Elsevier Global Medical News

"You can have that philosophy in your head, but if you don’t have a facility that supports that, it’s very hard to actualize the concept," said Ms. Slade, who worked actively on the facility’s design.

The new unit, known as Galter 13 because it is on the 13th floor of the hospital’s Galter Pavilion, is scheduled to open Sept. 24, but was recently previewed in a seminar at the hospital titled "Reinventing Inpatient Psychiatry." The unit includes patient rooms, a day room, group rooms, a gym, a dining room, a meditation/comfort room, and nursing stations.

Patient care occurs in the "on-stage" area, which is available only to those directly caring for or supporting patients. These might include consulting physicians, nursing staff, and environmental services, but not support personnel like pharmacy or materials management. The latter functions will be kept out of sight to maintain patients’ privacy.

Interview rooms allow family, significant others, or outside therapists to meet the staff without having the patient present, or for that matter ever entering the patient’s care space.

Therapeutic groups, structured activities, and community dining occur in one of four areas known as the "treatment mall": the dining room, group room, occupational therapy room, and gym. Programming in the mall occurs all day and into the evening, from 8 a.m. to 9 p.m.

Northwestern hopes that Galter 13’s novel design will create a sense of community, shelter, and comfort that models life: Patient rooms are to be considered home, the day room is the neighborhood, and the treatment mall is to be thought of as "working downtown."

Large glass picture windows protectively sheathed in unbreakable Lexan provide the entire space with ample daylight.

Photo Richard Hyer/Elsevier Global Medical News

"We want the patients ... to come out of their rooms and engage," Ms. Slade said. She hopes the unit’s many offerings will help patients develop skills in self-management.

Technology also is used to enhance care. All group rooms and the meditation/comfort room have monitors for educational DVDs. Special lighting features like atmospheric ceilings change color and brightness with the time of day or night to support the patients’ circadian rhythms.

The small but comfortable meditation/comfort room exists to supply a single patient with a quiet, healing space where even lighting can be individualized in both color and brightness. The room is equipped with various other soothing nuances, including aromatherapy and weighted blankets.

Advanced call and communication systems are made available to the staff.

The facility supports best practices, said Ms. Slade, including expert psychopharmacology, empowering communications like cognitive-behavioral therapy and behavioral activation, and neuromodulation, including transcranial magnetic stimulation, electroconvulsive treatment, and deep brain stimulation.

Most of the patient’s rooms are private, and all are uncluttered and designed for safety. Mirrors are not glass, hinges run the full length of doors, and all fixtures are either encased or are otherwise ligature-resistant. The unit also contains Stryker psychiatric beds without side rails, though patients deemed medically compromised get acute care beds.

"We’re pretty obsessed with safety and security ... we want zero suicides in our unit," Ms. Slade said.

Ms. Slade disclosed no conflicts of interest.

CHICAGO – A new 29-bed inpatient psychiatric care facility at Northwestern Memorial Hospital’s Stone Institute of Psychiatry was designed with two key elements in mind: the on-stage, off-stage concept, also known as the "Disney concept," and the idea of a treatment mall, said registered nurse Maureen Slade. Above all, the designers wanted patients to feel safe and comfortable, as in a neighborhood.

Photo Richard Hyer/Elsevier Global Medical News

"You can have that philosophy in your head, but if you don’t have a facility that supports that, it’s very hard to actualize the concept," said Ms. Slade, who worked actively on the facility’s design.

The new unit, known as Galter 13 because it is on the 13th floor of the hospital’s Galter Pavilion, is scheduled to open Sept. 24, but was recently previewed in a seminar at the hospital titled "Reinventing Inpatient Psychiatry." The unit includes patient rooms, a day room, group rooms, a gym, a dining room, a meditation/comfort room, and nursing stations.

Patient care occurs in the "on-stage" area, which is available only to those directly caring for or supporting patients. These might include consulting physicians, nursing staff, and environmental services, but not support personnel like pharmacy or materials management. The latter functions will be kept out of sight to maintain patients’ privacy.

Interview rooms allow family, significant others, or outside therapists to meet the staff without having the patient present, or for that matter ever entering the patient’s care space.

Therapeutic groups, structured activities, and community dining occur in one of four areas known as the "treatment mall": the dining room, group room, occupational therapy room, and gym. Programming in the mall occurs all day and into the evening, from 8 a.m. to 9 p.m.

Northwestern hopes that Galter 13’s novel design will create a sense of community, shelter, and comfort that models life: Patient rooms are to be considered home, the day room is the neighborhood, and the treatment mall is to be thought of as "working downtown."

Large glass picture windows protectively sheathed in unbreakable Lexan provide the entire space with ample daylight.

Photo Richard Hyer/Elsevier Global Medical News

"We want the patients ... to come out of their rooms and engage," Ms. Slade said. She hopes the unit’s many offerings will help patients develop skills in self-management.

Technology also is used to enhance care. All group rooms and the meditation/comfort room have monitors for educational DVDs. Special lighting features like atmospheric ceilings change color and brightness with the time of day or night to support the patients’ circadian rhythms.

The small but comfortable meditation/comfort room exists to supply a single patient with a quiet, healing space where even lighting can be individualized in both color and brightness. The room is equipped with various other soothing nuances, including aromatherapy and weighted blankets.

Advanced call and communication systems are made available to the staff.

The facility supports best practices, said Ms. Slade, including expert psychopharmacology, empowering communications like cognitive-behavioral therapy and behavioral activation, and neuromodulation, including transcranial magnetic stimulation, electroconvulsive treatment, and deep brain stimulation.

Most of the patient’s rooms are private, and all are uncluttered and designed for safety. Mirrors are not glass, hinges run the full length of doors, and all fixtures are either encased or are otherwise ligature-resistant. The unit also contains Stryker psychiatric beds without side rails, though patients deemed medically compromised get acute care beds.

"We’re pretty obsessed with safety and security ... we want zero suicides in our unit," Ms. Slade said.

Ms. Slade disclosed no conflicts of interest.

CHICAGO – A new 29-bed inpatient psychiatric care facility at Northwestern Memorial Hospital’s Stone Institute of Psychiatry was designed with two key elements in mind: the on-stage, off-stage concept, also known as the "Disney concept," and the idea of a treatment mall, said registered nurse Maureen Slade. Above all, the designers wanted patients to feel safe and comfortable, as in a neighborhood.

Photo Richard Hyer/Elsevier Global Medical News

"You can have that philosophy in your head, but if you don’t have a facility that supports that, it’s very hard to actualize the concept," said Ms. Slade, who worked actively on the facility’s design.

The new unit, known as Galter 13 because it is on the 13th floor of the hospital’s Galter Pavilion, is scheduled to open Sept. 24, but was recently previewed in a seminar at the hospital titled "Reinventing Inpatient Psychiatry." The unit includes patient rooms, a day room, group rooms, a gym, a dining room, a meditation/comfort room, and nursing stations.

Patient care occurs in the "on-stage" area, which is available only to those directly caring for or supporting patients. These might include consulting physicians, nursing staff, and environmental services, but not support personnel like pharmacy or materials management. The latter functions will be kept out of sight to maintain patients’ privacy.

Interview rooms allow family, significant others, or outside therapists to meet the staff without having the patient present, or for that matter ever entering the patient’s care space.

Therapeutic groups, structured activities, and community dining occur in one of four areas known as the "treatment mall": the dining room, group room, occupational therapy room, and gym. Programming in the mall occurs all day and into the evening, from 8 a.m. to 9 p.m.

Northwestern hopes that Galter 13’s novel design will create a sense of community, shelter, and comfort that models life: Patient rooms are to be considered home, the day room is the neighborhood, and the treatment mall is to be thought of as "working downtown."

Large glass picture windows protectively sheathed in unbreakable Lexan provide the entire space with ample daylight.

Photo Richard Hyer/Elsevier Global Medical News

"We want the patients ... to come out of their rooms and engage," Ms. Slade said. She hopes the unit’s many offerings will help patients develop skills in self-management.

Technology also is used to enhance care. All group rooms and the meditation/comfort room have monitors for educational DVDs. Special lighting features like atmospheric ceilings change color and brightness with the time of day or night to support the patients’ circadian rhythms.

The small but comfortable meditation/comfort room exists to supply a single patient with a quiet, healing space where even lighting can be individualized in both color and brightness. The room is equipped with various other soothing nuances, including aromatherapy and weighted blankets.

Advanced call and communication systems are made available to the staff.

The facility supports best practices, said Ms. Slade, including expert psychopharmacology, empowering communications like cognitive-behavioral therapy and behavioral activation, and neuromodulation, including transcranial magnetic stimulation, electroconvulsive treatment, and deep brain stimulation.

Most of the patient’s rooms are private, and all are uncluttered and designed for safety. Mirrors are not glass, hinges run the full length of doors, and all fixtures are either encased or are otherwise ligature-resistant. The unit also contains Stryker psychiatric beds without side rails, though patients deemed medically compromised get acute care beds.

"We’re pretty obsessed with safety and security ... we want zero suicides in our unit," Ms. Slade said.

Ms. Slade disclosed no conflicts of interest.

CHICAGO – Both the psychiatric patient and the medical patient with comorbid psychiatric conditions can be treated with a technique known as behavioral action communication.

"The challenge is ... to immerse the patient in a rich, evidence-based milieu that reinforces goal-directed behavior," said Jacqueline Gollan, Ph.D., director of the Translational Stress and Depression Laboratory at Northwestern University. The concept of behavioral activation is complex, said Dr. Gollan, but broadly invites the patient to reflect on her own behavior or inactivity in various contexts and to reinforce active, positive behaviors. On seeing the latter, "The staff can turn to the patient and say, ‘That’s great. Let’s see if you can do that again.’ "

The goals are to accelerate recovery, independence, and functionality, Dr. Gollan said at a seminar, "Reinventing Inpatient Psychiatry." In a well-controlled context, inpatients can actually learn how to manage their illnesses.

Passivity and avoidance are prevalent in psychiatric conditions, and this behavioral strategy is designed to reduce them, and to improve the quality and acceptability of care, she said.

Theoretically, overall health outcomes will also be improved. The psychiatric concept of avoidance has been linked in the literature to increased hypertension and cardiovascular mortality and diminished immunity, as well as substance abuse, depressive symptoms, overall lower quality of life, and increased mortality, she said.

Northwestern Memorial Hospital integrates behavioral action communication throughout the psychiatric unit, employing it in group meetings, education, nursing care, physician inquiry, discharge plans, and social work. A manual on the subject is given to each patient’s family members so they can reinforce goals at home, helping the individual to identify and reduce passivity and avoidance, and to understand that all behaviors have a purpose or goal. The intent is to teach the patient to connect context, behavior, and mood.

In the clinic, the first step in teaching the psychiatric patient to monitor his or her behavior is a self-reported instrument called the Checklist of Unit Behaviors, or CUB. This checklist assesses the patient’s activation (activities that create positive changes in symptoms or function) in two dimensions: approach and avoidance. The patient and staff members track progress each day with an item-by-item discussion that focuses on the patient’s successes. The conversations emphasize the context and function of behavior; avoidance behaviors are associated with negative affect.

"Every morning, they fill out a CUB," Dr. Gollan said. "It truly reflects what they’re doing. The patient reports being high or low on avoidance or approach. A set of avoidance behaviors is associated with negative affect. On intake you see high levels of avoidance ... then there’s feathering out."

The psychometric properties of the CUB allow clinicians to implement a treatment plan that increases positive affect, ultimately to help the patient have a greater interest in taking care of himself, said Dr. Gollan.

An experiment comparing the behavioral action communication (BAC) unit with the Treatment as Usual (TAU) unit reinforced this finding. Outcome measures were the Brief Symptom Inventory, Positive and Negative Affect Schedule (PANAS), Behavioral Inhibition/Activation Scale (BIS/BAS), and CUB.

The sample (n = 149) was divided between the BAC unit (72 patients) and TAU unit (77 patients), with the TAU acting as the control. No significant differences were found in patient age (mean = 38.7 years) or gender (49% male). A One-Sample T test did not reveal significant differences across psychiatric disorders using Brief Symptom Inventory for each unit at admission (P = .30). These disorders/behaviors included depression, anxiety, hostility, somatization, obsessive-compulsive, interpersonal sensitivity, phobic anxiety, paranoid ideation, and psychoticism.

The study found that increase in positive affect from admission to discharge was higher for those in the BAC unit. Patients in the BAC unit with elevated major depressive disorder reported improved positive affect at discharge, compared with those in the TAU unit. BAC unit patients also reported significantly higher approach behaviors at discharge than did TAU unit patients. BAC and TAU unit patients showed major reduction of avoidance equivalent across units at intake and discharge.

Overall, patients’ assessments of behavioral activation communication were positive. Their comments included: "It helps me visualize what’s going on," "It helps me to write things down instead of just thinking about them," and "It’s nice to know that someone is checking up on you and monitoring your progress."

A member of the audience asked whether the hospital had seen any change in repeat admissions. Dr. Gollan said data on repeat admissions were not yet available.

Dr. Gollan disclosed no relevant conflicts of interest.

CHICAGO – Both the psychiatric patient and the medical patient with comorbid psychiatric conditions can be treated with a technique known as behavioral action communication.

"The challenge is ... to immerse the patient in a rich, evidence-based milieu that reinforces goal-directed behavior," said Jacqueline Gollan, Ph.D., director of the Translational Stress and Depression Laboratory at Northwestern University. The concept of behavioral activation is complex, said Dr. Gollan, but broadly invites the patient to reflect on her own behavior or inactivity in various contexts and to reinforce active, positive behaviors. On seeing the latter, "The staff can turn to the patient and say, ‘That’s great. Let’s see if you can do that again.’ "

The goals are to accelerate recovery, independence, and functionality, Dr. Gollan said at a seminar, "Reinventing Inpatient Psychiatry." In a well-controlled context, inpatients can actually learn how to manage their illnesses.

Passivity and avoidance are prevalent in psychiatric conditions, and this behavioral strategy is designed to reduce them, and to improve the quality and acceptability of care, she said.

Theoretically, overall health outcomes will also be improved. The psychiatric concept of avoidance has been linked in the literature to increased hypertension and cardiovascular mortality and diminished immunity, as well as substance abuse, depressive symptoms, overall lower quality of life, and increased mortality, she said.

Northwestern Memorial Hospital integrates behavioral action communication throughout the psychiatric unit, employing it in group meetings, education, nursing care, physician inquiry, discharge plans, and social work. A manual on the subject is given to each patient’s family members so they can reinforce goals at home, helping the individual to identify and reduce passivity and avoidance, and to understand that all behaviors have a purpose or goal. The intent is to teach the patient to connect context, behavior, and mood.

In the clinic, the first step in teaching the psychiatric patient to monitor his or her behavior is a self-reported instrument called the Checklist of Unit Behaviors, or CUB. This checklist assesses the patient’s activation (activities that create positive changes in symptoms or function) in two dimensions: approach and avoidance. The patient and staff members track progress each day with an item-by-item discussion that focuses on the patient’s successes. The conversations emphasize the context and function of behavior; avoidance behaviors are associated with negative affect.

"Every morning, they fill out a CUB," Dr. Gollan said. "It truly reflects what they’re doing. The patient reports being high or low on avoidance or approach. A set of avoidance behaviors is associated with negative affect. On intake you see high levels of avoidance ... then there’s feathering out."

The psychometric properties of the CUB allow clinicians to implement a treatment plan that increases positive affect, ultimately to help the patient have a greater interest in taking care of himself, said Dr. Gollan.

An experiment comparing the behavioral action communication (BAC) unit with the Treatment as Usual (TAU) unit reinforced this finding. Outcome measures were the Brief Symptom Inventory, Positive and Negative Affect Schedule (PANAS), Behavioral Inhibition/Activation Scale (BIS/BAS), and CUB.

The sample (n = 149) was divided between the BAC unit (72 patients) and TAU unit (77 patients), with the TAU acting as the control. No significant differences were found in patient age (mean = 38.7 years) or gender (49% male). A One-Sample T test did not reveal significant differences across psychiatric disorders using Brief Symptom Inventory for each unit at admission (P = .30). These disorders/behaviors included depression, anxiety, hostility, somatization, obsessive-compulsive, interpersonal sensitivity, phobic anxiety, paranoid ideation, and psychoticism.

The study found that increase in positive affect from admission to discharge was higher for those in the BAC unit. Patients in the BAC unit with elevated major depressive disorder reported improved positive affect at discharge, compared with those in the TAU unit. BAC unit patients also reported significantly higher approach behaviors at discharge than did TAU unit patients. BAC and TAU unit patients showed major reduction of avoidance equivalent across units at intake and discharge.

Overall, patients’ assessments of behavioral activation communication were positive. Their comments included: "It helps me visualize what’s going on," "It helps me to write things down instead of just thinking about them," and "It’s nice to know that someone is checking up on you and monitoring your progress."

A member of the audience asked whether the hospital had seen any change in repeat admissions. Dr. Gollan said data on repeat admissions were not yet available.

Dr. Gollan disclosed no relevant conflicts of interest.

CHICAGO – Both the psychiatric patient and the medical patient with comorbid psychiatric conditions can be treated with a technique known as behavioral action communication.

"The challenge is ... to immerse the patient in a rich, evidence-based milieu that reinforces goal-directed behavior," said Jacqueline Gollan, Ph.D., director of the Translational Stress and Depression Laboratory at Northwestern University. The concept of behavioral activation is complex, said Dr. Gollan, but broadly invites the patient to reflect on her own behavior or inactivity in various contexts and to reinforce active, positive behaviors. On seeing the latter, "The staff can turn to the patient and say, ‘That’s great. Let’s see if you can do that again.’ "

The goals are to accelerate recovery, independence, and functionality, Dr. Gollan said at a seminar, "Reinventing Inpatient Psychiatry." In a well-controlled context, inpatients can actually learn how to manage their illnesses.

Passivity and avoidance are prevalent in psychiatric conditions, and this behavioral strategy is designed to reduce them, and to improve the quality and acceptability of care, she said.

Theoretically, overall health outcomes will also be improved. The psychiatric concept of avoidance has been linked in the literature to increased hypertension and cardiovascular mortality and diminished immunity, as well as substance abuse, depressive symptoms, overall lower quality of life, and increased mortality, she said.

Northwestern Memorial Hospital integrates behavioral action communication throughout the psychiatric unit, employing it in group meetings, education, nursing care, physician inquiry, discharge plans, and social work. A manual on the subject is given to each patient’s family members so they can reinforce goals at home, helping the individual to identify and reduce passivity and avoidance, and to understand that all behaviors have a purpose or goal. The intent is to teach the patient to connect context, behavior, and mood.

In the clinic, the first step in teaching the psychiatric patient to monitor his or her behavior is a self-reported instrument called the Checklist of Unit Behaviors, or CUB. This checklist assesses the patient’s activation (activities that create positive changes in symptoms or function) in two dimensions: approach and avoidance. The patient and staff members track progress each day with an item-by-item discussion that focuses on the patient’s successes. The conversations emphasize the context and function of behavior; avoidance behaviors are associated with negative affect.

"Every morning, they fill out a CUB," Dr. Gollan said. "It truly reflects what they’re doing. The patient reports being high or low on avoidance or approach. A set of avoidance behaviors is associated with negative affect. On intake you see high levels of avoidance ... then there’s feathering out."

The psychometric properties of the CUB allow clinicians to implement a treatment plan that increases positive affect, ultimately to help the patient have a greater interest in taking care of himself, said Dr. Gollan.

An experiment comparing the behavioral action communication (BAC) unit with the Treatment as Usual (TAU) unit reinforced this finding. Outcome measures were the Brief Symptom Inventory, Positive and Negative Affect Schedule (PANAS), Behavioral Inhibition/Activation Scale (BIS/BAS), and CUB.

The sample (n = 149) was divided between the BAC unit (72 patients) and TAU unit (77 patients), with the TAU acting as the control. No significant differences were found in patient age (mean = 38.7 years) or gender (49% male). A One-Sample T test did not reveal significant differences across psychiatric disorders using Brief Symptom Inventory for each unit at admission (P = .30). These disorders/behaviors included depression, anxiety, hostility, somatization, obsessive-compulsive, interpersonal sensitivity, phobic anxiety, paranoid ideation, and psychoticism.

The study found that increase in positive affect from admission to discharge was higher for those in the BAC unit. Patients in the BAC unit with elevated major depressive disorder reported improved positive affect at discharge, compared with those in the TAU unit. BAC unit patients also reported significantly higher approach behaviors at discharge than did TAU unit patients. BAC and TAU unit patients showed major reduction of avoidance equivalent across units at intake and discharge.

Overall, patients’ assessments of behavioral activation communication were positive. Their comments included: "It helps me visualize what’s going on," "It helps me to write things down instead of just thinking about them," and "It’s nice to know that someone is checking up on you and monitoring your progress."

A member of the audience asked whether the hospital had seen any change in repeat admissions. Dr. Gollan said data on repeat admissions were not yet available.

Dr. Gollan disclosed no relevant conflicts of interest.

CHICAGO – The literature is clear that suicide cannot be predicted, but clinicians are obliged to assess it, said Dr. Cathy Frank, vice chair of clinical affairs in the department of psychiatry and behavioral sciences at Northwestern University, Chicago.

There is no perfect algorithm, she said, and no standardized scale is associated with a high predictive value, despite a number of proposals.

And so, most frustrating for the physician is the inability to accurately identify the potential suicide, Dr. Frank said as she reviewed current data on risk assessment and therapy, epidemiology, and risk factors at a seminar on reinventing inpatient psychiatry.

In the United States alone, suicide claims a life every 16 minutes, adding up to 33,300 people annually, compared with 20,000 deaths by homicide, Dr. Frank reported, citing data from the Centers for Disease Control and Prevention.

And, she explained, "It’s not just an illness of industrial populations." Worldwide, 1 million people die from suicide each year, a ratio of 16.7 suicides/100,000 lives (Lancet 2009;373:1372-81).

Nonfatal self-injury is more common in females than males. "Men are three times as likely to complete a suicide ... so gender matters," Dr. Frank said. Patients who have attempted suicide once are five to six times more likely to attempt it again (Arch. Gen. Psychiatry 1983;40:249-57).

Adolescents and young adults are the most likely to attempt suicide, and emergency department data suggest that 75% have a mental disorder and 9% have a diagnosis of alcohol abuse.

There are a variety of social and biological risk factors. Social risk factors include parental separation, family discord, child abuse, bullying, peer victimization, unemployment, living alone, and never having been married.

Physicians and dentists are the occupations most at risk, followed by police officers and military personnel. In 2006, male veterans of the Iraq and Afghanistan wars aged 18-29 years suffered 46 suicides/100,000 lives, a rate 2.3 times higher than in matched civilian population, according to the U.S. Department of Veterans Affairs. The availability of lethal weapons is key risk factor, because 60% of lethal attempts involve firearms. Men are more likely than are women to choose a violent death.

Biological and genetic risk factors have also been identified for suicide. Suicide attempts and completions run in families, independent of psychiatric diagnosis, and adoption studies provide evidence of a genetic basis of, Dr. Frank reported.

"The effectiveness of lithium and clozapine suggests a biological mechanism for suicide," Dr. Frank said. Lithium has both antiaggressive and anti-impulsive effects, she said.

High-risk patients include those with absence of social support, with family conflict, and patients diagnosed with schizophrenia or a mood disorder, along with those who have a history of suicide attempts.

Known markers of acute risk are moderate to severe depression; current mania and/or psychosis; alcohol and/or substance abuse within the last month; hopelessness; and suicidal intent. Markers of moderate risk include mild depression, moderate anxiety, and a history of suicide attempts, as well as chronic pain. Patients at low risk might have anxiety that is neither moderate nor severe, depressive disorder, or bipolar disorder in remission.

Treatment interventions depend on the patient’s mental state, and can range from electroconvulsive therapy and the use of psychotropic medications to straightforward self-management. Self-management is a key to successful treatment, said Dr. Frank, and should begin at admission, making patients active members of the treatment team and letting them help direct the course of treatment.

Family involvement is a particularly essential part of the guidelines and an integral part of treatment, Dr. Frank said. Families "are your eyes and ears." They can provide important collateral information and help assess risk, and family involvement may lower litigation risk. Family conflict, however, has been linked to inpatient suicide (J. Nerv. Ment. Dis. 2010;198:315-28).

The patient’s "community" is now also part of every treatment plan at Dr. Frank’s institution. "No clinician can be everything at all moments to the patient. So how do we involve community?" she said. Community support might include the National Alliance on Mental Illness, Alcoholics Anonymous, Narcotics Anonymous, and bereavement support groups, for example. Dr. Frank also suggests removing weapons from the patient’s home.

Dr. Frank disclosed no relevant conflicts of interest.

CHICAGO – The literature is clear that suicide cannot be predicted, but clinicians are obliged to assess it, said Dr. Cathy Frank, vice chair of clinical affairs in the department of psychiatry and behavioral sciences at Northwestern University, Chicago.

There is no perfect algorithm, she said, and no standardized scale is associated with a high predictive value, despite a number of proposals.

And so, most frustrating for the physician is the inability to accurately identify the potential suicide, Dr. Frank said as she reviewed current data on risk assessment and therapy, epidemiology, and risk factors at a seminar on reinventing inpatient psychiatry.

In the United States alone, suicide claims a life every 16 minutes, adding up to 33,300 people annually, compared with 20,000 deaths by homicide, Dr. Frank reported, citing data from the Centers for Disease Control and Prevention.

And, she explained, "It’s not just an illness of industrial populations." Worldwide, 1 million people die from suicide each year, a ratio of 16.7 suicides/100,000 lives (Lancet 2009;373:1372-81).

Nonfatal self-injury is more common in females than males. "Men are three times as likely to complete a suicide ... so gender matters," Dr. Frank said. Patients who have attempted suicide once are five to six times more likely to attempt it again (Arch. Gen. Psychiatry 1983;40:249-57).

Adolescents and young adults are the most likely to attempt suicide, and emergency department data suggest that 75% have a mental disorder and 9% have a diagnosis of alcohol abuse.

There are a variety of social and biological risk factors. Social risk factors include parental separation, family discord, child abuse, bullying, peer victimization, unemployment, living alone, and never having been married.

Physicians and dentists are the occupations most at risk, followed by police officers and military personnel. In 2006, male veterans of the Iraq and Afghanistan wars aged 18-29 years suffered 46 suicides/100,000 lives, a rate 2.3 times higher than in matched civilian population, according to the U.S. Department of Veterans Affairs. The availability of lethal weapons is key risk factor, because 60% of lethal attempts involve firearms. Men are more likely than are women to choose a violent death.

Biological and genetic risk factors have also been identified for suicide. Suicide attempts and completions run in families, independent of psychiatric diagnosis, and adoption studies provide evidence of a genetic basis of, Dr. Frank reported.

"The effectiveness of lithium and clozapine suggests a biological mechanism for suicide," Dr. Frank said. Lithium has both antiaggressive and anti-impulsive effects, she said.

High-risk patients include those with absence of social support, with family conflict, and patients diagnosed with schizophrenia or a mood disorder, along with those who have a history of suicide attempts.

Known markers of acute risk are moderate to severe depression; current mania and/or psychosis; alcohol and/or substance abuse within the last month; hopelessness; and suicidal intent. Markers of moderate risk include mild depression, moderate anxiety, and a history of suicide attempts, as well as chronic pain. Patients at low risk might have anxiety that is neither moderate nor severe, depressive disorder, or bipolar disorder in remission.

Treatment interventions depend on the patient’s mental state, and can range from electroconvulsive therapy and the use of psychotropic medications to straightforward self-management. Self-management is a key to successful treatment, said Dr. Frank, and should begin at admission, making patients active members of the treatment team and letting them help direct the course of treatment.

Family involvement is a particularly essential part of the guidelines and an integral part of treatment, Dr. Frank said. Families "are your eyes and ears." They can provide important collateral information and help assess risk, and family involvement may lower litigation risk. Family conflict, however, has been linked to inpatient suicide (J. Nerv. Ment. Dis. 2010;198:315-28).

The patient’s "community" is now also part of every treatment plan at Dr. Frank’s institution. "No clinician can be everything at all moments to the patient. So how do we involve community?" she said. Community support might include the National Alliance on Mental Illness, Alcoholics Anonymous, Narcotics Anonymous, and bereavement support groups, for example. Dr. Frank also suggests removing weapons from the patient’s home.

Dr. Frank disclosed no relevant conflicts of interest.

CHICAGO – The literature is clear that suicide cannot be predicted, but clinicians are obliged to assess it, said Dr. Cathy Frank, vice chair of clinical affairs in the department of psychiatry and behavioral sciences at Northwestern University, Chicago.

There is no perfect algorithm, she said, and no standardized scale is associated with a high predictive value, despite a number of proposals.

And so, most frustrating for the physician is the inability to accurately identify the potential suicide, Dr. Frank said as she reviewed current data on risk assessment and therapy, epidemiology, and risk factors at a seminar on reinventing inpatient psychiatry.

In the United States alone, suicide claims a life every 16 minutes, adding up to 33,300 people annually, compared with 20,000 deaths by homicide, Dr. Frank reported, citing data from the Centers for Disease Control and Prevention.

And, she explained, "It’s not just an illness of industrial populations." Worldwide, 1 million people die from suicide each year, a ratio of 16.7 suicides/100,000 lives (Lancet 2009;373:1372-81).

Nonfatal self-injury is more common in females than males. "Men are three times as likely to complete a suicide ... so gender matters," Dr. Frank said. Patients who have attempted suicide once are five to six times more likely to attempt it again (Arch. Gen. Psychiatry 1983;40:249-57).

Adolescents and young adults are the most likely to attempt suicide, and emergency department data suggest that 75% have a mental disorder and 9% have a diagnosis of alcohol abuse.

There are a variety of social and biological risk factors. Social risk factors include parental separation, family discord, child abuse, bullying, peer victimization, unemployment, living alone, and never having been married.

Physicians and dentists are the occupations most at risk, followed by police officers and military personnel. In 2006, male veterans of the Iraq and Afghanistan wars aged 18-29 years suffered 46 suicides/100,000 lives, a rate 2.3 times higher than in matched civilian population, according to the U.S. Department of Veterans Affairs. The availability of lethal weapons is key risk factor, because 60% of lethal attempts involve firearms. Men are more likely than are women to choose a violent death.

Biological and genetic risk factors have also been identified for suicide. Suicide attempts and completions run in families, independent of psychiatric diagnosis, and adoption studies provide evidence of a genetic basis of, Dr. Frank reported.

"The effectiveness of lithium and clozapine suggests a biological mechanism for suicide," Dr. Frank said. Lithium has both antiaggressive and anti-impulsive effects, she said.

High-risk patients include those with absence of social support, with family conflict, and patients diagnosed with schizophrenia or a mood disorder, along with those who have a history of suicide attempts.

Known markers of acute risk are moderate to severe depression; current mania and/or psychosis; alcohol and/or substance abuse within the last month; hopelessness; and suicidal intent. Markers of moderate risk include mild depression, moderate anxiety, and a history of suicide attempts, as well as chronic pain. Patients at low risk might have anxiety that is neither moderate nor severe, depressive disorder, or bipolar disorder in remission.

Treatment interventions depend on the patient’s mental state, and can range from electroconvulsive therapy and the use of psychotropic medications to straightforward self-management. Self-management is a key to successful treatment, said Dr. Frank, and should begin at admission, making patients active members of the treatment team and letting them help direct the course of treatment.

Family involvement is a particularly essential part of the guidelines and an integral part of treatment, Dr. Frank said. Families "are your eyes and ears." They can provide important collateral information and help assess risk, and family involvement may lower litigation risk. Family conflict, however, has been linked to inpatient suicide (J. Nerv. Ment. Dis. 2010;198:315-28).

The patient’s "community" is now also part of every treatment plan at Dr. Frank’s institution. "No clinician can be everything at all moments to the patient. So how do we involve community?" she said. Community support might include the National Alliance on Mental Illness, Alcoholics Anonymous, Narcotics Anonymous, and bereavement support groups, for example. Dr. Frank also suggests removing weapons from the patient’s home.

Dr. Frank disclosed no relevant conflicts of interest.