I updated my suicide risk assessment presentation today in light of new data on suicide risk assessment stratification. It turns out that using such tools might not be supported by the research evidence. That’s not going to stop the use of such tools, which include the Columbia–Suicide Severity Rating Scale, which is in wide use.
I found criticism of these scales in a recently published article in Clinical Psychiatry News, published June 21, 2019, “Why we need another article on suicide contracts,” by Nicholas Badre, MD and Sanjay S. Rao, MD.
For many years now, psychiatrists and other health care professionals have learned that trying to use no-suicide or no-self harm contracts are controversial and don’t prevent suicide. Badre and Rao sound like they’re easing away from that contention although they still say that a thorough clinical suicide risk assessment out to be done.
Until I saw this article, I was not aware of a recent review of 70 studies showed that: “no individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”
Carter, G., et al. (2017). “Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales.” Br J Psychiatry 210(6): 387-395.
This was even more interesting because we recently changed our practice regarding suicide risk assessments on the psychiatry consultation service based on relatively new recommendations from the Joint Commission on Accreditation of Hospital Organizations (JCAHO). The Joint Commission favors the risk assessment tools.
Of course I’m not going to second-guess the Joint Commission but after 27 years (counting residency) of struggling to assess suicide risk, I’ve learned that it can hardly be reduced to any single rating instrument.
I have often said to patients that I don’t use no-suicide contracts because they’re too much like promises—and promises are broken every day. That segues into what I prefer which is to work with the patients on developing a safety plan, which I compare to no-suicide contracts by saying “a plan is better than a promise any time.”
Working on the safety plan with patients gives me another way of assessing the strength of my alliance with them and a way to improve it as well as a method for evaluating their ability to formulate a workable way to stay safe that emphasizes their individuality.
On the other hand, the safety plan is no guarantee of safety, any more than the no-suicide contract.
But often enough I’ve gotten the sense that some patients and I have even had a little fun working on suicide safety plans—ironic as that sounds. I find how important pets are, hear little anecdotes about a favorite hobby or goal, aspirations, hopes, and memories of better times when they coped really well.
Listening for understanding to someone who is contemplating suicide or who has attempted suicide is never easy. It’s the hardest thing I do. I can’t say that I’ll miss it when I retire. I have great faith in the next generation of doctors.