Asking about suicidal ideation in the outpatient world

[lyla]

In the outpatient world, assuming you have a stable patient who is gainfully employed, happy, future oriented, taking meds as directed... how practical is it to always screen for SI? Could it actually hinder the therapeutic alliance if you screen for this at every visit when it's not indicated?

I've seen things documented in the chart, such as "No SI was endorsed or elicited." Even in patients who have history of suicidal behavior. It doesn't have quite the same definitive oomph as, DENIES SI, yet I see this type of thing done sometimes.

Thoughts? ThAnks in advance!

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[splik]

The standard of care is to ask for SI at the first visit and if there is a change in clinical status (for example an adverse life event, worsening symptoms, decompensation etc). Unless working with a particularly high risk group it is not appropriate to ask about SI every visit with patients, and it could hinder a fragile therapeutic alliance (though if you had an actual alliance with the patient asking about SI would not impact it). In terms of documentation I wouldn't document anything about SI if I didnt ask about it, but it would be okay to put no SI elicited. (You shouldn't put no SI endorsed if you didn't ask about though as that makes it sound like you specifically asked). Outpatient psychiatrists in private practice certainly don't ask their patients about SI every visit or event most visits.

It's common for clinics to use something like the PHQ-9 (which again might irritate patients but they can choose not to fill it in) and that will specifically ask about SI, so you don't have to if the pt doesn't check the box on the form and you see nothing on eval that warrants inquiry.

 

[Fan_of_Meehl]

In the outpatient world, assuming you have a stable patient who is gainfully employed, happy, future oriented, taking meds as directed... how practical is it to always screen for SI? Could it actually hinder the therapeutic alliance if you screen for this at every visit when it's not indicated?

I've seen things documented in the chart, such as "No SI was endorsed or elicited." Even in patients who have history of suicidal behavior. It doesn't have quite the same definitive oomph as, DENIES SI, yet I see this type of thing done sometimes.

Thoughts? ThAnks in advance!

While waiting on a no-show earlier this week I was reviewing some of the empirical literature on self-report of SI (especially denial of SI) and ran across some information regarding completed suicides and what the patients in question reported (or, that it was documented that they reported) to the health care provider at their last visit. I am going off memory here but I think it was something like 70% apparently DENIED (or this is what was documented) SI at their last visit. The authors also (wisely) added that--in the absence of other information/context--a simple denial of SI when routinely asked may be meaningless. The fundamental problem, as I see it, is that our professional has become way too hyper-concerned about engaging in concrete 'rituals' (and abundant documentation) such as saying 'you HAVE to ask EVERY TIME (no matter what their mood, prior history, whatever)' and you HAVE to use the 'So-and-So's' structured 128-item outpatient risk assessment tool (even if it takes the entire session to complete and you ignore the fluid patient situation in front of you...you know, actually flexibly addressing what's going on in that patient's life right now that may be contributing to their hopelessness). Most practicing clinicians (as well as anyone with a moment of logical clarity and who looks at the empirical literature on suicide) realize that we will never (despite all the flag-waving and histrionic emotional appeals to the camera that 'OMG, ONE SUICIDE IS TOO MANY!!! NEVER AGAIN! WE MUST NEVER AGAIN LOSE ANOTHER VETERAN TO SUICIDE!!!!!!!!!!')...the only thing we will NEVER do is live in a world 'without suicide.' You cannot eliminate risk of suicide/homicide. You can only engage in meaningful and empirically-supported efforts to reduce risk of these adverse events. Period. I mean, we don't expect cardiologists to ELIMINATE heart failure. There's a certain degree of morbidity/mortality to psychiatric conditions and there always will be. It doesn't mean we can't improve our efforts and engage in practical, sensible, and effective things like completing suicide safety plans when our patients present with significant suicidal ideation and any intent/plan or access to means. Everyone (especially administrators and lawyers) want quick and easy algorithms and 'solutions' to the problem of suicide (e.g., just demand that clinicians ask and document every time that they asked, regardless of context; or, demand that clinicians complete Sally Joe Ph.D.'s 78-item structured suicide assessment gizmo interview everytime anyone even hints at hopelessness or emotional dysregulation in the face of stress; or, my favorite, OMG, the patient admitted that they had 'thought about' suicide and are going through a rough time right now...we HAVE to send them to the hospital immediately! It's always an interesting exercise (though done at your own peril) to make the differentiation between two types of 'thou shalts' in terms of clinical practice: 1) 'thou shalts' that actually make sense, have a good empirical backing, and represent true 'standard of care/practice' among professionals--for example, completing suicide management/safety plans with patients who present with significant suicidal ideation vs. 2) 'administratively/politically/legally/OCD- driven 'thou shalts' that are driven by the fantasy of ELIMINATING risk of adverse events in outpatient practice and that sound good to the press and to the adminstrative staff in central office (who can assure the politicians that we're doing 'everything we can' to ensure that no one ever commits suicide again under our watch (eye roll)).

 

[heysexylady]

The standard of care is to ask for SI at the first visit and if there is a change in clinical status (for example an adverse life event, worsening symptoms, decompensation etc). Unless working with a particularly high risk group it is not appropriate to ask about SI every visit with patients, and it could hinder a fragile therapeutic alliance (though if you had an actual alliance with the patient asking about SI would not impact it). In terms of documentation I wouldn't document anything about SI if I didnt ask about it, but it would be okay to put no SI elicited. (You shouldn't put no SI endorsed if you didn't ask about though as that makes it sound like you specifically asked). Outpatient psychiatrists in private practice certainly don't ask their patients about SI every visit or event most visits.

It's common for clinics to use something like the PHQ-9 (which again might irritate patients but they can choose not to fill it in) and that will specifically ask about SI, so you don't have to if the pt doesn't check the box on the form and you see nothing on eval that warrants inquiry.

Can yo provide an article or guidelines about this because in my program we are required to ask about si on every visit. At times when I know the patient is stable is just unrealistic for me to ask about si, Hi, and psychotic symptoms.

 

[Fan_of_Meehl]

The reality is that you're not likely to find an administrator or clinical supervisor who will formally go 'on the record' and say that it's 'okay' not to ask about suicide in every patient encounter. They're going to be far too concerned about liability in the case of an actual completed suicide case under your care. Unfortunately, at the administrative level, the top priority is 'covering one's ass' medico-legally ('How do we avoid getting sued/fired?') rather than on promoting sensible, logistically-feasible, flexible, and empirically-supported approaches to assessing/managing risk ('How do we do this most effectively, in the context of real clinical encounters in a way that is appreciative of the complexity of the issue while also ensuring that we don't get lazy and fail to do things that actually help reduce risk'). One option would be to just get into the habit of asking about suicide/homicide, first thing, for every patient on every visit and at least you could get it out of the way and be able to honestly document that you did this. However, it has never seemed natural to me to begin a session in this manner and I would question the reliability of the information as most patients won't be comfortable just saying 'yes' to this question right off the bat (after a more in-depth discussion of their current circumstances, thoughts, and feelings).

In terms of empirically-based arguments and information to develop and back up your personal practices (vs. general inflexible rules) regarding how SI is managed, a few recent texts I've used and referenced are:

The Oxford Handbook of Suicide and Self-Injury

Suicide: Phenomenology and Neurobiology (Springer Press)

Behavioral Emergencies: An Evidence-Based Resource for Evaluating and Managing Risk of Suicide, Violence, and Victimization

I find that the chapters in these sources are written by well-informed, experienced clinicians and researchers who are willing to address some of these issues head-on, including the lack of an empirical basis for many commonly employed clinical practices. Of course, if you're still in training/residency, you may be operating under the license and supervision of another professional in which case I would carry out their orders to the letter on how to operate.

 

[splik]

Can yo provide an article or guidelines about this because in my program we are required to ask about si on every visit. At times when I know the patient is stable is just unrealistic for me to ask about si, Hi, and psychotic symptoms.

I dont see how you can be doing dynamic/psychoanalytic therapy if you re asking your patients if they are suicidal or not every f'ing visit. This is neither standard, nor appropriate, and does nothing to reduce the liability of the psychiatrist (if anything it increases it because the clinic is then creating its own standards). Some of the clinics at my residency program tried to introduce these stupid policies and I made no friends by pointing out how idiotic these policies were and refused to comply with it. And you definitely should NOT be asking every patient about HI or psychosis. your program sucks.

 

[Ceke2002]

While waiting on a no-show earlier this week I was reviewing some of the empirical literature on self-report of SI (especially denial of SI) and ran across some information regarding completed suicides and what the patients in question reported (or, that it was documented that they reported) to the health care provider at their last visit. I am going off memory here but I think it was something like 70% apparently DENIED (or this is what was documented) SI at their last visit. The authors also (wisely) added that--in the absence of other information/context--a simple denial of SI when routinely asked may be meaningless. The fundamental problem, as I see it, is that our professional has become way too hyper-concerned about engaging in concrete 'rituals' (and abundant documentation) such as saying 'you HAVE to ask EVERY TIME (no matter what their mood, prior history, whatever)' and you HAVE to use the 'So-and-So's' structured 128-item outpatient risk assessment tool (even if it takes the entire session to complete and you ignore the fluid patient situation in front of you...you know, actually flexibly addressing what's going on in that patient's life right now that may be contributing to their hopelessness). Most practicing clinicians (as well as anyone with a moment of logical clarity and who looks at the empirical literature on suicide) realize that we will never (despite all the flag-waving and histrionic emotional appeals to the camera that 'OMG, ONE SUICIDE IS TOO MANY!!! NEVER AGAIN! WE MUST NEVER AGAIN LOSE ANOTHER VETERAN TO SUICIDE!!!!!!!!!!')...the only thing we will NEVER do is live in a world 'without suicide.' You cannot eliminate risk of suicide/homicide. You can only engage in meaningful and empirically-supported efforts to reduce risk of these adverse events. Period. I mean, we don't expect cardiologists to ELIMINATE heart failure. There's a certain degree of morbidity/mortality to psychiatric conditions and there always will be. It doesn't mean we can't improve our efforts and engage in practical, sensible, and effective things like completing suicide safety plans when our patients present with significant suicidal ideation and any intent/plan or access to means. Everyone (especially administrators and lawyers) want quick and easy algorithms and 'solutions' to the problem of suicide (e.g., just demand that clinicians ask and document every time that they asked, regardless of context; or, demand that clinicians complete Sally Joe Ph.D.'s 78-item structured suicide assessment gizmo interview everytime anyone even hints at hopelessness or emotional dysregulation in the face of stress; or, my favorite, OMG, the patient admitted that they had 'thought about' suicide and are going through a rough time right now...we HAVE to send them to the hospital immediately! It's always an interesting exercise (though done at your own peril) to make the differentiation between two types of 'thou shalts' in terms of clinical practice: 1) 'thou shalts' that actually make sense, have a good empirical backing, and represent true 'standard of care/practice' among professionals--for example, completing suicide management/safety plans with patients who present with significant suicidal ideation vs. 2) 'administratively/politically/legally/OCD- driven 'thou shalts' that are driven by the fantasy of ELIMINATING risk of adverse events in outpatient practice and that sound good to the press and to the adminstrative staff in central office (who can assure the politicians that we're doing 'everything we can' to ensure that no one ever commits suicide again under our watch (eye roll)).

In the 6 years I have been seeing a Psychiatrist I've had a suicide risk assessment done roughly 4 times, in that whole time. Honestly I'd probably worry about my Psychiatrist's competency if he started running suicide risk checks on me every session, like "dude, seriously, are you *that* bad at your job that you think I'm going to top myself every time I see you?"

I know there was that big push, especially back in the 80s and 90s, towards dispelling the myth that people who talk about suicide never actually commit suicide, but now the dispelling of that myth seems to have gone full circle, almost, and become 'people who are going to commit suicide will always give some indication of their intent, and as long as you don't miss the signs you can stop them'. And that just isn't true. Not everyone who attempts or completes suicide starts dropping hints X number of days or weeks in advance. I know I didn't. When I attempted suicide, many, many, many years ago now, I planned everything at least 6 weeks in advance, and in that whole time I didn't deviate from my daily routine, I didn't go around dropping cryptic hints about 'not being here anymore', I didn't start randomly giving my stuff away, I didn't draw up a will, I didn't draft up a suicide note, I certainly didn't mention the word 'suicide' to anyone - about the only thing that might have been picked up on as any sort of a 'clue' was the fact that I withdrew from my friends in the last 2-3 weeks, or so, but even that wasn't uncommon behaviour because we always went through phases where we kept in touch more than others. Essentially I was planning to die, that was my sole intent at the time; not to go around sending out little 'save me' hints so that someone would come along and stop me.

Had I succeeded in my attempt it wouldn't have been anyone's fault. How are you supposed to predict that someone's going to try and kill themselves, or step in to stop them when they give you zero idea of what they're intending to do.

 

[nexus73]

Asking about suicide or not, it's nice to have a risk assessment in the note.

 

[WisNeuro]

Well, in many cases, I do it for every visit (eval, feedback, followup) because if I don't, I will get dinged on my 6 month review of random note samples. It'snot about whether or not we think it's clinically indicated using our best clinical judgment and empirical reasoning, it's about whether or not it's a mandate passed down in the organization by someone who really doesn't know what they're doing.

 

[Jules A]

Well, in many cases, I do it for every visit (eval, feedback, followup) because if I don't, I will get dinged on my 6 month review of random note samples. It'snot about whether or not we think it's clinically indicated using our best clinical judgment and empirical reasoning, it's about whether or not it's a mandate passed down in the organization by someone who really doesn't know what they're doing.

I tend to do it also for the above reason and will usually tell people up front "look I ask everyone this and will probably ask it every time you come in so just bear with me". Often during the assessment I'll ask "so no suicidal thoughts?" not exactly an open ended therapeutic question but is does the job. I do medication management only so disrupting the whole therapeutic alliance with a couple of trite but what I feel necessary questions isn't a major concern.