This is on a bit of a different topic but, I think, a very important one rarely discussed at VA hospitals.
I don't know about anyone else but I just recently read through the published VA/DoD clinical practice guidelines regarding suicide assessment/management and found it really illuminating. So many of the emphases/ 'thou shalt's' that are thrown around in practice in VA settings don't really have that strong a basis (at all) in the literature. Shouldn't surprise me (in principle) that this is the case...I guess I was just taken aback at how bad it was (the disconnect between the literature and our practices and the fact that this is sitting right out there in the open--in the VA's OWN published 'guidelines').
Really, there were only two practices for which it was concluded that there was 'Strong for' evidence:
1) assessment of main suicide risk factors
2) use CBT with patients who have a recent history of self-directed violence
Everything else was 'weak for' or WORSE.
Very interesting.
Thoughts?
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Rankings of Intervention/Assessment Practices From the Most Recent VA/DoD Assessment and Management of Patients at Risk for Suicide Guidelines
Using these elements, the grade of each recommendation is presented as part of a continuum:
• Strong for (or “We recommend offering this option …”)
- [assessment of suicide risk using main factors] We recommend an assessment of risk factors as part of a
comprehensive evaluation of suicide risk, including but not limited to: current suicidal ideation, prior suicide attempt(s), current psychiatric conditions (e.g., mood disorders, substance use disorders) or symptoms (e.g., hopelessness, insomnia, and agitation), prior psychiatric hospitalization, recent bio-psychosocial stressors, and the availability of firearms.
- [using CBT with patients who have a recent history of self-directed violence] We recommend using cognitive behavioral therapy-based interventions focused on suicide prevention for patients with a recent history of self-directed violence to reduce incidents of future self-directed violence.
-----but note (p. p.32, full guidelines), "The evidence base in support of factors that can protect against suicidal behavior is limited. Nonetheless, evaluation of such factors, particularly those associated with reasons for living, should be included in a comprehensive suicide risk evaluation"
• Weak for (or “We suggest offering this option …”)
- [universal screening with the PHQ-9, item 9] With regard to selecting a universal screening tool, we suggest
the use of the Patient Health Questionnaire-9 item 9, to identify suicide risk.
-----but note (p. 29, full guidelines) "Consistent with previous reviews of the evidence base related to the identification of those who are at elevated risk of dying by suicide, our review found that most screening tools do not accurately predict risk of suicide.[42-48] These tools tend to yield an unacceptably high false-positive prediction rate (i.e., many of those determined to be “at risk” never experience clinically significant suicidal thoughts or behavior) alongside an unacceptably low degree of accuracy when identifying true cases (i.e., a substantial portion of those individuals who die by suicide were not identified by the screening tool)."
AND
"Nonetheless, 71.6% of deaths by suicide during the study periods were among those who endorsed “not at all,” highlighting that use of the item 9 alone is likely to result in a number of at risk patients being missed."
AND (regarding the use of the C-SSRS, specifically)
For example, the Columbia Suicide Severity Rating Scale (C-SSRS) was included in the Runeson et al. (2017) systematic review regarding instruments for assessing suicide risk; however, the one study identified for inclusion in Table 1 entitled, “Instruments evaluated in studies with acceptable risk of bias,” was conducted among 124 adolescents.[52] In their conclusions the authors noted, “There were too few studies to assess the diagnostic accuracy of …the C-SSRS.”[52]Studies that use larger samples, adult cohorts, mortality as their key outcome, and employ prolonged follow-up periods are needed"
- [suicide safety plans] We suggest completing a crisis response plan for individuals with
suicidal ideation and/or a lifetime history of suicide attempts.
---(and note, p. 37 of the full guidelines) Completing a crisis response plan has been found to decrease suicide attempts among military personnel with an ***acute history of suicidal ideation during the past week*** and/or a ***lifetime history of suicide attempts***"
- [caring communication cards] We suggest sending periodic caring communications (e.g.,
postcards) for 12-24 months in addition to usual care after
psychiatric hospitalization for suicidal ideation or a suicide
attempt
- [lethal means counseling] We suggest reducing access to lethal means to decrease suicide
rates at the population level
---(and note, p. 52 of full guidelines), "MSC (means safety counseling) approaches have not been shown to reduce suicide, but have been shown to impact firearm storage practices" and (p. 53 of full guidelines), The Work Group systematically reviewed evidence related to the five recommendations above. The Work Group’s confidence in the quality of the evidence on lethal means safety was very low."
• No recommendation for or against (or “There is insufficient evidence…”)
- [risk stratification - low, intermediate, high risk] While it is an expected standard of care, there is insufficient evidence to recommend for or against the use of risk stratification to determine the level of suicide risk.
----(and note, p. 34, full guidelines) "A valid and reliable tool to classify the degree of risk that accurately represents a patient’s suicide-related thoughts and behavior (i.e., risk stratification) remains elusive"
---(and note--bizarrely and confusingly enough--all of these guidelines, algorithms and our suicide prevention policies/procedures and assessment instruments appear to HEAVILY EMPHASIZE the importance/criticality of using a LOW/ INTERMEDIATE/ HIGH and ACUTE/CHRONIC classification/ risk stratification approach. I'm not sure what exactly to make of this. 'There is insufficient evidence for this practice...but we're just going to go ahead and mandate its use and build our policies/procedures around it as a paradigm.'
• Weak against (or “We suggest not offering this option …”)
- [using just one method} When evaluating suicide risk, we suggest against the use of a
single instrument or method (e.g., structured clinical interview,
self-report measures, or predictive analytic models)
• Strong against (or “We recommend against offering this option …”
none
----------------Notably absent from these guidelines / the professional literature:
- [our no show follow-up policy/procedure] YOU ABSOLUTELY MUST IN EVERY CASE OF EVERY SINGLE PATIENT YOU TREAT EVEN IF THEY NEVER HAVE THOUGHT ABOUT OR REPORTED THINKING ABOUT SUICIDE EVER EVER IN THEIR LIVES AND STATE THAT THEY WOULD NEVER DO IT FOR XYZ REASONS (FOR LIVING) IN 1,000,000 YEARS...IF THEY NO-SHOW YOU ABSOLUTELY MUST CALL X3 TIMES (AND DOCUMENT) WITHIN A WEEK OF THEIR NO-SHOW AND IF THEY DO NOT PICK UP AT THE THIRD PHONE CALL YOU MUST CONDUCT AND DOCUMENT IN THE MEDICAL RECORD AN 'EVALUATION OF IMMINENT RISK' AND DECIDE WHETHER OR NOT TO SEND THE POLICE TO THEIR HOME TO DO A WELFARE/SAFETY CHECK!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
- [the requirement to 'update' various things (C-SSRS [via clinical reminders], CSRE, Suicide Safety Plans) on an ANNUAL basis. This appears completely arbitrary but is SO emphasized in terms of implementation (e.g., 'chart audits' by non-providers).
- [emphasis on using the C-SSRS as a follow-up to a 'positive' screen on the PHQ-9] Maybe I missed it in the full guidelines...but I didn't see this apparent 'cornerstone' of our 'policies/practices' of PHQ-9 --> C-SSRS --> CSRE stratification for suicide risk assessment that we've been hammered on implementing for the past several years. Is this a change from the prior (2013) guidelines/analysis? Are they going to change/update our approach?
