Identifying patients at risk for suicide is complicated because suicide is rare (relatively speaking), and the various clinical risk factors that correlate with suicide risk are exceedingly common. This leads clinicians to a high rate of false-positive identification of risk. In addition, no specific factor, such as a suicide attempt, or set of factors allows a clinician to predict whether a patient will attempt suicide. As stated in the American Psychiatric Association's Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors:
The goal of the suicide risk assessment is to identify factors that may increase or decrease a patient's level of suicide risk, to estimate [emphasis added] an overall level of suicide risk, and to develop a treatment plan that addresses patient safety and modifiable contributors to suicide risk.1
These basic principles are true for children, adolescents, and adults.
In 2006, the Joint Commission, noting that suicide is a common cause of sentinel events, declared that one of the National Patient Safety Goals for 2007 would require that “the organization identify clients at risk for suicide.”2 Providence Health and Services in Portland, Oregon, accredited by the Joint Commission, has cared for patients who have attempted or eventually committed suicide. We have reviewed those events to identify quality improvement opportunities. We identified inconsistent risk assessment and documentation, communication problems between caregivers, and inconsistent management of suicide risk as areas needing improvement. Based on these experiences, our behavioral health program decided to develop an evidence-based, consistent approach for documenting both the risk assessment and the treatment plan for adult patients to improve communication and patient safety (We are in the process of developing a similar approach for children and adolescents).
Our risk-assessment process focuses on the following key areas.
The psychiatric examination. The first step in estimating suicide risk is completing a psychiatric examination.3 Indications for a suicide assessment include:
clinical circumstances such as an emergency department or crisis evaluation;
an inpatient or outpatient intake evaluation;
before a change in observation status or treatment setting;
an abrupt change in clinical presentation (sudden worsening or improvement);
a lack of improvement or gradual worsening despite treatment;
in anticipation of or following a significant interpersonal loss or psychosocial stressor; or
the onset of physical illness.
The clinician conducting the examination, who could be a psychiatrist or nonphysician member of the multidisciplinary team, must recognize the variety of risk factors to be reviewed during the interview.
Specific questioning about suicide ideation. In general, the longer a person has been thinking about suicide, and the more specific and potentially lethal his plans and intent, the higher his risk will be. Several direct questions are required to fully understand these elements of ideation, and clinicians may commonly understand this point. However, clinicians also must understand that “accepting a negative response may not be enough to determine actual suicide risk.”3 Full documentation of the relevant information pertaining to ideation may not fit simply on a form, and instead may require elaboration in the clinical record.
Modifiable risk factors and protective factors. A variety of risk factors (e.g., demographics, prior suicide attempts, history of trauma, and family history) are immutable. While these factors are important to identify for risk-assessment purposes, the focus of treatment must be on modifiable factors.
Identifying modifiable factors yields opportunities to reduce a patient's suicide risk. A psychiatric disorder can be identified in more than 90% of patients who commit suicide.4 Major depression is the most common diagnosis, present in 86% of patients who commit suicide.5 The greater the number of comorbid psychiatric diagnoses a patient has, the higher the risk of suicide. A variety of psychological symptoms, psychosocial factors, and medical factors should be considered. If the patient is having difficulty forming a treatment alliance with caregivers, this too may increase risk and warrants special therapeutic attention. Protective factors, which may be strengthened, include effective coping skills, social support, a strong therapeutic relationship, and religious beliefs.
Documenting the Risk Assessment
Documentation is fundamental to clinical practice. An accurate, sufficiently detailed, concise record of a patient's treatment supports quality care and effective communication between caregivers.