The Suicidal Patient: Risk Assessment, Management, and Documentation

In a person with suicidal ideation, alcohol use and intoxication can be disinhibiting and thereby lead to suicide attempts. Alcoholism alone increases suicide risk 6-fold.³⁴ Persons with alcoholism and major depression are more prone to suicide than individuals with major depression or alcoholism alone, and major depression has been found in 50% to 75% of persons with alcoholism who commit suicide.³⁵ Suicide has also been associated with the quantity of alcohol consumed per day but not with drinking frequency.³⁶ Abuse of other substances has also been associated with an increased suicide rate, especially among younger individuals.³⁷ In an analysis of completed suicides in 13 states, 33.3% tested positive for alcohol and 16.4% tested positive for opiates.³⁸

A positive family history of suicide increases suicide risk, probably through both genetic and environmental effects. Genetic studies have shown that identical twins have a higher concordance of suicide and suicide attempts than do fraternal twins.³⁹ Other studies have consistently shown that there is an approximate 4.5-fold increased relative risk of suicide completions or suicide attempts in close relatives of suicidal patients compared with relatives of nonsuicidal individuals.⁴⁰ Thus, a family history of suicide and suicide attempts should be obtained.

Finally, a clinician should inquire about psychosocial risk factors in a patient expressing suicidal ideation, including the patient's employment status and current support systems. Unemployment is associated with increased rates of suicide, and suicide rates are higher in socioeconomically deprived geographical areas.⁴¹ In estimating suicide risk, both the patient's social supports and the patient's perception of available social supports should be assessed. Living alone as well as social isolation may increase the risk of suicide.^42,43

While the above risk factors (Table 1) of suicide are not comprehensive, they serve as a basis for a suicide risk assessment. However, in addition to factors that increase suicide risk, there are known protective factors. These factors are listed in Table 2. It is useful to ask suicidal patients about their reasons for living. Also, the Reasons for Living Inventory, a self-report instrument measuring patient beliefs that may contribute to the inhibition of suicidal behavior, can be used to formally identify protective factors.⁴⁴ The presence of children and the number of children in the home appear to decrease suicide risk in women.⁴⁵ In addition, religious belief is protective. In the United States, Catholics have the lowest suicide rate, followed by Jews and Protestants.⁴⁶ However, it appears that the strength of religious beliefs is more protective than a specific religious belief system per se.⁴⁷ Finally, the presence of good social supports is a protective factor, regardless of whether support comes from family members or others.⁴⁸ Social supports can also be used in the management of suicidality, as outlined in the next section.

Management and documentation
The results of a formal suicide risk assessment should be organized and well documented, especially the identified risk factors and protective factors. Risk factors can be divided into 2 types: static and dynamic. Static risk factors are those factors that cannot be changed and therefore are not used as a target for treatment interventions. They include race, age, gender, marital status, history of suicide attempts, and family history of suicide. Dynamic risk factors, on the other hand, can be targeted for treatment intervention. These include current suicidal thinking (including plan and intent), current psychiatric illness and symptomatology, current interpersonal or life crises, alcohol or illicit drug use, unemployment, and lack of social support. A list of the dynamic risk factors with a corresponding intervention designed to address each risk factor indicates that the clinician has successfully identified the significant risk factors and has taken steps to develop a comprehensive approach to treatment.

The first and most important step in the management of suicidality is to decide in what setting treatment may safely occur. Consideration should be given to hospitalization for patients with significant intent or who have a history of attempts in similar circumstances. Adjustments in medication dosage, changes in medication, more frequent appointments, temporary relocation with a family member or increased family involvement in the patient's treatment, removal of access to weapon(s) or changing weapon storage practices,⁴⁹ attendance at Alcoholics Anonymous or Narcotics Anonymous meetings, referral to vocational rehabilitation, and other strategies may be considered as the clinical presentation warrants. The use of a no-suicide contract is controversial and cannot take the place of a formal suicide risk assessment.⁵⁰ Furthermore, these contracts do not protect a clinician from malpractice liability.⁵¹ Finally, suicide risk assessment is not a one-time event. Serial assessments should be done as warranted by the clinical picture and when significant changes occur in the patient's treatment.

Documentation is the cornerstone to the defense of a potential lawsuit resulting from a patient suicide. While failing to document a suicide risk assessment is not usually by itself a cause of patient suicide, the quality of documentation can determine whether a malpractice attorney accepts or declines a suicide malpractice case⁵² (although failing to document is a deviation in the standard of care). The common belief among attorneys is, "If it isn't written down, it didn't happen." Good documentation does several things: it records clinician competence at identifying suicide risk factors and designing interventions, it makes a challenge to the physician's standard of care much more difficult, and it helps prevent suicide by creating a record that the physician can review and use at future patient encounters. In the process of documentation, patient comments that indicate decreased suicide risk, such as "I would never kill myself," should be quoted in the record; why the patient may be unlikely to attempt suicide should also be noted. Patient quotes can carry significant weight with jurors.

In general, it is more important to document the details of decisions that increase suicide risk rather than those that decrease it. For example, more documentation of suicide risk assessment is indicated when a patient is discharged from a hospital following a suicide attempt than when a decision has been made to hospitalize a potentially suicidal patient from an emergency department. When a clinician consults with a colleague in the course of risk assessment, that consultation should also be documented. Consultation with another psychiatrist before the discharge of a potentially suicidal patient is highly recommended.

Liability prevention in the event of a completed suicide
Postsuicide entries in a medical chart are looked upon with great suspicion and will be framed by plaintiff's counsel as purely self-serving.⁵³ Also, never alter or destroy parts of a patient record after an adverse incident. Reaching out to the family of a patient who committed suicide can be an important clinical and compassionate response, and risk management strategies usually support such a response.⁵⁴ However, psychiatrists have an obligation to maintain patient confidentiality after death, even in the face of family members' understandable desire for information.⁵⁵ Therefore, treatment information should not be released without valid authorization from a person legally authorized to give consent after death. Such requests should be placed in writing and be accompanied by written documentation of the requester's legal authorization.

Finally, losing a patient to suicide can have a significant emotional impact on the treating psychiatrist. Attendance at the patient's funeral may occur after consideration of several factors: the relationship with the patient's family, the family's current attitude towards the psychiatrist, and the psychiatrist's own feelings about the patient's suicide. Should the psychiatrist need to process his or her feelings, this should be done in the context of a therapeutic relationship and not with family members, colleagues, or others.