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Avoiding Common Pitfals
Suicide risk assessment is a gateway to patient treatment and management. It is a core competency requirement for psychiatric residents.1 It is no longer assumed that psychiatrists will somehow acquire this skill during their careers. The purpose of suicide risk assessment is to identify treatable and modifiable risks and protective factors that inform the patient's treatment and safety management requirements. Patients at risk for suicide often confront the psychiatrist with life-threatening emergencies. Most clinicians rely on the clinical interview and certain valued questions and observations to assess suicide risk.2
Unlike general physicians, psychiatrists do not have laboratory tests and sophisticated diagnostic instruments available to assess suicidal patients. In evaluating an emergency cardiac patient, the clinician can order a number of diagnostic tests and procedures (eg, ECG, serial enzyme levels, imaging, catheterization). However, the quintessential diagnostic instrument available to psychiatrists is systematic suicide risk assessment informed by evidence-based psychiatry.
No suicide assessment method has been empirically tested for reliability and validity.3 The standard of care encompasses a range of reasoned clinical approaches to suicide risk assessment based on the clinician's training, experience, and familiarity with the evidence-based psychiatric literature. Systematic suicide risk assessment is an example of a comprehensive methodological approach.
Commonly occurring pitfalls
Quality assurance reviews of clinical records and the analyses of litigated suicide cases reveal commonly occurring shortcomings in suicide risk assessment.
No assessment. Next to conducting no suicide risk assessment, the all too familiar notation "No SI, HI, CFS" (no suicidal ideation, homicidal ideation, contracts for safety) is little improvement. The clinician must do more. Approximately 25% of suicidal patients deny suicidal ideation when asked.4 When the patient denies suicidal ideation, additional questions should be asked about prior suicide attempt(s) and family history of mental illness and/or suicide. For patients who are determined to commit suicide, the clinician is their enemy.5 Denial of suicidal ideation should not end the suicide risk assessment process but be the beginning of a systematic inquiry.
Delegating risk assessment. On most inpatient units, the overall care of the patient is directed by the treatment team. The psychiatrist sees the patient briefly, usually for medication management. Nonetheless, the psychiatrist is responsible for independently conducting suicide risk assessments. It cannot be delegated solely to...