MIRECC / CoE

Rocky Mountain MIRECC for VA Suicide Prevention

Updated: 1 April 2019

Biography

Dr. Hal S. Wortzel 

Title: Co-Director of Suicide Risk Management Consultation Program
Contact:
720-723-6481
hal.wortzel@va.gov

 

Dr. Wortzel graduated from Amherst College majoring in Biology in 1996 and then went on to medical school at NYU, graduating AOA in 2001. He completed his training in general psychiatry at the University of Colorado in 2005, serving as Chief Resident for the University’s Outpatient and Consultation-Liaison services. Following residency, Dr. Wortzel completed the University of Colorado’s Fellowship in Forensic Psychiatry. He then went on to complete a two year combined fellowship integrating the University’s Behavioral Neurology & Neuropsychiatry Fellowship with the VA’s MIRECC Fellowship in Advanced Psychiatry, emphasizing research in suicidology. He now brings his combined training and skills as a forensic neuropsychiatrist to the Denver VA’s Rocky Mountain MIRECC, where he serves as Director of Neuropsychiatric Consultation Services, and Co-Director of the VA Suicide Risk Management Consultation Program. Dr. Wortzel is an associate professor of Psychiatry, Neurology, and Physical Medicine & Rehabilitation at the University of Colorado. He serves as the Michael K. Cooper Professor of Neurocognitive Disease, Director of the Neuropsychiatry Service, and as faculty for the Division of Forensic Psychiatry. Dr. Wortzel maintains a private practice in Forensic Neuropsychiatry & Behavioral Neurology. Current areas of clinical and academic focus include aggression and suicide in the context of PTSD and TBI, incarcerated veterans, and the application of emerging neuroscientific tools to the legal arena.

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Recent Publications

Publication: Therapeutic Risk Management: Chain Analysis of Suicidal Ideation and Behavior

1 April 2019 - RMIRECC PIs Lauren Borges, PhD, Sarra Nazem, PhD, Bridget Matarazzo, PsyD, Sean Barnes, PhD, and Hal Wortzel, MD write "Structural approaches to suicide risk assessment (eg, evaluating the frequency and intensity of suicidal ideation and classifying types of suicidal behavior) often fall short of providing an idiographic and dynamic analysis of the factors driving and maintaining an individual's suicide risk. Structural approaches can be bolstered through chain analysis which facilitates an exploration of the factors maintaining suicidal ideation and behavior based on positive and negative reinforcement. By uncovering the factors causing suicidal ideation and behavior to persist, efficient intervention strategies can be selected to target these pathways. In this column, the authors delineate the use of chain analysis to guide suicide risk assessment and inform treatment planning." Read more

Arciniegas DB, Wortzel HS. Emotional and Behavioral Dyscontrol After Traumatic Brain Injury. Psychiatr Clin North Am. 2014 Mar;37(1):31-53.

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol. Published by Elsevier Inc.

Keywords: Traumatic Brain Injury (TBI)

Brenner, L. A., Hoffberg, A. S., Shura, R. D., Bahraini, N., & Wortzel, H. S. (2013). Interventions for mood-related issues post traumatic brain injury: Novel treatments and ongoing limitations of current research. Current Physical Medicine and Rehabilitation Reports, September 2013, Volume 1, Issue 3, pp 143-150.

Mood-related issues following traumatic brain injuries (TBI) are highly prevalent and negatively impact psychosocial functioning. Such symptoms are also frequently undertreated. The aim of this publication is to highlight work regarding interventions for the treatment of post-TBI mood issues. Twelve recently published articles were identified (two systematic reviews, one Cochrane protocol, and nine original research studies). Presented manuscripts support both traditional (e.g., psychotherapy) and novel (e.g., exercise) interventions. Despite these scholarly endeavors, definitive findings regarding effective treatments for post-TBI mood disorders remain sparse. Of particular concern was the lack of recent research regarding traditional pharmacological interventions. Further work is required to identify efficacious and effective interventions for members of this high risk population.

Keywords: Traumatic Brain Injury (TBI)

Homaifar B, Matarazzo B, Wortzel HS. Therapeutic risk management of the suicidal patient: augmenting clinical suicide risk assessment with structured instruments. J Psychiatr Pract. 2013 Sep;19(5):406-9.

This column is the second in a series presenting a model for therapeutic risk management of the suicidal patient. As discussed in the first part of the series, the model involves several elements including augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. This column explores in more detail how to augment clinical risk assessment with structured instruments. Unstructured clinical interviews have the potential to miss important aspects of suicide risk assessment. By augmenting the free-form clinical interview with structured instruments that demonstrate reliability and validity, a more nuanced and multifaceted approach to suicide risk assessment is achieved. Incorporating structured instruments into practice also serves a medicolegal function, since these instruments may become a living part of the medical record, establishing baseline levels of suicidal thoughts and behaviors and facilitating future clinical determinations regarding safety needs. We describe several instruments used in a multidisciplinary suicide consultation service, each of which has demonstrated relevance to suicide risk assessment and screening, ease of administration, and strong psychometric properties. In addition, we emphasize the importance of viewing suicide risk assessment as an ongoing process rather than as a singular event. Finally, we discuss special considerations in the evolving practice of risk assessment. (Journal of Psychiatric Practice 2013;19:406-409).

Keywords: Suicide Prevention

Matarazzo BB, Homaifar BY, Wortzel HS. Therapeutic risk management of the suicidal patient: safety planning. J Psychiatr Pract. 2014 May;20(3):220-4.

This column is the fourth in a series describing a model for therapeutic risk management of the suicidal patient. Previous columns presented an overview of the therapeutic risk management model, provided recommendations for how to augment risk assessment using structured assessments, and discussed the importance of risk stratification in terms of both severity and temporality. This final column in the series discusses the safety planning intervention as a critical component of therapeutic risk management of suicide risk. We first present concerns related to the relatively common practice of using no-suicide contracts to manage risk. We then present the safety planning intervention as an alternative approach and provide recommendations for how to use this innovative strategy to therapeutically mitigate risk in the suicidal patient. (Journal of Psychiatric Practice 2014;20:220-224).

Keywords: Suicide Prevention

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Richards P, Wortzel HS: Avoiding Dual Agency in Clinical and Medicolegal Practice. Law and Psychiatry Column, Journal of Psychiatric Practice 21(5):370-73, 2015

Mental health professionals who provide medicolegal services need to be aware of the very important differences between clinical and retained expert/forensic roles. This column offers a distinction between clinical and forensic roles in terms of responsibilities, objectives, and guiding ethical principles. Existing professional guidelines and other views from the medical literature that discourage the mixing of such roles are reviewed. The conflation of clinical and forensic roles and the attendant risks are considered, in terms of both competing interests and the possible ethical threat associated with assuming a dual role. Knowingly or unwittingly assuming a dual role is potentially harmful to the therapeutic alliance, threatens the expert's objectivity, and may jeopardize a patient's legal case. Guidance is offered as to how to avoid conflating clinical and forensic roles when compelled to provide medicolegal services.

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Vasile M, Hamalian G, Wortzel HS. New Guidelines for Forensic Assessment. J Psychiatr Pract. 2016 Mar;22(2):124-7. doi: 10.1097/PRA.0000000000000141.

The American Academy of Psychiatry and the Law (AAPL) recently published guidelines for forensic assessment intended for psychiatrists and other clinicians working in medicolegal roles, or performing evaluations and offering opinions in relation to legal or regulatory matters. Although these guidelines do not establish a singular standard for forensic evaluation, they are intended to inform practice. Although nuances pertaining to any given case and the pertinent medicolegal issues involved will require professional judgment as to how best to conduct any particular evaluation, the guidelines do offer many helpful tenets and guiding principles that are broadly applicable. Psychiatrists and other clinicians performing forensic evaluations need to be aware of these guidelines and should strive to incorporate them as appropriate. In this column we offer a brief synopsis of the approach to the forensic psychiatric assessment based upon the AAPL Practice Guideline for the Forensic Assessment.

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Wortzel HS: Book Review of Psychiatric Expert Testimony – Emerging Applications. American Journal of Psychiatry 172(9): 915-16, 2015

No abstract available

Wortzel HS: Chronic Traumatic Encephalopathy: Should We Be Worried? Psychiatric Times, Special Report – Neuropsychiatry: 12-17, April 2014

No abstract available

Wortzel HS. The DSM-5 and Forensic Psychiatry. J Psychiatr Pract. 2013 May;19(3):238-41.

In his first Law and Psychiatry column for the Journal of Psychiatric Practice, the author discusses potential forensic consequences of the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). While the transition to DSM-5 may prove challenging for both patients and clinicians, the scrutiny and adversarial process associated with forensic psychiatric practice will entail a unique set of challenges. The philosophy of innovation behind the DSM-5, and the attendant changes, could lead to some unintended consequences, particularly in medicolegal settings. This column highlights some of the major changes in DSM-5 and explores points of particular concern for forensic psychiatric practice, such as the move toward a non-multiaxial diagnostic system and dimensional severity ratings being superimposed on certain categorical diagnoses. The innovative changes featured in DSM-5, and the controversies surrounding some of them, could yield an environment of increased cynicism in courts of law, with renewed skepticism regarding mental health diagnoses and the forensic psychiatrists who testify about them. Fortunately, the best method for forensic psychiatric practice in this environment of change is to continue to adhere to a meticulous and transparent medicolegal process, with recognition that changes in the diagnostic manual will seldom alter essential medicolegal conclusions. Forensic psychiatrists may enhance their credibility and the strength of the opinions they offer by proactively illustrating how nuances in diagnosis do not change legally defined constructs such as insanity or incompetence. (Journal of Psychiatric Practice 2013;19:238-241).

Wortzel HS, Arciniegas DB: A Forensic Neuropsychiatric Approach to Traumatic Brain Injury, Aggression, and Suicide. Journal of the American Academy of Psychiatry and the Law 41:274-86, 2013

Aggression is a common neuropsychiatric sequela of traumatic brain injury (TBI), one which interferes with rehabilitation efforts, disrupts social support networks, and compromises optimal recovery. Aggressive behavior raises critical safety concerns, potentially placing patients and care providers in harm’s way. Such aggression may be directed outwardly, manifesting as assaultive behavior, or directed inwardly, resulting in suicidal behavior. Given the frequency of TBI and posttraumatic aggression and the potential medicolegal questions surrounding the purported causal relationships between the two, forensic psychiatrists need to understand and recognize posttraumatic aggression. They also must be able to offer cogent formulations about the relative contributions of neurotrauma versus other relevant neuropsychiatric factors versus combinations of both to any specific act of violence. This article reviews the relationships between TBI and aggression and discusses neurobiological and cognitive factors that influence the occurrence and presentation of posttraumatic aggression. Thereafter, a heuristic is offered that may assist forensic psychiatrists attempting to characterize the relationships between TBI and externally or internally directed violent acts.

Keywords: Suicide Prevention, Traumatic Brain Injury (TBI)

Wortzel HS, Brenner LA, Arciniegas DB. Traumatic Brain Injury and Chronic Traumatic Encephalopathy: A Forensic Neuropsychiatric Perspective. Behav Sci Law. 2013 Sep 9.

Recent scientific reports and popular press describing chronic traumatic encephalopathy (CTE) collectively link this condition to a broad array of neuropsychiatric symptoms, including extremely rare and multi-determined behaviors such as murder-suicide. These reports are difficult to reconcile with several decades of research on the science of traumatic brain injury (TBI) and its consequences, especially the natural history and prognosis of mild TBI. This article attempts to reconcile these sources by reviewing the state of the science on CTE, with particular attention to case definitions and neuropathological criteria for this diagnosis. The evidence for links between TBI, CTE, and catastrophic clinical events is explored, and the complexity of attributing rare frequency behavioral events to CTE is highlighted. The clinical and medicolegal implications of the best available evidence are discussed, concluding with a cautionary note against prematurely generalizing current findings on CTE to entire populations of persons with, or at risk for, concussion exposures. Copyright © 2013 John Wiley & Sons, Ltd.

Keywords: Traumatic Brain Injury (TBI)

Wortzel HS, Homaifar B, Matarazzo B, Brenner LA. Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. J Psychiatr Pract. 2014 Jan;20(1):63-7.

This column is the third in a series describing a model for therapeutic risk management of the suicidal patient. In the preceding column, we described augmenting clinical suicide risk assessment with structured instruments. In this column, we describe how clinicians can use the totality of available clinical data to offer a two-dimensional risk stratification that qualifies risk in terms of both severity and temporality. By offering two separate designations that reflect severity for both acute and chronic risk, conceptualizing and communicating a patient's risk for suicide is accomplished in a more nuanced way, providing the level of detail necessary when working with high risk individuals, especially those struggling with chronic suicidal ideation. Formulations reflecting suicide risk need to be accurate and facilitate good clinical decision-making in order to optimally balance the principles of autonomy, non-maleficence, and beneficence. Stratifying risk in terms of both severity and temporality helps identify situations in which involuntary hospitalization is warranted, while also helping to minimize unnecessary admissions. Hence, two-dimensional risk stratification that addresses both acute and chronic risk for suicide is an essential component of therapeutic risk management of the suicidal patient.

Keywords: Suicide Prevention

Wortzel HS, Matarazzo B, Homaifar B. A model for therapeutic risk management of the suicidal patient. J Psychiatr Pract. 2013 Jul;19(4):323-6.

While the practice of psychiatry involves many challenges, few scenarios are as clinically and emotionally demanding as managing the patient who is at high risk for suicide. Risk management is a reality of psychiatric practice, and this necessitates practicing and documenting thoughtful suicide risk assessment and management. Therapeutic risk management is based on clinical risk management that is patient-centered, supportive of the treatment process, and maintains the therapeutic alliance. In this article, the authors present a broad overview of a model for achieving therapeutic risk management of the suicidal patient that involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. These elements are readily accessible to and deployable by mental health clinicians in most disciplines and treatment settings, and they collectively yield a suicide risk assessment and management process (and attendant documentation) that should withstand the scrutiny that often occurs in the wake of a patient suicide or suicide attempt. (Journal of Psychiatric Practice 2013;19:323-326).

Keywords: Suicide Prevention

Wortzel HS, Tsiouris AJ, Filippi CG. (2014). The Potential for Medicolegal Abuse: Diffusion Tensor Imaging in Traumatic Brain Injury, AJOB Neuroscience, 5:2, 9-15.

This article discusses the nature and value of diffusion tensor imaging (DTI) in medicolegal settings. Although the technology and theory that supports DTI is provocative and exciting, we argue that expert testimony that confidently relies on DTI is highly problematic. In this article, we discuss the current limitations inherent in acquiring and analyzing DTI data; list problems especially with specificity that limit DTI’s appropriateness in single-subject instances; and provide a brief history of the misuse and abuse of neuroimaging in mental illness and brain injury.We conclude with a plea for healthy skepticism regarding the value of these latest modalities in medicolegal settings, especially given the nature of their frequently visually spectacular impact on judges and jurors.

Keywords: law, neuroimaging

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