suicide risk assessment

[IAmAUser]

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[TenaciousGirl]

I'm not a doctor but I do psych consults in the ED during the day and sometimes have to be on call. There isn't a formal assessment that we use ... just the standard questions to see if they have a plan, is there intent, is there a means, etc. Fortunate for them, it's our decision as to whether or not they get 5150'd. Of course you need to have cause to do this but if I feel someone is in danger of hurting themself, I don't care if they're meeting the Pope tomorrow, they're coming in. Lastly, something I've had to remind myself is that there's only so much we can do. We aren't superheroes. If someone wants to hurt themselves, they're going to find a means to do it. Of course we should try and stop them but sometimes it's out of our control.

 

[whopper]

I have talked to and had lectures from speak in generalities, "listen to the music, not the words," "go with your gut," or will give examples of known risk factors such as prior attempts, impulsivity, substance use, clear plan, etc. Are there any well valiadated tools for suicide risk assesment?

Risk assessment in this field is at a level where there is much to be desired.

There are several tools out there, but most of them are specific to certain populations, and all were not very statistically accurate.

This page has several scales!

But how effective are they? Not very.

A study done by the US military showed that the Beck Scale of Suicide Ideation had the most reliability.
http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD=ADA381300

It can be purchased here.
http://www.pearsonassessments.com/H...oductdetail.htm?Pid=015-8018-443&Mode=summary

Ultimately, risk assessment is based on 2 factors: acturarial and clinical. Acturarial data is very scientific, but clinical observation is very touchy feeling.

There may be a reason why your attendings were vague. It could be because of the lack of a good model that can accurately predict suicide. It could also be that they don't know the extent of the limitations in predicting future suicide. Since there has been no glaringly good data, it's not taught much, and hence, generation after generation of residents are only given vague information.

It's very frustrating to hold a patient or let a patient go when suicidal ideation has been expressed. I suggest no first year resident within the first 6 months of training ever let a patient go without first verifying it with the attending.

 

[strangeglove]

And never let your guilt about making someone miss a deadline/wedding/barmitzvah/whatever impact your decision to either hold the patient or discharge him. Would you do the same thing for someone who just had a massive stroke?

 

[OldPsychDoc]

And never let your guilt about making someone miss a deadline/wedding/barmitzvah/whatever impact your decision to either hold the patient or discharge him. Would you do the same thing for someone who just had a massive stroke?

My standard line is: "And how well will that thing turn out if they are mourning your death along with the festivities?"

Always get "you've got to let me go to take care of my kids..."
Uh, now who was going to do that while you were busy expiring from that overdose...?

 

[IAmAUser]

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[nancysinatra]

And never let your guilt about making someone miss a deadline/wedding/barmitzvah/whatever impact your decision to either hold the patient or discharge him. Would you do the same thing for someone who just had a massive stroke?

No, but stroke patients (assuming they have capacity to make medical decisions) can't be admitted involuntarily. They are free to leave AMA. Medicine, neuro, etc--they have it easy in a way--they can give their recommendations and then sit back and let the patient decide. Many patients decide to attend the wedding.

Plus those fields all have lab tests and imaging to go on. Can you imagine neuro residents having to decide whether to admit stroke patients (involuntarily, no less) just based on physical exam alone? Like, "ooh your previously existing facial droop MIGHT be a little worse today--could be a new stroke--so, hate to break it to you, but you're coming in!"

 

[235750]

it turned out that the patient who prompted me to make this post actually thanked me today for making him come in and apologized for being rude on admission

Good job, that's gotta feel great!

 

[worriedwell]

The most important aspect of doing a suicide risk assessment, whether you formally use a tool with checklist items or if you do a less formalized assessment is that you explicitly show that you used clinical judgement to formulate the level of danger one is in, especially imminent danger. Suicidality is not a sin e que non of psychiatric hospitalization by any means, it simply means it is your responsibility to provide treatment that reduces suicide risk and that you explicitly explain what you did and why, and in particular why you think a reasonable therapeutic standard was adhered to. That might include reducing agitation by giving a benzo and referring promptly to a provider, and ensuring they do not have access to means and that they know where they can go and what they can do if the suicidality becomes more imminent (ie a suicide safety plan). Involving collateral supports to this end is also important. There is nothing to say that someone having suicidal thoughts alone requires involuntary hospitalization, it really is the nature and imminence of the thoughts. In particular, if they have INTENT which means they essentially don't have the capacity to make rational decisions based on our working model of suicide...that is when they should be involuntarily hospitalized. And of course there is clinical and legal leeway if uncertain to err on the side of safety (and as a psychiatrist, you are essentially the only one on the planet who has the authority to "kidnap" with the understanding that you are making a medical intervention).

 

[whopper]

Here's my recommendation:
Look at static factors (actuarial): age, race, prior history of suicide attempts, unemployed/employed, etc.

Then look at clinical factors: how do they present during an interview, do they have a plan, do they look depressed/manic/psychotic, etc.

Look at risk factors should that person be discharged: will you be discharging them to a location where they are alone? Do they have a gun in the home? What factors will be different in the community vs what led them to a suicide evaluation?

Once you've examined all 3 areas, make a decision.
Most of the better risk assessment scales work on this model.

One of the existing suicide risk assessment scales should only be used as a guide. Clinical judgment should play heavily into the decision to discharge or hold the patient.

If you do decide to discharge, document why, and make it in a manner where it would stand up in court.

Another recommendation outside the usual scope is to call up your insurance carrier. I know most of you residents don't have insurance yet. TRUST ME, INSURANCE COMPANIES HAVE A VESTED INTEREST IN MAKING SURE YOU DO STANDARD OF CARE WORK ON THIS AREA. THEY WILL HELP YOU. (Or at least mine will). My insurance company regularly provides forums for doctors to better document on this area, and provides us with risk assessment tools. Suicide is the #1 reason why psychiatrists are sued.