Preventing Patient Suicide: Know Thy Patient

Psychiatrists cannot always prevent patient suicide, even with the best of care. Nonetheless, it is a very desirable goal. What we can do, and assuredly must do, is to reduce suicide risk by taking the time and making the necessary effort to know and care for the patient. This is not a radical idea. It is as old as the practice of medicine. The “know thy patient” imperative is central to good clinical practice.

Knowing one’s patient is not an easy task, given the current limitations on mental health benefits. Time is of the essence. Outpatient visits are curtailed. High-risk, acutely suicidal patients are admitted to inpatient units for short lengths of stay, some under five days. Stretched staffs tend to rely on suicide prevention contracts. Patient self-assessment checklists are commonplace. The medical record reveals many checked boxes but little documentation. Documented, competent suicide risk assessments are a rarity.

In outpatient settings, suicidal patients are often treated in collaborative treatment arrangements. Psychiatrists frequently see patients for brief med checks, while therapists conduct the psychotherapy. Close collaboration is necessary to prevent the suicidal patient from “falling through the cracks.” However, insurers do not pay for clinical time spent in collaboration. Emails and videoconferencing are limited in providing essential clinical information needed to properly assess and manage the suicidal patient.

Psychiatrists no longer have the privilege and luxury of treating patients for months or even years. The delivery of mental health care will certainly change in the years ahead, though not necessarily for the better. Nonetheless, psychiatrists must continue to possess a reasonable, “good enough,” working knowledge of their suicidal patients to provide competent care, usually in close collaboration with other mental health professionals.

Suicide Risk Assessment: Gateway to Treatment and Management

Suicide risk assessment is a core competency requirement for psychiatrists. Most clinicians rely on the clinical interview and certain valued questions and observations to assess suicide risk. The psychiatrist, unlike the general physician, does not have laboratory tests and sophisticated diagnostic instruments to assess patients at risk of harm to self or others. By comparison, when evaluating an emergency cardiac patient, the clinician can order a number of diagnostic tests and procedures, for example, EKG, serial enzymes, imaging, and catherization. The psychiatrist’s quintessential diagnostic instrument is systematic suicide risk assessment informed by evidence-based psychiatry.

A standard of care does not exist for the prediction of suicide, in part because suicide is such a rare event. Efforts to predict who will commit suicide lead to a large number of false positive and false negative predictions. No method of suicide risk assessment can reliably identify who will become violent (sensitivity) and who will not (specificity). Suicide is the result of multiple factors, including diagnosis (psychiatric and medical), psychodynamic, genetic, familial, occupational, environmental, social, cultural, situational, and unique individual factors.

Systematic Suicide Risk Assessment

Systematic suicide risk assessment helps the clinician identify acute, modifiable, and treatable risk and protective factors essential to informing the psychiatrist’s treatment and safety management of patients at risk for suicide. It is an essential clinical tool. Conceptually, risk assessment is a process of analysis and synthesis that identifies, prioritizes, and integrates acute and chronic risk and protective factors. It is easy to overlook important risk and protective factors in the absence of systematic assessment. Given the high stakes, getting the suicide risk assessment right is of critical importance.

Suicide risk assessment is an integral part of the psychiatric examination, yet it is rarely performed systematically or, when performed, it is not contemporaneously documented. Protective factors often are not considered. It is evident from the review of quality-assurance records and the forensic analysis of cases in litigation that the extent of suicide risk assessment is usually no more than the “Patient denies HI, SI, CFS” (homicidal ideation, suicidal ideation, contracts for safety). Frequently, one finds no documentation of a suicide risk assessment. Instead a talismanic “no-harm contract” replaces an adequate suicide risk assessment. Laypersons could just as easily ask these same questions and obtain a no-harm contract. Moreover, there is no evidence that safety contracts decrease or prevent suicide. (The road to patient suicides is strewn with broken safety contracts.)

Mandated Suicidal Prevention Education

In its 2012 legislative session, Washington state passed bill ESHB 2366, also known as the Matt Adler Suicide Assessment, Treatment, and Management Act of 2012. It is the first law in the United States to require certain health professionals to obtain continuing education in the assessment, treatment, and management of suicide risk as a requirement to obtain and maintain professional licensure. The law requires a minimum of six hours of continuing education every six years for psychologists, occupational therapists, mental health counselors, marriage and family therapists, advanced social workers, chemical dependency professionals, certified counselors, and certified advisors. Prominent in framing the law was evidence that the majority of mental health professionals are unprepared to assess and treat suicidal individuals.

Spokespersons for psychiatrists argued that the training would be redundant. Proponents of the law agreed that the discipline of psychiatry is unique among mental health disciplines because of exposure to patients at risk for suicide throughout their training. However, the routine exposure of trainees to skills training and suicide risk assessment training in the treatment and management of the suicidal patient in psychiatry is not sufficient. Ultimately, psychiatry remained neutral on the legislation in Washington. However, mandated CME requirements for suicide risk assessment and management have now come into the domain of legislators and public policy. Other states may soon adopt similar requirements. ■