You are working for a crisis agency and receive a call from a Social Worker in another state. They are concerned about their client who has recently moved to your area without knowing anyone.

They provide you with the following information. The patient has a history of violent behavior three years ago when he attacked his sister at his Mother’s funeral with a machete. The sister required medical treatment.

She stated the patient receives disability and has a payee. The payee called her yesterday to tell her of a call received from a motel manager where the patient stopped at. The manager stated the patient showed up in his lobby with a machete and he made the patient leave the machete at the front desk in order to continue staying there.

You contact the payee who tells you about her client.

He came to your town two weeks ago and called his Payee, reporting that his luggage was stolen at the bus station. The payee stated she wired him $450.00 for expenses.

At the patients request she began mailing him checks every Friday for $250.00. He would not give her an address and insisted she mail them to your local post office to "General Delivery.” She stated she has mailed two checks so far and neither of them has been cashed.

The payee stated he spent his first week at the Grand Inn but left after reporting there were swastikas on the office manager’s wall. She also indicated he presented as tired and irritable on the phone from sleeping outside for several nights, but was rational, coherent and goal-directed during the conversation.

On the morning of the phone call, the payee stated he arrived at the Best Value Inn and the owner allowed him to call his payee. The payee offered to mail his check to the motel, but he refused and stated he was heading to the post office to pick up his other checks.

The payee stated she had attempted to contact the Post Office three times without success to determine if he had picked up his checks.

The payee and the Social Worker contacting you are afraid the patient may be a danger to self or someone else.

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·     Do you have enough information to contact Law Enforcement and request a welfare check? Why?

·     What other information would you need to have?

·     Is the patient’s refusal to have the payee send check to a specific hotel related to paranoia?

·     Is the patient’s purchase of a machete a problem for you?

·     What other reasons could explain his purchase a machete?

·     Did his report of a swastika indicate possible hallucinations?

·     Would you call the motel where the patient saw a swastika and ask about it?

·     Would you contact the last motel he was at, where the owner let him call out-of-state on the phone to his payee?

The ART of Suicide Risk Assessment?

Suicide Risk Assessment often seems like an ART FORM rather than a SCIENCE. Unfortunately it is laced with liability risks and challenges for the clinician. Problems start when you realize that approximately 25% of all suicidal patients deny suicidal ideation when asked by the clinician. (Robins 1981)

While there are many different types of Suicide Risk Assessments, it is important to understand that “No suicide assessment method has been empirically tested for reliability and validity.” (Busch 1993) There are no laboratory tests and sophisticated diagnostic instruments available to assess suicidal patients.

Most clinicians rely on the clinical interview and certain valued questions and observations to assess suicide risk. (Sullivan 2006)

Important Concepts to Understand During a Suicide Risk Assessment.

First, when a patient denies suicidal ideation … it is time to ask additional questions, not to simply mark, “Patient denied ideations.” Some of the areas to ask about include prior suicide attempts, family history of attempts, family history of mental illness as well as concerns about support systems and who they can call in an emergency. (Resnick 2002)

Remember: When a patient is determined to commit suicide, you (the clinician) are their enemy! It is always OK to lie to the enemy!

There is only thing worse than no Suicide Risk Assessment. That is a poor assessment. Often chart reviews will indicate notations like; “No SI/HI” for ‘No Suicidal/Homicidal ideations’.

This notation will not cover you in a lawsuit. Another phrase you see in charts is “Pt CFS” for ‘Patient contracts for Safety’. Just like the previous documentation, this will do very little to mitigate litigation when or if a patient successful completes a suicide.

The denial of suicidal ideation should not be the end of the suicide risk assessment process, but be the beginning of a systematic inquiry, which includes a multifaceted evaluation.

It is important to understand that, under Standards of Care, the treating psychiatrist is responsible for the Suicide Risk Assessment. Delegating the risk to another clinical professional (non-psychiatric) does not relieve the psychiatrist of their liability for the patient.

The Suicidal Prodromal Phase:

All suicidal patients work their way through a prodromal phase. Another way of looking at this is the patient will not get out of bed one day and say, “Today, I think I will kill myself!”

Part of the complete Suicide Risk Assessment should include information on the patient’s activities during the prodromal phase. This information can be gathered by a review of prior hospitalization records, interviews with family members and significant others.

Suicidal patients often display unique, “signature” prodromal risk factors. A thorough knowledge of the progression of suicide risk informs the clinician’s interventions.

It is crucial to realize, just because a client has a prior prodromal pattern before a suicide attempt, does not mean the pattern will remain the same. Now is the time to ask questions about prodromal thoughts and behavior.

·      Prodromal patterns can change over time.

·      Risk factors can change over time.

·      Protective factors can change over time.

When reviewing risk factors, always remember that a single risk factor “does not have adequate statistical power on which to base an assessment.” (Meltzer 2003)

When you complete a systematic assessment you should gather essential information on risks, supports, safety factors, familial history and any other information you think would be helpful. If you are not complete, your assessment will show a clear lack of details, which could be used against you during a lawsuit or liability review.

There are numerous risk factors, which are often missed, when the initial evaluation is rushed of perfunctory. Some of the risk factors often overlooked include a history of child abuse, a family history of mental illness or suicide, guns at home, melancholic features of major depression, and perceived burdensomeness. (Van Orden 2006)

This complete risk assessment requires spending more time with the patient than may be perceived as necessary. However, the benefits of spending this time can be enormous.

Fawcett (Fawcett, et. al.) completed a ten-year cohort study focused on patients with major affective disorders and found risk factors that were predictive of suicide within one year of evaluation. This was done by focusing on individual risk and protective factors above and beyond focusing on the general risk factors. Unfortunately assessing individual risk factors may help, there appears to be no current way to bring the predictive range down to any time within a year. This is to say, you cannot predict whether is will be in weeks, months, or days from the evaluation.

Suicide Risk Assessment is a Process, Not an Event.

The Good, the Bad and the Ugly (guidelines to remember):

o   A documented, concise narrative of a complete risk assessment is sufficient.

o   Continuing documentation of suicide risk assessments at important clinical junctures is sufficient (e.g., inpatient admission, change of safety status, discharge).

o   Documenting the suicide risk assessment in a separately labeled section of the psychiatric evaluation is sufficient.

o   Checking off boxes on a risk-assessment form is insufficient.

o   Failure to document at these clinical junctures is insufficient (e.g., inpatient admission, change of safety status, discharge).

o   Including the documentation among the regular psychiatric progress note is insufficient.

o   Identifying risk and protective factors that are scattered throughout the chart is insufficient.

Best practice for Suicide Assessment involves gathering all the information on risk, protective and individual factors into a process of analysis and synthesis. The clinician can then identify risk, prioritize risk, and construct a clinical mosaic along with protective factors to develop a comprehensive assessment.

The Dangers of Jargon and Forms:

There are fundamental flaws in the use of using suicide risk forms in the absence of a process of analysis and synthesis.

American Psychiatric Association’s practice guideline for the assessment and treatment of patients with suicidal behaviors (2003) states, “The [suicide risk] assessment is comprehensive in scope, integrating knowledge of the patient’s specific risk factors, clinical history, including psychopathological development and interaction with the clinician.”

Use of jargon in assessments can cause mistakes or failures. A good example is the use of the word ‘Imminent’ when describing suicide risk. ‘Imminent’ is a non-clinical term frequently used in assessments which is really a ‘predictive illusion’. (Simon 2011)

The clinician can never truly state the time parameters for predicting ‘imminent’ suicidal behavior. Therefore the use of the word imminent is neither predictive nor helpful in an assessment.

Pokorny (1983) firmly established that clinicians can not predict “when or if” a suicide will occur. When a suicide risk assessment is not complete and systematic, omissions of important risk and protective factors create substandard assessments.

The Discharge Assessment:

A comprehensive suicide risk assessment is an essential part of the discharge process.

Suicide risk assessment forms are favored by clinicians who treat patients in settings with rapid patient turnover. (Simon 2009)

High-risk suicidal inpatients can and will often evoke anxiety among the clinical staff. Often, clinical staff will place their confidence in checked-off suicide risk assessment forms. This will lead to an unwarranted reliance on suicide risk assessment forms that can be checked off rapidly as well as a reliance on patient safety contracts. However, it should always be understood that suicide risk assessment is fundamentally a reasoned clinical judgment. (APA 2003)

It is often much quicker to check off a form in lieu of conducting a thorough suicide risk assessment, forms often trump substance. If the clinician uses forms for suicide risk assessment, it is important to write an accompanying narrative, which explains their reasoning process.

Remember, sudden improvement in high-risk suicidal patients is suspect.

Suicide Risk Assessment is about care, safety and liability. Any time you are reviewing or assessing a suicidal patient you open yourself up to liability. If you are ever involved in a lawsuit for negligent discharge of a suicidal patient, you need to be able to fall back on more than a form and a perfunctory assessment. If you testify you relied on a “gut assessment”, you will loose. The plaintiff’s expert will likely testify that the patient displayed a number of evidenced based risk factors that were not adequately addressed and that would have indicated a high-risk for suicide. The plaintiff’s lawyer can easily put forth the argument that the patient should not have been released from the hospital.

Take your time when completing a Suicide Risk Assessment. Lives depend on it!

Citations:

American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors [published correction appears in AM J Psychiatry. 2004;161:776] Am J Psychiatry. 2003;160(11suppl):1-60.

Busch KA, Clark DC, Fawcett J, et al. Clinical Features of Inpatient Suicide. Psychiatry Ann. 1993;23:256-262

Fawcett J, Scheftner WA, Fogg L, et al. Time-Related predictors of Suicide in Major Affective Disorder. Am J Psychiatry 1990;147:1189-1194.

Meltzer HY, Conley RR, ed Leo D, et al. Intervention Strategies for Suicidality. J Clin Psychiatry Autograph Series. 2003;6(2):1-16.

Porkorny AD. Prediction of Suicide in Psychiatric Patients. Reports of a prospective Study. Arch Gen Psychiatry. 1983;40:249-257.

Resnick PJ. Recognizing that the suicidal patient views you as an adversary. Curr Psychiatry. 2002;1:8.

Robins E. The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide. New York: Oxford University Press; 1981.

Simon RI: Suicide Risk Assessment: Clinical Assessment and Management. Washington, DC American Psychiatric Publishing; 2011

Simon RI. Suicide Risk Assessment Forms: Form over Substance? J Am Acad Psychiatry Law. 2009;37:290-293.

Sullivan GR, Bongar B. Psychological Testing in Suicide Risk Management. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Washington, DC: American Psychiatric Publishing; 2006:177-196.

Van Orden KA, Lynam ME, Hollar D, Joiner TE Jr. Perceived Burdensomeness as an indicator of Suicidal Symptoms. Cognit Ther Res. 2006;30:457-467.