OVERVIEW

Definition

Suicide risk assessment involves assessing risk factors and protective factors for suicide.

General Principles of Suicide Risk Assessment

Although suicide cannot be predicted, an adequate suicide risk assessment should serve as a basis for clinical decision making. Static risk factors for suicide include:

Male gender
Caucasian or American Indian race
Single or divorced marital status
Past suicide attempts
A family history of suicide
Chronic medical illness.

Dynamic risk factors for suicide include:

Current suicidal thoughts, plans, and behavior
Current psychiatric illness
Substance abuse
Loss of employment
Feelings of hopelessness
Lack of social support
Life crises such as marital separation, recent death of family member, or recent job loss.

Protective factors for suicide include:

Concern about impact of suicide on one’s family
Having children under 18 living in the home
Strong religious beliefs condemning suicide
Pregnancy
Positive social support, and a positive therapeutic relationship.¹

Psychiatrists are more likely to be sued because of a patient’s suicide than other causes of action. Although psychiatrists are not able to accurately predict suicide, the standard of care requires that they do an adequate suicide risk assessment.² An error of judgment is not likely to lead to a successful lawsuit if the clinician has acted in good faith and exercised reasonable care. However, an error of fact, such as failing to obtain relevant data or to inquire about suicidality, is likely to lead to a malpractice suit.

A suicide assessment should be documented on admission to a psychiatric hospital, when suicide precautions are decreased, and upon discharge. Unless a patient objects, it is useful to gather information from the patient’s family. The family should be instructed to let you know if the patient talks about suicide, giving up, putting their affairs in order, or acquiring a firearm. In patients expressing suicidal ideation, inquiry should be made to see if a firearm is in the home. If it is, the family should be requested to remove the firearm and notify the psychiatrist once the removal has been completed. This removal should be documented by the psychiatrist.

Although we like to think of patients always being in a therapeutic alliance with us, once patients decide to take their own life they may view the psychiatrist as an adversary.³ That is, the patient wants to commit suicide and the psychiatrist wants to prevent the suicide. Therefore, we cannot accept a patient’s disavowal of suicidality at face value. It is best to get collateral information from family and look for objective signs of improvement, such as improved appetite, sleep, and brightness of affect.

CLINICAL SCENARIOS

Scenario #1: A 43 year old woman was brought to the hospital after a suicide attempt by overdose. Her husband came home unexpectedly and found her unconscious with a suicide note placed next to her bed. After 36 hours in a medical intensive care unit, she was seen by a psychiatric consultant. She minimized the seriousness of her attempt by saying that she simply had a “bad day.” She reported that she was happy to be alive and declined transfer to a psychiatric unit. Two hours after being discharged she jumped off a bridge.

This patient’s suicide note contained 17 single spaced pages. The patient’s chart indicated that there was a suicide note but the EMS did not deliver the actual note to the hospital. One third of patients who complete suicide leave a suicide note. Suicide notes should always be carefully scrutinized. In this case, the note would have shown that this patient had given considerable thought to suicide. She wrote extensive goodbyes to family members and specified detailed arrangements for her funeral.
The psychiatrist in this case overly relied upon the patient’s disavowal of suicidality and failed to recognize that once patients make up their mind to kill themselves, they may view psychiatrists as adversaries.

Scenario #2: A 62 year old man spent 10 days in a psychiatric hospital after being admitted with a diagnosis of Major Depression and suicidal thoughts. He was allowed to go home on a 4 hour pass with his wife. During the pass, the patient’s wife found him in their basement with a noose attempting to hang himself. Upon returning to the hospital, the nurse asked the patient how his pass had gone. He replied that it had gone fine. The next day at shift change the patient was found dead hanging in his hospital room. When staff informed the patient’s wife, she said she was not surprised because her husband had attempted suicide the previous day.

This is an example of the hospital staff failing to tell the family to let them know if they see evidence of a patient’s suicidal thinking or behavior. Upon their return to the hospital, the nurse also failed to make inquiry of the wife about how the patient functioned during the pass. Of course, the patient said that his leave went fine because he did not want any increased suicidal precautions which would make it harder for him to kill himself.
Although you might expect this patient’s wife to inform staff of her husband’s suicide attempt when she brought her husband back to the hospital, she did not do so. When asked about it after she brought a lawsuit, she explained that the hospital staff knew that her husband was admitted with suicidal thinking so she believed that the hospital would provide a safe environment.

Scenario #3: A wealthy entrepreneur was being treated every two weeks in the outpatient practice of a psychiatrist for major depression. He became more depressed over time and had not yet responded to CBT or antidepressant medication. In his last visit, the patient became fixated on a belief that he would lose all of his finances and live in homeless poverty even though this was not realistic. The patient called to move his next appointment from 2 weeks to 4 weeks later. The psychiatrist’s last progress note did not mention the presence or absence of suicidal ideation. However, the psychiatrist testified that it was his practice to always ask about suicide and only to make a note of positive findings. One week before the next appointment the patient shot himself in the head.

The fact that the psychiatrist did not specify the absence of suicidal thoughts in the chart may cause the jury to suspect that he did not actually ask about it. In an outpatient situation, the absence of suicidal ideas should be noted in depressed patients, especially if a patient is becoming more depressed.
The fact that the patient was becoming more depressed should have alerted the psychiatrist to call the patient to inquire about the delayed appointment. If the patient had refused to come in before 4 weeks, it may have been prudent to involve family members.

ADDITIONAL TIPS

Suicide risk assessments should ideally be documented in each new patient, after any new stressor, before increasing privileges and upon hospital discharge. The Joint Commission requires a researched based structured instrument of some sort. Risk and Protective factors should be recorded.

REFERENCES

Jobes, DA. Managing Suicidal Risk: A Collaborative Approach, 2nd edition, Guilford Press, 2016.
Obegi JH. Probable Standards of Care for Suicide Risk Assessment. J Am Acad Psychiatry Law. 2017 Dec;45(4):452-459.
Resnick PJ, Recognizing That the Suicidal Patient Views You As an Adversary,” Current Psychiatry. 2002: 1(8). Available from: https://www.mdedge.com/psychiatry/article/59557/depression/recognizing-suicidal-patient-views-you-adversary

Additional Readings

Chu C, Klein KM, Buchman-Schmitt JM, Hom MA, Hagan CR, Joiner TE. Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update. J Clin Psychol. 2015 Dec;71(12):1186-200. Available from: https://onlinelibrary.wiley.com/doi/10.1002/jclp.22210
Shea SC, Suicide Assessment – Part I: Uncovering Suicidal Intent – A Sophisticated Art. Psychiatric Times. 2009 Dec: 17.

Overview | Clinical Scenarios | Additional Tips | References

By Phillip Resnick, MD