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The Suicidal Patient: Risk Assessment, Management, and Documentation

The Suicidal Patient: Risk Assessment, Management, and Documentation

Suicide is a serious public health problem that ranks as the 11th leading cause of death in the United States. Within the 15- to 24-year-old age group, it is the third leading cause of death.1 Many suicide victims have had contact with the mental health system before they died, and almost one fifth had been psychiatrically hospitalized in the year before completing suicide.2,3 A recent review found that psychiatric illness is a major contributing factor to suicide, and more than 90% of suicide victims have a DSM-IV diagnosis.4,5 Because of these statistics, the assessment of suicide risk is a much needed core competency in psychiatric practice and has recently been recognized as a core curriculum requirement in the residency training of psychiatrists. The American Psychiatric Association (APA) has also recognized the importance of this clinical skill with its publication of a practice guideline for the assessment and treatment of patients with suicidal behaviors.6

Unfortunately, many clinicians take 1 of 2 approaches to suicide risk assessment.7 Some are overly cautious and assume that anyone who reports suicidal thoughts is at high risk for suicide. This approach leads to unnecessary deprivation of patients' liberties and rights as well as to the squandering of scarce clinical resources. Others underestimate suicidality through a dismissive attitude or inept assessment, thereby jeopardizing patient safety and increasing physician liability should there be a negative outcome.

Suicide is rare. Like an earthquake and other rare events, it is difficult to predict; attempts at prediction have led to a high number of false-positive predictions.8 For that reason, suicide prediction is not the goal of risk assessment. Rather, risk assessment serves a dual purpose.

First, more than any psychiatric intervention (other than successful treatment of an eating disorder) it has the potential to reduce patient mortality. While not aimed at predicting who will likely commit suicide, its purpose is to identify modifiable or treatable acute, high-risk suicide factors and available protective factors that will inform and guide patient treatment as well as safety management.9

Second, in the event of a malpractice suit, a thorough and documented risk assessment can help establish that a psychiatrist was not derelict in the duty to practice in a manner that adheres to a reasonable standard of care.

A survey of primary care physicians who lost a patient to suicide found that a risk assessment was only completed in 38% of cases.10 Studies of risk assessment documentation in psychiatric practice are lacking, although since 1998, suicide and attempted suicide account for 15% to 16% of malpractice claims by cause of loss in the United States.11,12 In lawsuits involving patient suicide, the determination of whether actions of the psychiatrist met the standard of care is made by a review of certain factors:

  • Whether there was adequate identification and evaluation of suicide risk indicators and protective factors.
  • Whether a reasonable treatment plan was developed on the basis of the patient's clinical needs.
  • Whether the treatment plan was appropriately implemented and modified on the basis of ongoing clinical assessment.
  • Whether the psychiatrist's knowledge was current in the assessment and treatment of suicidal patients.
  • Whether there was adequate documentation in the record to support that appropriate care was provided.

This article will outline the principles of suicide risk assessment from an evidenced-based and liability-prevention standpoint and provide a model for medical record documentation from a risk management perspective.

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