First AD

Second AD

A major component of suicide risk management is safety planning, which can help the clinician better understand targets for intervention. Is "risk stratification," designed to specify severity for both acute and chronic risk of suicide, an effective strategy?

A. Tends to emphasize static risk factors over dynamic risk factors and warning signs

D. Facilitates appropriate involuntary admissions while helping to avoid unnecessary hospitalizations

A major component of suicide risk management is safety planning. Planning can help the clinician better understand risk and targets for intervention (eg, that the patient is unable to identify warning signs and has limited coping skills) while also providing information about what types of management approaches may be indicated. It is critical to note the many pitfalls of the management approach of “no suicide contracts.”

These types of contracts, which essentially involve the patient making a commitment to not die by suicide until the next session or that he or she will not enact suicidal behavior without first contacting the clinician, have no evidence base behind their efficacy, afford no medicolegal protection, are not patient-centered, and can have paradoxical effects for both the patient (eg, less disclosure about suicidal desire to not disappoint the clinician) and the clinician (eg, false sense of security which leads to less engagement in appropriate management approaches).

In contrast, the safety planning process involves a hierarchical set of strategies designed to help a patient know how to identify and how to cope when in a suicidal crisis. A therapeutic risk management of the suicidal patient (TRMSP) framework is built on and integrates the tenets of prior research and clinical evidence, the ethical principles of autonomy, nonmaleficence, and beneficence, and medicolegal knowledge and awareness. TRMSP consists of three core components:

1. a clinical interview/suicide risk assessment that is augmented by an evidence-based structured instrument

2. stratification of risk by severity and temporality, and

3. a collaboratively developed safety plan

The TRMSP framework provides an alternate approach to the risk formulation by using a stratification across both severity and temporality. This allows for a more nuanced discussion of risk by enabling a clinician to simultaneously speak to chronic factors (ie, demographic risk factors, past suicide attempts, diagnoses) as well as acute presentation (ie, indicators of risk like preparatory behaviors, intent).

Suicide Risk Assessment and Management: Tips for Improving Care and Outcomes

Suicide

Quizzes

What are the core components of a therapeutic risk management framework for a suicidal patient? Find out in this quiz.

Mini Quiz: Suicide Risk Stratification

Hal Wortzel, MD