Suicide Assessment and Prevention _ ____________________________________________________________
Low Acute Risk Low acute risk patients include those with recent suicidal ide- ation who have no specific plans or intent to engage in lethal self-directed violence and have no history of active suicidal behavior. Consider consultation with behavioral health to determine need for referral to treatment addressing symptoms and safety issues. These patients should be followed up for reassessment. Patients at low acute risk should be considered for consultation with or referral to a behavioral health prac- titioner [79]. Not at Elevated Acute Risk or Risk Unknown Persons with a mental disorder who are managed appropriately according to evidence-based guidelines and do not report suicidal thoughts are outside the scope of the classification of risk for suicide. Patients who at some point in the past have reported thoughts about death or suicide but currently do not have any of these symptoms are not considered to be at acute risk of suicide. There is no indication to consult with behav- ioral health specialty in these cases, and the patients should be followed in routine care, continue to receive treatment for their disorder, and be re-evaluated periodically for thoughts and ideation. Patients at no elevated acute risk should be followed in routine care with treatment of their underlying condition and evaluated periodically for ideation or suicidal thoughts. Patients for whom the risk remains undetermined (i.e., no collaboration of the patient or provider concerns about the patients despite denial of risk) should be evaluated by a behavioral health practitioner [79]. DOCUMENTATION In order to ensure optimal patient care and to prevent mis- communication and litigation, the results of any suicide risk assessment should be fully documented. At a minimum, documentation should include the following points, noted by the mnemonic SUICIDE [17]: • S uicide assessment: The results of suicide screening or assessment, including any relevant history (personal or family), access to lethal means, suicide plans, recent history of stressful events, and protective factors, should be noted. • U npredictable: Family members and/or other support- ive third parties should be alerted that suicide can be unpreventable, even given the best efforts and plans. • I nterventions: All interventions planned and under- taken should be included in the patient’s record. • C lear and comprehensive: It is important to ensure that all documentation is clear and comprehensive, with specific notes regarding the patient’s own words. • I ntent: The intentions of any suicide attempt(s) or intentional self-harm should be noted.
• D iscussions with family members and/or other sup- portive third parties: Supportive third parties can be invaluable to the treatment process, and their inclusion in risk assessments and treatment planning should be documented. • E ducate, engage, empathize: Documentation should include notes regarding the patient’s involvement in treatment planning and the creation of a safety plan. Patient B arrives at the office with her daughter. She appears with- drawn and preoccupied, having a look of resignation and despair. Seated together, you begin the interview in a positive, affirming manner: “I’m pleased that all your laboratory work, including your thyroid tests, is normal. You know you told me you would be okay, and I believe if we work together, so as to know and understand better what you are going through, we can relieve many of your symptoms and get you to a much better place.” She is receptive, and after further discussions, the following picture emerges: Patient B has been unhappy for “a very long time.” There is little to add to the somatic complaints related on the first visit. She sleeps poorly and is tired all the time; she has lost interest in what was previously an active social life and rarely “goes out.” There is a good deal of psychic stress and pain attached to the relationship with her husband, and a sense of hopelessness has been building for months. In recent days, she has not slept and has periods of confusion. She wishes not to be a burden to those closest to her and has thought often of ending her life. Recently she has been thinking about just how to do this, the options available to her, and how it might be done so as to mask her intent. At the conclusion of the interview, you glance at the nurse with an expression of appreciation, and shudder to think how easily you might have missed all this. • Recall the mnemonic device IS PATH WARM. How many of the elements are positive for Patient B? Which ones? • Would you rate Patient B’s suicide risk as low? Intermediate? High? • Which of the following management options is the LEAST appropriate at this juncture? − Send the patient home with a prescription for an anti- depressant and a plan for regular return psychotherapy sessions in your office. − Refer her to a psychiatrist (appointment in 48 to 72 hours) and negotiate a “contract” with the patient that she is not to take matters into her own hands but will call you immediately if she has thoughts of doing so. − Arrange admission to the hospital medical service with a “sitter” and place an urgent psychiatry consultation. − Call your psychiatry consultant to summarize the case and request immediate consultation or admission to the inpatient psychiatry service.
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