4. Other - Reduce access to lethal means 5. Interventions to improve adherence: Facilitating access to care VA/DoD Guideline Recommendations Screening and Examination
• Outreach (e.g., telephone contact, home visit, mailing caring letters/postcards) • Case/care management • Counseling and other psychosocial interventions ● Psychiatric symptoms (e.g., hopelessness); recent biopsychosocial stressors (e.g., loss of relationship) ● Availability of firearms When evaluating suicide risk, the VA/DoD guidelines warn against the use of a single instrument or method (e.g., structured clinical interview, self-report measures, or predictive analytic models). A research review on suicide risk assessment methods does not provide any specific risk evaluation methods sufficient to clinically predict the future risk of suicide. However, suicide risk assessment is considered a vital part of SIB management. The VA/DoD guidelines recognize the most popular tools widely available in medical circles. However, it cautions clinicians against the use of a single suicide risk assessment tool, given the lack of research evidence and clinical observation supporting the use of a single tool/method. Also, the guidelines maintain that the potential harm of using only a single instrument or method to assess suicide risk outweighs the burden of utilizing multiple instruments and a multimethod approach to assess an individual’s risk for suicide. It should also be noted that while it is an expected standard of care, currently there is insufficient evidence to recommend for or against the use of risk stratification to determine the level of suicide risk (Pittman et al., 2021). Perhaps this recommendation demonstrates one of the differences between the VA/DoD guidelines and other guidelines widely referenced in the medical community. Risk stratification assessments involve the use of “reliable” tools to clinically classify the degree of risk that accurately corresponds to a patient's suicide-related ideation and behavior. Drawing clinical notes from Large et al. (2018), this guideline emphasizes how suicide-related deaths among patients have been observed to be largely independent of their risk stratification class. In the clinical notes that Large submitted, he noted that just over half of the suicide-related deaths occurred among patients in the high-risk category who were admitted to inpatient psychiatric facilities. Also, the odds ratio for suicide in the high-risk group compared to the low-risk group was 7:1, but this is in the context of a patient population that met the criteria for admission to inpatient psychiatry. However, this recommendation does not nullify risk stratification assessments currently recommended in other guidelines. In many cases, risk stratification, when completed as part of a comprehensive evaluation, enables providers to formulate a clinical impression of a patient’s suicide risk, which can help inform risk mitigation strategies and treatment decisions. Though the use of a risk stratification tool is considered necessary, the VA/DoD guidelines advise adopting consistent and standardized approaches to suicide risk assessment and stratification that can enhance the clinical utility and feasibility of conducting risk stratification in an equitable and replicable manner. Using a consistent lexicon to describe a patient’s risk stratification is also important because of the need to communicate a patient’s risk level from one provider to another. to resolve the clinical complications of suicide behavior by changing problematic thinking and behavioral patterns. Patients are subsequently equipped with the mental frame to identify proximal thoughts and images and handle them appropriately. Evidence-based research also demonstrated how patients who presented to the hospital following a suicide attempt and received Cognitive Therapy for Suicide Prevention (CT-SP) as compared to those who received usual care were 50% less likely to report a repeat suicide attempt during the follow-up period.
Related to the screening and examination processes, the VA/ DoD recommends universal screening with an evidence-based screening tool to identify individuals at risk for suicide-related behavior. The recommended screening tool is the Patient Health Questionnaire-9 (PHQ-9), specifically the response to Item 9 in the tool that asks: “Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” Possible responses may include: ● “Not at all.” ● “Several days.” ● “More than half the days.” ● “Nearly every day.” VA/DoD guidelines also acknowledge that some available screenings tool are inadequate in identifying and accurately predicting the risk of suicide. Many of these tools yield a high number of false-positives, skewing screening results and disrupting the algorithm for proper management and monitoring. Many research studies have been conducted to ascertain the test the accuracy and effectiveness of the PHQ-item 9 in suicidal ideations and behavior risk evaluation in different populations over the years (Kim et al., 2021b). These studies suggest higher levels of suicidal ideation are associated with an increased risk of death by suicide in patients who received the PHQ-9 across different healthcare settings. In these study populations, the endorsements of responses were also largely predictive of both suicide attempts and deaths within the year following administration of the questionnaire. Risk Factors When it comes to assessing risk factors as part of a comprehensive evaluation of suicide risk, it is recommended that the assessment includes the following: ● 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) Emphasizing the need for a comprehensive evaluation of risk factors, VA/DoD guidelines outline factors to consider and their corresponding category. The categorization of factors is based on evidence-based research supporting them in the context of suicidal ideation and behavior. The categories include: ● Self-directed violence (SDV) (e.g., current suicidal ideation) ● Current psychiatric conditions/current or past mental health treatment (e.g., prior psychiatric hospitalization) Psychotherapy The VA/DoD guidelines recommend that clinicians use cognitive- behavioral therapy–based interventions that emphasize suicide prevention for patients with a recent history of self- directed violence to reduce incidents of future self-directed violence. These guidelines support the use of cognitive behavioral therapy–based interventions as a nonpharmacologic treatment option for suicidal ideation and behavior. Based on the Observations reported supports this method of suicide prevention and management in teaching at-risk patients ● Prior psychiatric hospitalization ● Recent biopsychosocial stressors ● Availability of firearms
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Book Code: PYMA2024
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