CONDUCTING SUICIDE RISK ASSESSMENT: REALITY AND REMEDY ROBERT I. SIMON, M.D.*

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1 CONDUCTING SUICIDE RISK ASSESSMENT: REALITY AND REMEDY ROBERT I. SIMON, M.D.* Suicide Risk Assessment is a core competency that psychiatrist must possess (1). A competent suicide assessment identifies modifiable and treatable risk and protective factors that inform patient treatment and safety management (2). A clinical axiom holds that there are two kinds of psychiatrists, those who have had patients commit suicide and those who will. Patient suicide is an occupational hazard. Psychiatrists, unlike other medical specialists, do not often experience patient deaths, except by suicide. Psychiatrists frequently assess suicidal patients who present life-threatening emergencies. Unlike other physicians, psychiatrists do not have laboratory tests and sophisticated diagnostic instruments to assess patients at risk for suicide. For example, when evaluating an emergency cardiac patient, the clinician can order a number of diagnostic tests and procedures, e.g., EKG, serial enzymes, imaging, catherization. The psychiatrist s diagnostic instrument is competent suicide risk assessment. No single suicide risk assessment method has been empirically tested for *Clinical Professor of Psychiatry Director, Program in Psychiatry and Law Georgetown University School of Medicine Washington, DC Robert I. Simon, M.D

2 reliability and validity (2). Standard practice encompasses a range of reasoned clinical approaches to suicide risk assessment. From a risk management perspective, the law does not require ideal, best practices or even good care. The clinician s duty is to provide reasonable risk assessment (3). The Reality A review of suicide cases in litigation finds an absence of documented suicide risk assessments (3). Instead, a note containing NO SI, HI, CFS (no suicide ideation, homicidal ideation, contracts for safety) often masquerades as a suicide risk assessment. A lay person could just as well conduct such an assessment. The situation is no different with quality assurance reviews. Repeated requests for documented suicide risk assessments have proved fruitless. Substandard suicide risk assessment are the second most common root cause contributing to approximately 85% of inpatient suicides (4). Documented suicide risk assessments are a core measure of quality care. The Question Why then are documented suicide risk assessments a rarity? When this question is posed to colleagues, a variety of opinions are given: 1. The clinician has not learned how to perform an adequate suicide risk assessment. Risk and protective factors may be identified during the course of an evaluation but not prioritized and integrated into a clinical judgment of overall suicide risk that informs patient treatment and management. 2. The clinician does not do suicide risk assessments, delegating it to others. 2

3 3. The clinician performs adequate suicide risk assessments but fails to document assessments. 4. The clinician experiences anxiety in the treatment of the suicidal patient that creates denial and minimization of risk, resulting in inadequate assessment. 5. The clinician worries that documenting the risk assessment process creates liability exposure, if the assessment is wrong and the patient attempts or completes suicide. 6. The clinician who treats patients in an inpatient setting with rapid patient turnover and short length of stay or in a busy outpatient medication management practice may not take or have the time to perform a competent suicide risk assessment. Time, money, inadequate training and litigation fears can combine to negatively influence adequate suicide risk assessment and documentation. The fear of becoming embroiled in a malpractice suit, if a patient attempts or completes suicide, can engender inappropriate defensive practices as noted above. Countertransference hate of a suicidal patient who provokes anxiety in the psychiatrist can result in inadequate risk assessment and treatment (5). Many psychiatrists have not been formally trained on how to conduct suicide risk assessments. It is generally assumed that clinicians will somehow acquire this knowledge in the course of clinical practice. As the clinician must be trained to assess the emergency cardiac patient, so the psychiatrist must be trained to competently assess the suicidal patient. The core competence necessary to perform suicide risk assessments is difficult to obtain by unaided clinical experience alone. Learning how to perform competent suicide risk 3

4 assessments must begin during psychiatric residency. Lectures, tutorials and especially case conferences that follow patients at suicide risk during the course of treatment are essential. Suicide risk assessment is a process that requires identifying, prioritizing and integrating risk and protective factors into an overall clinical judgment of suicide risk. An extensive psychiatric literature exists on suicide but relatively little on the topic of suicide risk assessment. This is beginning to change. In a recent publication, McNeil et al (6) demonstrated that structured clinical training in evidence-based risk assessment can improve the documentation of assessment and management of suicidal patients. The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors (7) is an excellent informational source regarding the conduct of suicide risk assessment. The Remedy Forms and checklists are not effective substitutes for clinical assessment. Generally, self-assessment instruments cannot be relied upon because guarded or deceptive suicidal patients will not answer honestly. Some patients, however, may reveal more about suicide risk on self-assessment than at the clinical interview (8). No psychological tests exist that can predict suicide (8). Assessment forms and checklists often omit evidence-based general risk factors. Some checklists contain items that are not recognized risk factors for suicide. Unique, individual suicide risk factors are not present on assessment forms. The know your patient imperative is absent. Checking off forms robotically is not a credible risk assessment. If litigation ensues following a patient s suicide, the plaintiff s attorney will invariably point out to the jury suicide risk factors that the deceased patient manifested, but were not on the form. 4

5 There are a number of suicide risk assessment methods (2). The suicide risk assessment process requires identifying, ranking, and integrating multiple risk and protective factors into an overall clinical judgment of risk. Figure 1 depicts a conceptual model for suicide risk assessment. Clinicians, however, must fashion their own approach to suicide risk assessment based upon their training, clinical experience and their familiarity with the suicide literature. Because of the singular importance of suicide risk assessments, they should be documented as a separate narrative paragraph in the psychiatric evaluation and in the progress notes. Armed with the ability to perform competent suicide risk assessments, the psychiatrist can confidently manage the patient at risk for suicide, one of the most complex, difficult, and challenging clinical tasks in psychiatry. In a Sentinel Event Alert The Joint Commission (TJC) (9) conducted a root cause analysis of 65 inpatient suicides. Failure to perform adequate suicide risk assessments was found to be a root cause in the suicides. Revising suicide risk assessment procedures was noted as an important risk reduction strategy. Effective January 1, 2007, the TJC required psychiatric facilities to use established tools to assess patients at risk for suicide(10). What is the remedy? First, regular chart review for documented, competent suicide risk assessments can be performed by quality assurance committees on inpatient services or similarly constituted committees in outpatient settings. Consensus criteria for evaluating the adequacy of documented suicide risk assessments must be determined. The assessment framework will vary according to the clinical setting and the clinical staff s experiences with suicidal patients. Once established, the criteria can be modified 5

6 over time, as necessary. Secondly, the TJC (11) requires that objective measures of the quality of a physician s performance be established for recredentialing. Suicide risk assessment is an important measure of clinical competence for periodic chart review. Thirdly, a Suicide Risk Assessment Memorandum (see Table 1) can be included in the medical chart. The memorandum does not obtain the suicide risk assessment. Instead, it documents that a suicide risk assessment was performed. A review of the chart will verify that the memorandum boxes checked were actually done. Table 2 accompanies the memorandum and describes the suicide risk assessment process. Unless there is a continuing review and oversight process for compliance with standard suicide risk assessment measures, competent risk assessment of suicidal patients will likely continue to be sporadic, idiosyncratic and inadequate. Conclusion There is no fool-proof way of ensuring that competent suicide risk assessments will be performed. The unfortunate reality is that documented suicide risk assessments are rare, if in fact they are actually conducted or conducted competently. As with other measures of physician quality measures, performing competent suicide risk assessments must be subject to continuing, consistent monitoring. 6

7 References 1. Scheiber SC, Kramer TAM, Adamowski SE: Core Competencies For Psychiatric Practice: What Clinicians Need to Know. American Psychiatric Publishing, Arlington, VA Simon RI: Suicide Risk: Assessing the Unpredictable in Textbook of Suicide Assessment and Management (Simon RI, Hales RE, eds). American Psychiatric Publishing, Arlington, VA Simon RI: Suicide Risk Assessment: What is the Standard of Care? Journal American Academy of Psychiatry Law 30: , Sokolov G, Hilty DM, Leamon M, Hales RE: Inpatient Treatment and Partial Hospitalization in Simon RI, Hales RE (eds.) The American Psychiatric Publishing Textbook of Suicide Assessment and Management. American Psychiatric Publishing, Arlington, VA Gabbard GO, Allison SE: Psychodynamic Treatment in Textbook of Suicide Assessment and Management (Simon RI, Hales RE, eds.) American Psychiatric Publishing, Arlington, VA McNeil DE, Fordwood SR, Weaver CM, et al. Effects of Training on Suicide Risk Assessment. Psychiatric Services 59:1462:1465, American Journal of Psychiatry (supplement) 160:11, November Sullivan GR, Bongar B: Psychological Testing in Suicide Risk Management in Textbook of Suicide Assessment and Management (Simon RI, Hales RE, eds.) American Psychiatric Publishing, Arlington, VA

8 National Patient Safety Goal The organization identifies safety risks inherent in its patient population Medical Staff Standard MS. O MS

9 Table 1: Suicide Risk Assessment Memorandum Please check upon completion: Assessed suicide risk and protective factors* Documented suicide risk assessment Treated acute suicide risk factors Mobilized protective factors Implemented safety management interventions based on the patient s suicide risk assessment Documented decision-making rationale Assessed effectiveness of interventions Signature Time and Date * Admission, discharge and significant changes in the patient s clinical status 9

10 Table 2: The Suicide Risk Assessment Process A. Purpose: Identify treatable and modifiable suicide risk and protective factors that guide the patient s treatment and management. B. Assessment: There is no standard suicide risk assessment methodology. One way of conceptualizing assessment is to divide acute and chronic risk factors into 5 categories: individual, clinical, interpersonal, situation and demographic. Acute risk factors include the patient s symptoms and circumstances that require immediate clinical attention. Assess both suicide risk and protective factors. Suicide risk assessment is a process that requires identifying, prioritizing and integrating risk and protective factors into an overall clinical judgment of suicide risk. It is a "Here and Now" assessment that needs frequent updating. C. Documentation: Record all suicide risk assessments. The standard of care requires clinicians to document important assessments and interventions. Documentation is essential to patient care. It supports good patient care and explains clinical decision-making. Documentation is also good risk management. Because of the importance of suicide risk assessment, it should be so identified and 10

11 recorded as a separate narrative paragraph in the clinical evaluation or progress note. D. Treatment: Identify and prioritize acute risk and protective factors for aggressive treatment and safety management. Suicide risk assessments are performed on admission, on discharge and at significant changes in the patient s clinical status. Assessment is a process that needs frequent updating. 11

12 E. Safety Management: Suicide risk assessment guides clinical judgment regarding the patient s safety requirements. Perform and document risk assessments that support changes in the patient s level of safety management. F. Decision-making rationale: Write a brief narrative summary describing how the suicide risk assessment informed treatment and safety management decisions. Avoid conclusory statements such as low, moderate, or high risk, unless it is supported by the suicide risk assessment. G. Effectiveness of interventions: Assess and document the patient s response to treatment and management of suicide risk and protective factors. 12

13 FIGURE 1: A CONCEPTUAL MODEL FOR SUICIDE RISK ASSESSMENT Risk Factors Protective Factors Acute EXAMPLES: Depression EXAMPLES: Therapeutic Alliance Current Anxiety Child under 18 at home Insomnia Spousal/Family support Chronic Suicide Attempt(s) Coping/Survival skills Lifelong Family history of suicide Moral/Religious beliefs Childhood abuse Capacity for relationships Instructions: 1. Complete all grid boxes to form an overall clinical judgment of suicide risk. 2. Treat acute risk factors and mobilize protective factors. 13