Risk Management Considerations for Chronically Suicidal Patients

In 2015, the Centers for Disease Control and Prevention identified suicide as the 10th leading cause of death in the United States and recently released data showing a substantial increase in the rates of suicide among teens. For some patients, chronic suicidal thoughts and self-injurious behaviors are present and result in frequent use of the health care system for assessment of suicide potential. What are some risk management strategies for psychiatrists that help reduce the potential overuse of limited inpatient resources while providing an effective management of this very difficult patient population?

• Establish and maintain a therapeutic alliance: This includes collaboration, communication, and alliance between the psychiatrist and patient.

• Attend to the patient’s safety: Develop a safety plan.

• Develop a plan of treatment: In outlining a detailed safety plan, it is helpful to incorporate input from the patient and significant others when clinically appropriate.

• Promote adherence to the treatment plan: Helping patients develop skills for coping with self-injurious impulses is often a valuable part of treatment.

• Provide education to the patient and the family, including assessment of access to firearms and other potential dangers: If present, document instructions given to the patient and significant others. If absent, document as a pertinent negative.

• Reassess safety and suicide risk and keep careful and attentive documentation, including the following: Risk assessments; Record of decision-making processes; Descriptions of changes in treatment; Record of communications with other clinicians; Record of telephone calls from patients or family members; Prescription log and copies of prescriptions or electronic tracking of prescriptions; Medical records of previous treatment, if available, particularly treatment related to past suicide attempts.

• Monitor psychiatric status and response to treatment, and note these critical junctures for documentation: At first psychiatric assessment or admission. With occurrence of any suicidal behavior or ideation. Whenever there is any noteworthy clinical change.

• Obtain additional consultation, if indicated.

• Plan for coverage when away from practice.

Consistent documentation of risk assessments for changes in suicidal completion potential for the chronically suicidal patient is critical. It is important to weigh the risk factors and pay attention when significant changes occur. Employing these strategies will help you decide when hospitalization may be indicated. Obtain risk management or legal advice should you have questions. ■