Suicide Risk Assessment: Always Look for Ways to Improve

Today I’d like to call attention to a couple of interesting articles on suicide risk assessment, which is something I do every day as a consulting psychiatrist in the general hospital (and I’m always looking for ways to improve). The easiest way to start is to let you have a look at a couple of my tweets about them:

The Current Psychiatry article by Dimitry Francois, MD and colleagues is basically about a mnemonic (S.U.I.C.I.D.E.) that might be helpful to clinicians to remind them of the essential components of a suicide risk assessment. Some might be a little put off by the “U” item, which might seem to some readers to imply that suicide is always “unpredictable” and “unpreventable.” Although some might think I’d be overreading it, you could also get the impression that this item is more about protecting the clinician from lawsuits than about protecting the patient from suicide.

On the other hand, I have read articles from experts who specifically say that even lawyers don’t expect psychiatrists to predict suicide. And then there is the alternative expectation which is that, while we can’t predict suicide, it’s possible that a particular suicide may be foreseeable. The problem with that perspective of course, is that it might be foreseeable only in hindsight.

I’ve also seen papers that discourage doctors from documenting suicide risk using the modifier “imminent.” Yet the Psychiatric Annals paper by Dr. Igor Galynker, MD, PhD suggests that it might be possible to foresee imminent suicide.

You might remember Dr. Galynker from my blog post on his Suicide Trigger Scale risk instrument that has 42 questions and probably not that practical for use in the emergency room because of the time it would take to administer.

Bumpy the Bipolar Bear and the Practical Psychosomaticist

Bumpy the Bipolar Bear and the Practical Psychosomaticist

You might also recall that Dr. Galynker sent me Bumpy the Bipolar Bear. I still have not figured that one out.

But hang on, Dr. Galynker has a short form, which makes a lot of sense to me and likely would to anyone else who performs suicide risk assessment–that capitalizes on a suicide trigger state. He has shortened the assessment to a set of just two key questions which it wouldn’t necessarily take a psychiatrist to ask.

  1. Do you feel trapped with no good options left?
  2. Are you overwhelmed, or have you lost control by negative thoughts filling your head?

The other point to make about the Galynker paper is the importance of paying attention to what is often called “countertransference” reactions by physicians to their patients. This vitally important skill seems to be difficult to teach to trainees, but it occurs to me that its development might be facilitated by teaching mindfulness meditation to residents and other clinicians [1].

Little BuddhaIt makes sense that if countertransference is a reaction composed of components of feelings, thoughts, and physical sensations that are often just under the radar of awareness and elicited during an encounter with a patient, then engaging in a regular practice of mindfulness meditation, a process that nurtures nonjudgmental moment to moment awareness, might be a way to hone this empathic skill.

So that’s my two cents. What do you think? Let’s give a big thanks to Igor, who is always looking for ways to improve our ability to care for our patients.

And while we’re at it, how can we improve our will and the skill to give to those who want to die the kind of resilience that would make them want to live?

Reference:

1. Fatter, D. M. and J. A. Hayes (2013). “What facilitates countertransference management? The roles of therapist meditation, mindfulness, and self-differentiation.” Psychother Res 23(5): 502-513.
Abstract Countertransference (CT) reactions can negatively affect psychotherapy, and research has found that effectively managing these reactions is positively associated with psychotherapy outcome (Hayes, Gelso, & Hummel, 2011). Therefore, it is important to understand factors that might facilitate CT management. In this study, 78 therapist trainees completed measures of meditation experience, mindfulness, and self-differentiation, and their supervisors rated trainees’ CT management qualities. Results indicated that trainees’ meditation experience predicted CT management qualities but self-differentiation did not; one aspect of mindfulness, non-reactivity, was related to CT management qualities. Implications for theory, practice, research, and supervision are discussed. Link http://www.tandfonline.com/doi/full/10.1080/10503307.2013.797124#.VEKHafl4qt0

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Comments

  1. Jim,

    Interesting articles but like most they depend on risk factor analysis.

    In my experience the suicidal person undergoes a transition in their conscious state that turns them from a person who is not suicidal to one who is. That can appear to be greater or less than the sum of the risk factors. This state can be fluid. It is often only detectable by an apparent change in their personality and/or affect. There is direct and indirect evidence for this. I have talked with many people who in retrospect told me that I missed this but for whatever reason survived the transition. Of course, the problem is that clinicians are often in a situation that when they detect this change they can’t do anything anyway. The same is true for the risk factor analysis.

    On the issue of countertransference, I think that clinicians tend to overestimate the impact of their relationship with the patient. We have to keep in mind that our patients who are chronically ill are in frequent contact with intimate partners and family members who are angry and at times overtly hostile to them. That is the product of the personality of the involved person and the fact that the patient is not getting much better. It is a family systems variable that I rarely see discussed.

    I think there is also a risk factor that nobody talks about and that is paranoia. Even in the absence of mood symptoms there are individuals who become suicidal due to the fear that they will be killed or tortured and see suicide as a preventive step if they are extremely anxious.

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    • Thanks, George; your observations about our tendency to overrate our importance in the lives of patients is spot on. I’ve seen the persecutory delusion issue and it’s harrowing for the patient. How would you address it?

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      • Typically involves addressing the psychosis with medications and supportive psychotherapy and removal of weapons or placement in a secure environment. There are fewer secure environments capable of these interventions these days so clinicians end up following these high risk patients in outpatient settings. Many people with these symptoms also realize that if they just stop talking about them they will attract a lot less attention.

        I usually try to argue (in the nicest sense of the word) with delusional and suicidal patients. It is always important to ask them the question: “Have you ever considered suicide as an option when you are being pursued by these people who want to harm you?” If I can argue with them and demonstrate that the delusional thought pattern is amenable to modification and I can come up with a reasonable safety plan – I can treat them on an outpatient basis.

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  2. This post is really helpful!
    Love it ❤
    Best wishes,R
    Great Post!

    http://ramonacrisstea.wordpress.com

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