Improving Suicide Risk Assessment

Flower Owl Butterfly 2I read an interesting short online article on suicide risk assessment in which an expert, Dr. Morton Silverman, MD, points out that we should change our focus from predicting suicide to preventing it [1]. This is from a presentation by Dr. Silverman at the 2015 U.S. Psychiatric and Mental Health Congress:

“We need to reconceptualize risk factors into enduring risk factors and dynamic risk factors. We need to reconceptualize risk status from a prediction model to a prevention model, and our argument is [that] we are not interested in predicting something, we are interested most in preventing someone from engaging in self-harm. I believe it is our duty and responsibility, not only to prevent it, but to come up with a treatment plan or approach that is in the patient’s best interest and will result in their not engaging in suicidal behavior,” Morton M. Silverman, MD, assistant clinical professor of psychiatry, University of Colorado School of Medicine, Denver, said during a presentation. 

Well said. I’m always looking for ways to improve my practice. Dr. Silverman clearly makes these points:

  1. We shouldn’t just ask the one screening question “Are you suicidal?” and drop the inquiry if the patient says “No.”
  2. We should inquire about suicidality with a timeline, asking not just about suicide ideation now but in the recent past as well.
  3. We are at risk for failing to look for the behavioral cues indicating someone might not be answering questions about suicidality honestly.
  4. We may assign less importance to so-called “passive” suicide ideation, believing that the risk for eventual suicide is lower than active suicide ideation–it isn’t.

Dr. Silverman went on to say, “We have to recognize that people die by suicide, even when they don’t express suicidal ideation. What are really missing in our field are good studies that look at the 30-day span of lifetime before someone kills themselves; [we need] to identify those risk factors that play an important part in making them vulnerable and leading them to engage in actual suicidal behaviors.”

That reminded me of of what I often notice is on the list of my most frequently viewed blog posts, the one about the Columbia Suicide Severity Rating Scale. I had a look at the link, Learn to Save a Life: Training in the C-SSRS (you might want to open this in a new window rather than a new tab if you’re using Google Chrome). The video at this link pretty much outlines the approach Dr. Silverman says is needed. It takes about 30 minutes to get through it and I think it’s worth your time. As a psychiatric consultant, I get requests to assess suicide risk nearly every day and even I learned something useful from this site. It would be worthwhile for anyone to view; and try the post test. It may surprise some to learn that a few non-psychiatric physicians don’t know what a suicide attempt is.

This is critically important and the emergency room (ED) is only one place where the skill of suicide risk assessment is vital. Our ED physicians are getting experience in doing these and other types of psychiatric assessments, even asking magistrates for emergency legal hold orders when necessary in order to ensure patients’ safety. While the Columbia Suicide Severity Rating Scale could be a useful tool for them (in fact, it can be used by non-medical personnel), the forms look like they could take too much time. However, as I’ve said in a previous blog post, you can use the C-SSRS as a cheat sheet as a reminder of the important questions to ask. ED physicians (and psychiatrists as well) can have trouble remembering to document their suicide risk assessments, according to a recent survey [2]. One of the authors of the study, Dr. Taras Reshetukha, MD, says:

“The only tools we have are actual skills in clinical assessment, the gold standard in assessing patient risk of suicidal behavior. The whole idea behind suicide risk assessment is not to predict suicide from happening [sic] but rather to appreciate the basis of suicidality done through eliciting important risk factors that would allow us to implement well informed intervention for a particular patient.”

So what does Dr. Reshetukha mean by “actual skills in clinical assessment” as the gold standard of suicide risk assessment? For now, in part, it means conducting a structured, evidence-based empathic inquiry guided by experience (as opposed to an interrogation using only a checkbox list) in paying attention in the moment to behavioral cues as well as verbal communication from the patient. I say “for now” because we probably don’t yet have enough reliable research evidence in blood tests and iPad apps to predict suicide risk–although I acknowledge the progress.

Should we be screening every patient in primary care? Probably not, based on the most current research. The Academy of Psychosomatic Medicine annotated abstract about this is below [3]:

“Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care: U.S. Preventive Services Task Force Recommendation Statement

LeFevre ML: Ann Intern Med 2014; 160:719–726

The Finding: Although the United States Preventive Services Task Force recommended that primary care clinicians should remain attentive to screening patients in high-risk groups (such as immediately following dismissal from an emergency department visit for a suicidal act or following a psychiatric hospitalization), there was insufficient evidence of benefit to support routine screening for suicide risk in primary care. The American Academy of Family Physicians and the Canadian Task Force on Preventive Health Care reached similar conclusions. The United States Preventive Services Task Force continues to support screening for depression in primary care, provided such screening is coupled with adequate resources to ensure accurate diagnosis, treatment, and follow-up. However, the United States Preventive Services Task Force concluded that there was no clear evidence that screening for suicide risk in asymptomatic primary care patients yielded improved health outcomes.

Strengths and Weaknesses: Given that suicide was the 10th leading cause of death in the United States in 2010, this update of the 2004 United States Preventive Services Task Force recommendations is timely. Unfortunately, available studies for review were sparse, the accuracy of the screening instruments used varied widely, and no 2 studies used the same instrument.

Relevance: Recent emphases on patient safety and the recognition of the potential adverse effects of depression in select groups of medical and surgical patients have increased the attention given to suicide screening in and out of the hospital. Awareness of the paucity of evidence for benefit from routine screening for suicide risk in primary care patients may enable consultation psychiatrists to inform these efforts, such that the energy and work invested are directed toward high-risk individuals where intervention may favorably influence outcome.”

This is hardly the last word on suicide risk assessment. Here are a couple of other posts you might find interesting:

CPCP on suicide risk assessment  by Dr. Andrew Segraves

Look for ways to improve suicide risk assessment

References:

  1. Hower, C. (2015) Expert calls for change in suicide assessment, formulation models. Healio Psychiatric Annals. Accessed on line September 15, 2015.
  2. Oldt, A. (2015) Important suicide risk factors may be missed in ED. Healio Psychiatric Annals. Accessed on line September 15, 2015.
  3. Freudenreich, O., et al. (2015). “Updates in Psychosomatic Medicine: 2014.” Psychosomatics 56(5): 445-459. BACKGROUND: The amount of literature published annually related to psychosomatic medicine is vast; this poses a challenge for practitioners to keep up-to-date in all but a small area of expertise. OBJECTIVES: To introduce how a group process using volunteer experts can be harnessed to provide clinicians with a manageable selection of important publications in psychosomatic medicine, organized by specialty area, for 2014. METHODS: We used quarterly annotated abstracts selected by experts from the Academy of Psychosomatic Medicine and the European Association of Psychosomatic Medicine in 15 subspecialties to create a list of important articles. RESULTS: In 2014, subspecialty experts selected 88 articles of interest for practitioners of psychosomatic medicine. For this review, 14 articles were chosen. CONCLUSIONS: A group process can be used to whittle down the vast literature in psychosomatic medicine and compile a list of important articles for individual practitioners. Such an approach is consistent with the idea of physicians as lifelong learners and educators.
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