Enhancing Suicide Risk Assessment Through Evidence-Based Psychiatry

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Educational Objectives

After reading this article, you will be familiar with:

• The factors that contribute to increase suicide risk as well as those that are protective.
• The importance of well-documented suicide risk assessments.
• Evidence-based methodology for suicide risk assessment.

Who will benefit from reading this article?
Psychiatrists, neurologists, primary care physicians, geriatricians, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.

Suicide risk assessment is a core competency that all psychiatrists must have.¹ A competent suicide assessment identifies modifiable and treatable protective factors that inform patient treatment and safety management.² Psychiatrists, unlike other medical specialists, do not often experience patient deaths, except by suicide. Patient suicide is an occupational hazard. A clinical axiom holds that there are 2 kinds of psychiatrists: those who have had patients commit suicide—and those who will.

The psychiatrist frequently assesses suicidal patients who present with life-threatening emergencies. The psychiatrist, unlike other physicians, does not have laboratory tests and sophisticated diagnostic instruments to evaluate patients at risk for suicide. The psychiatrist’s diagnostic instrument is competent suicide risk assessment.

Substandard suicide risk assessments are the second most common root cause of suicide, after depression, and contribute to more than 85% of inpatient suicides.³ No single suicide risk assessment method has been empirically tested for reliability and validity.

Well-documented suicide risk assessments are a core measure of quality of care.² Currently, standard practice encompasses a range of reasoned clinical approaches to suicide risk assessment. Using evidence-based psychiatry is best practice. It is not, however, a standard-of-care requirement for suicide risk assessment.

The problem
Various factors including tradition, caprice, defensiveness, and preconceptions can lead to the uncritical acceptance and perpetuation of substandard, suicide risk assessments. Mental health professionals must do more than merely ask patients if they are suicidal and then record, “No SI, HI, or CFS (no suicidal ideation, homicidal ideation, contracts for safety).” Suicide assessment necessitates identifying, ranking, and integrating multiple risk and protective factors into an overall clinical judgment of risk.

Time, money, inadequate training, and litigation fears can combine to negatively influence adequate suicide risk assessment and documentation. The fear of becoming embroiled in a malpractice suit if a patient attempts or commits suicide can engender inappropriate defensive practices. Countertransference from an anxiety-provoking, suicidal patient can result in inadequate risk assessment and treatment.⁴ In addition, many psychiatrists have not been trained to do adequate suicide risk assessments.

It is generally assumed that clinicians will somehow acquire this knowledge in the course of clinical practice. Just as the internist must be trained to assess the emergency cardiac patient, the psychiatrist must acquire knowledge necessary to competently evaluate the suicidal patient. The core competence necessary to perform suicide risk assessments is difficult to obtain by unaided clinical experience alone.

No psychological tests exist that can predict suicide.⁵ Although self-assessment instruments generally cannot be relied on because guarded or deceptive suicidal patients may not answer honestly, some patients may reveal more about suicide risk on self-assessment than at the initial clinical interview.⁵ Assessment forms and checklists, however, often omit evidence-based general and important individual suicide risk factors. Some checklists contain items that are not recognized risk factors for suicide. The “know your patient imperative” is absent. Checking off forms robotically is not credible risk assessment.

An extensive psychiatric literature exists on suicide but relatively little exists on the topic of suicide risk assessment. The American Psychiatric Association’s “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors” is an excellent source for the conduct of suicide risk assessment.⁶ Learning how to perform competent suicide risk assessments must begin during psychiatric residency. Lectures, tutorials, and especially case conferences that monitor patients for suicide risk during their course of treatment are essential. Assessment is a process, not an event.

Evidence-based assessment
Sackett and colleagues⁷ defined evidence-based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

The preferred methods of evidence-based psychiatry described by Gray⁸ for determining harm (risk) are cohort and case-control studies. Online evidence-based psychiatric information sources include the National Electronic Library for Mental Health (comprehensive sources), Evidence-Based Mental Health (structured abstracts), the Cochrane Database of Systematic Reviews (systematic reviews), and PubMed (original articles).

Table 1 provides examples of evidence-based suicide risk factors, which are arranged according to the hierarchy of supporting evidence. The hierarchy of evidences for studies of harm (risk) include systematic reviews (meta-analyses), the highest level of evidence, followed by cohort studies (prospective or retrospective), and case control studies (retrospective).⁸ In a retrospective cohort study, a historical cohort is identified through existing records for outcomes of interest at the beginning of the study. Dependence on existing records, however, raises questions of data quality.⁸ The basis for non–evidence-based suicide risk factors comes from case reports, case series, clinical opinion, and clinical consensus. Clinical opinion and consensus are important in suicide risk assessment, if buttressed by evidence-based studies.