The evaluation of suicide risk is a challenging clinical task. Suicide is a multi-determined act that results from a complex interaction between a number of factors. It is unfortunate but true that most clinicians have had or will have patients who attempt or commit suicide, making patient suicide an occupational hazard for clinicians.
Suicide is a rare, unpredictable event. Suicide risk factors are present in many patients with depression who do not commit suicide. Clinical standards for the prediction of suicide do not exist; however, the standard of care requires clinicians to perform adequate suicide risk assessments. Systematic suicide risk assessment is an inductive process that identifies and weighs the suicidal patient's risk and protective factors before arriving at an overall assessment of low, moderate or high risk. Merely obtaining a "contract for safety" from the patient and documenting that "the patient denies suicidal ideation, intent or plan" is not an adequate suicide risk assessment. Patients who are determined to commit suicide regard the clinician as an enemy, not as a benefactor (Resnick, 2002). Studies show that patients frequently deny suicidal ideation, intent or plan before attempting or committing suicide.
Suicide risk assessment helps the clinician to identify treatable risk factors, evaluate protective factors and inform patient safety management. The immediate treatment of acute risk factors such as anxiety, panic attacks and severe insomnia can be lifesaving. For example, a patient may be able to withstand severe depression until antidepressants or electroconvulsive therapy become effective. However, the presence of panic attacks can make life intolerable, increasing the risk that the patient will seek quick relief through suicide.
Most clinicians can treat only a few patients who are suicidal at any given time. Some clinicians will not treat patients at risk for suicide. Patients who are suicidal can rapidly deplete the clinician's physical and mental resources. For example, the clinician may feel frustration, anger, despair and hopelessness. Countertransference hate may be experienced because a patient's suicide represents a severe threat to the clinician's competence and raises the spectre of a malpractice suit (Maltsberger and Buie, 1974). Countertransference mismanagement may be associated with an increased risk for patient suicide. Consultation is always appropriate with difficult, complex cases. If the clinician is unable to effectively treat the patient, referral should be made. However, the patient must not be abandoned.
The excellent articles in this special report section by recognized authorities will help clinicians in the challenging tasks of assessing, treating and managing patients at risk for suicide.
Psychiatric Times thanks Dr. Simon for his assistance in planning and reviewing this special report section.
Dr. Simon is the author of Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management, recently published by American Psychiatric Publishing Inc.
1. Maltsberger JT, Buie DH (1974), Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry 30(5):625-633.
2. Resnick PJ (2002), Recognizing that the suicidal patient views you as an adversary. Current Psychiatry 1(1):8.