Enhancing Suicide Risk Assessment Through Evidence-Based Psychiatry

Psychiatric Times - Category 1 Credit (Expired) 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. Risk factors Psychiatric diagnosis In a systematic review (meta-analysis), Harris and Barraclough9 abstracted 249 reports from the medical literature regarding mortality associated with mental disorders. They compared the number of suicides in patients with mental disorders with those in the general population. The standardized mortality ratio (SMR) is a measure of the relative risk of suicide for a particular disorder compared with the expected rate in the general population (SMR of 1). The SMR was calculated for each disorder by dividing observed mortality by expected mortality (Table 2). The highest relative risk for suicide was associated with eating disorders. The SMR for eating disorders was significantly higher than that for major affective disorders and substance abuse disorder. Virtually all psychiatric disorders, except mental retardation, are associated with an increased risk of suicide. The importance of making an accurate psychiatric diagnosis, one of the most important indicators of risk for suicide, is essential to competent suicide risk assessment.10 Medical and psychiatric comorbidities Comorbidity is an independent suicide risk factor. Physical illness, especially in the elderly, is associated with suicide risk. Recognizing specific medical conditions that are associated with increased risk of suicide aids the clinician’s suicide risk assessment. Quan and colleagues11 found that older adults with mental disorders and coexisting cancer, prostatic disorder (excluding prostaticcancer), or chronic pulmonary disease were more likely to complete suicide than those without the medical illness. HIV/AIDS, malignant neoplasms as a group, head and neck cancers, Huntington chorea, multiple sclerosis, peptic ulcer, renal disease, spinal cord injury, and systemic lupus erythematosus are all associated with increased risk of suicide.12 Psychiatrc patients often present with more than 1 psychiatric disorder. For example, a patient with bipolar disorder may have borderline personality disorder or may be a substance abuser. Beautrais and colleagues13 found that individuals who made serious suicide attempts had high rates of comorbid mental disorders. These investigators compared 302 people who had made serious suicide attempts with 1028 randomly selected participants. The risk of suicide increased with increasing comorbidity: patients with 2 or more disorders had an 89.7 times higher risk for suicide than those without a psychiatric disorder. Using a case-control design, Hawton and colleagues14 assessed 111 patients who had attempted suicide (72 female and 39 male). More patients with comorbid disorders had made previous and repeated attempts during the follow-up period. Comorbidity of Axis I disorders and personality disorders was present in 44% of patients. Findings from a national population survey of 5877 respondents between 1990 and 1992 showed that a dose-response relationship existed between the number of comorbid psychiatric disorders and suicide attempts.15 Deliberate self-harm In a prospective cohort study of 7968 deliberately self-harming patients, Cooper and colleagues16 found that the risk of suicide was approximately 30-fold higher than in persons in the general population during a 4-year follow-up period. Suicide rates were highest within the first 6 months after the initial self-harm, and female patients, in particular, were at high risk for suicide. The investigators underscored the importance of early intervention following self-harm. In a follow-up study of 11,583 patients who presented to a hospital after DSM between 1978 and 1997, Hawton and colleagues17 found a significant and persistent risk of suicide. In this study, the risk was far higher in men than in women. Suicide increased markedly with older age at initial presentation. Anxiety Fawcett and colleagues18 identified short-term suicide risk factors from a 10-year prospective study of 954 patients with major affective disorders that were statistically significant for suicide within 1 year of assessment. The risk factors included panic attacks, psychic anxiety, loss of pleasure and interest, moderate alcohol abuse, diminished concentration, global insomnia, and depressive turmoil (agitation). Clinical interventions directed at treating the anxiety-related symptoms in patients with major affective disorders can rapidly diminish suicide risk.19 Childhood abuse An essential part of the psychiatric examination and systematic risk assessment is inquiry about childhood abuse. A history of suicide was more than twice as likely among both men and women who were abused as children.20 Brown and colleagues21 studied a cohort of 776 randomly selected children from a mean age of 5 years to adulthood over a 17-year period. Adolescents and young adults with a history of childhood abuse were 3 times more likely to become depressed or suicidal than those without such a history. Childhood sexual abuse effects were the largest and most independent of associated factors. The risk of repeated suicide attempts was 8 times greater with a history of sexual abuse. The nature and extent of childhood sexual abuse is associated with the severity of suicide risk. Study findings show a consistent relationship between the extent of child sexual abuse and risk of a psychiatric disorder.22 Those who reported being subjected to intercourse were at highest risk for psychiatric disorders and suicidal behaviors. Impulsivity and aggression Violent threats or violence toward others is a suicide risk factor. Clinicians more commonly encounter patients who threaten violence against themselves. Violence, however, has a vector: it can be directed at oneself, at others, or both, as in murder-suicide. Conner and colleagues,23 in a case-control study, found that violent behavior in the last year of life is a significant risk factor for suicide. The relationship was especially strong in those with no history of alcohol abuse, in younger persons, and in women. In the study, 753 suicide victims were compared with 2115 accident victims. Violent behavior distinguished suicide victims from accident victims, and the findings were not attributable to alcohol use disorders alone. Higher levels of impulsivity and aggression have been found to be associated with suicide.24 Current (6-month prevalence) abuse of or dependence on alcohol or drugs increased the risk of suicide in persons with major depressive disorder (MDD). In a retrospective study of 408 patients who had schizophrenia spectrum, mood, or personality disorders, those who externally directed aggression distinguished past suicide attempters from nonattempters.25 The risk of future suicide attempts was also increased among those in the aggression group. Melancholia Melancholic features associated with MDD have been found to confer a higher risk of suicide attempts than in nonmelancholic MDD. In a case-control study, Grunebaum and colleagues26 compared suicide attempts in patients with and without melancholia. Melancholia was associated with more serious past suicide attempts and the increased probability of suicide attempts during follow-up. While MDD is associated with a high risk of suicide, melancholia is a less commonly recognized feature of MDD that may further increase the risk of suicide attempts or completions. Protective factors Malone and colleagues27 assessed 84 patients with symptoms of MDD based on DSM-III-R criteria. Of the 84 patients, 45 had attempted suicide and 39 had not. The depressed patients who had not attempted suicide expressed more responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater coping and survival skills, and more fear of suicide than depressed patients who had attempted suicide. The authors concluded that the assessment of reasons for living should be part of the assessment of patients at risk for suicide. The Linehan Reasons for Living Inventory assesses the strength of a patient’s commitment not to die.28 The inventory is a 48-item self-report measure that takes about 10 minutes to administer. A 72-item version is also available. Internal consistency is high. The inventory’s test-retest reliability is moderately high for 3 weeks. The inventory is sensitive to reductions in depressive symptoms, hopelessness, and suicidal ideation in patients with borderline personality disorder who are being treated. How important are religious beliefs in preventing suicide? Dervic and colleagues29 evaluated 371 depressed inpatients about their religious affiliation. Patients who were without a religious affiliation had significantly more suicide attempts and more first-degree relatives who completed suicide than did patients who had religious affiliations. Patients with no religious affiliation were younger and less likely to be married or have children; they had less contact with family members. These patients felt they had fewer reasons for living and had relatively few moral objections to suicide. There was no difference in subjective and objective depression, hopelessness, or stressful life events between persons with religious affiliations and those without. Their findings indicate that greater moral objection to suicide and lower aggression level in religiously affiliated patients may act as protective factors. Religious beliefs, however, may not necessarily protect against suicide-severe mental illness can overcome protective factors. For example, a patient with bipolar disorder stated hopelessly that “God has forsaken me.” A devout, severely depressed patient hurled blasphemous insults at God. In a twist, where religion became a facilitating risk factor, a suicidal patient stated, “God will forgive me if I kill myself.” Additional resources Case reports, case series, and clinical consensus, though not evidence-based, can aid suicide risk assessment. For example, in a systematic review of the relevant literature, Hansen30 found that akathisia could not be definitively linked to suicidal behavior. In individual cases, however, clinical judgment may determine that akathisia adds to the patient’s total illness burden, thus potentially increasing suicide risk. Evidence-based studies must be interpreted through the lens of the clinician’s education, training, experience, and reasoned clinical judgment. The suicide prevention contract (SPC), also referred to as a no-harm contract, is a classic example of misconception. The SPC often masquerades as a protective factor, but it can be an iatrogenic suicide risk factor. The SPC can falsely reassure the clinician, which may preempt an adequate suicide risk assessment and increase the patient’s risk of suicide.10 There have not been any studies that demonstrate that the SPC is effective in preventing suicide attempts or completions.31 Managed care settings become a potential suicide risk factor if clinicians allow third-party payers to dictate premature discharges of suicidal patients. Very often, these decisions are made based on so-called safety contracts with severely mentally ill suicidal patients, who are rapidly treated and discharged, compounding suicide risk. Beyond evidence-based general suicide risk factors, suicidal patients have individual “signature” symptoms and behaviors that are associated with suicide risk. “Signature” risk factors recur during subsequent suicide crises. A patient’s distinctive suicide risk factor pattern should receive high priority in assessing suicide risk.32 An example is when a guarded, schizophrenic patient with a severe stutter speaks clearly when at high risk for suicide. Once his stutter returns, he is discharged from the hospital at low suicide risk. This individual specific behavior is repeated a number of times and the clinician considers it to be a reliable behavioral indicator of suicide risk. The assessment of behavioral risk factors is important, especially with guarded or deceptive suicidal patients.2 Employing evidence-based risk factors in suicide assessment is essential, but knowing a patient’s unique suicide risk profile is critical. Summary There are a number of suicide risk assessment methods.2 Clinicians, however, must fashion their own approach based on their training, clinical experience, and familiarity with the suicide literature. Because of its singular importance, the suicide risk assessment should be documented as a separate narrative paragraph in the initial psychiatric evaluation and thereafter in the progress notes. Armed with the ability to perform competent suicide risk assessments, the psychiatrist can confidently treat the patient at risk for suicide, one of the most complex, difficult, and challenging clinical tasks in psychiatry. Earn CME Credit References: References 1. Scheiber SC, Kramer TAM, Adamowski SE. Core Competencies for Psychiatric Practice: What Clinicians Need to Know. Arlington, VA: American Psychiatric Publishing, Inc; 2003. 2. Simon RI. Suicide risk: assessing the unpredictable. In: Simon RI, Hales RE, eds. Textbook of Suicide Assessment and Management. Arlington, VA: American Psychiatric Association; 2003. 3. Sokolov G, Hilty DM, Leamon M, Hales RE. Inpatient treatment and partial hospitalization. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Arlington, VA: American Psychiatric Publishing, Inc; 2006. 4. Gabbard GO, Allison SE. Psychodynamic treatment. In: Simon RI, Hales RE, eds. Textbook of Suicide Assessment and Management. Arlington, VA: American Psychiatric Publishing; 2006. 5. Sullivan GR, Bongar B. Psychological testing. In: Simon RI, Hales RE, eds. Suicide Risk Management in Textbook of Suicide Assessment and Management. Arlington, VA: American Psychiatric Publishing; 2006. 6. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60. 7. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-72. 8. Gray GE. Evidence-Based Psychiatry. Arlington, VA: American Psychiatric Publishing; 2004. 9. Harris EC, Barraclough B. Suicide as an outcome for mental disorders: a meta-analysis. Br J Psychiatry. 1997;170:205-228. 10. Simon RI. Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Arlington, VA: American Psychiatric Publishing; 2004. 11. Quan H, Arboleda-Florez J, Fick GH, et al. Association between physical illness and suicide among the elderly. Soc Psychiatry Psychiatr Epidemiol. 2002;37:190-197. 12. Harris EC, Barraclough BM. Suicide as an outcome for medical disorders. Medicine (Baltimore). 1994;73:281-296. 13. Beautrais AL, Joyce PR, Mulder RT, et al. Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case control study. Am J Psychiatry. 1996;153:1009-1014. 14. Hawton K, Houston K, Haw C, et al. Comorbidity of Axis I and Axis II disorders in patients who attempted suicide. Am J Psychiatry. 2003; 160:1494-1500. 15. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Study. Arch Gen Psychiatry. 1999;56:617-626. 15. Kessler RC, Borges G,Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Study. Arch Gen Psychiatry. 1999;56:617-626. 16. Cooper J, Kapur N,Webb R, et al. Suicide after deliberate self-harm: a 4-year cohort study. Am J Psychiatry. 2005;162:297-303.17. Hawton K, Zahl D,Weatherall R. Suicide following deliberate selfharm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry. 2003;182:537-542. 18. Fawcett J, Scheftner WA, Fogg L, et al. Time-related predictors of suicide in major affective disorders. Am J Psychiatry. 1990;147:1189- 1194. 19. Fawcett J. Treating impulsivity and anxiety in the suicidal patient. Ann N Y Acad Sci. 2001;932:94-105. 20. Dube SR, Anda RF, Whitfield CL, et al. Long-term consequences of childhood sexual abuse by gender of victim. Am J Prev Med. 2005; 28: 430-438. 21. Brown J, Cohen P, Johnson JG, Smailes EM. Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry. 1999;38:1490- 1496. 22. Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse and psychiatric disorder in young adulthood, II: psychiatric outcomes of childhood sexual abuse. J Am Acad Child Adolesc Psychiatry. 1996;35: 1365-1374. 23. Conner KR, Cox C, Duberstein PR, et al. Violence, alcohol, and completed suicide: a case-control study. Am J Psychiatry. 2001;158:1701- 1705. 24. Dumais A, Lesage AD, Alda M, et al. Risk factors for suicide completion in major depression: a case-control study of impulsive and aggressive behaviors in men. Am J Psychiatry. 2005;162:2116-2124. 25. Mann JJ, Ellis SP,Waternaux CM, et al. Classification trees distinguish suicide attempters in major psychiatric disorders: a model of clinical decision making. J Clin Psychiatry. 2008;69:23-31. 26. Grunebaum MF, Galfalvy HC, Oquendo MA, et al. Melancholia and the probability and lethality of suicide attempts. Br J Psychiatry. 2004; 184:534-535. 27. Malone KM, Oquendo MA, Hass GL, et al. Protective factors against suicidal acts in major depression: reasons for living. Am J Psychiatry. 2000;157:1084-1088. 28. Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol. 1983;51:276-286. 29. Dervic K, Oquendo MA, Grunebaum MF, et al. Religious affiliation and suicide attempt. Am J Psychiatry. 2004;161:2303-2308. 30. Hansen L. A critical review of akathisia, and its possible association with suicidal behavior. Hum Psychopharmacol. 2001;16:495-505. 31. Stanford EJ, Goetz RR, Bloom JD. The No Harm Contract in the emergency assessment of suicide risk. J Clin Psychiatry. 1994;55:344- 348. 32. Simon RI. Behavioral risk assessment of the guarded suicidal patient. Suicide Life Threat Behav. 2008;38:517-522.