I know the term “suicide risk assessment” sounds very clinical. That’s because I did it for many years as a consultation-liaison psychiatrist in the general hospital.
The human part of it was using the suicide safety plan, which I got from the Centre for Applied Research in Mental Health & Addiction (CARMHA). You can download it yourself and adapt it by writing in the National Suicide Prevention Lifeline: 988 Suicide and Crisis Lifeline. That’s because the phone numbers on the form are specific to Canada.
Most often I interviewed patients in the intensive care units, where they were admitted after a suicide attempt. The interviews were very short if they refused to talk to me or were still delirious—often the case.
If they were awake and able to converse, the interviews were often pretty long. One way to connect with the patient was working on the safety plan together. I was often able to tell whether they were sincere or not by the level of detail they gave me about support persons they could get in touch with or things they could do to help them cope with whatever was troubling them.
A lack of detail in the plan, or refusal to work on some parts of it were areas of concern. If there were comments about friends, pets, or pastimes that spontaneously led to laughter (yes, that happened occasionally!), I was more confident that the patient was able to look toward the future and make specific plans for staying alive.
There is healthy debate about how useful specific suicide risk assessment scales are for predicting and preventing suicide. They are an essential part of the computerized medical records now, whatever anyone thinks of their reliability at predicting imminent suicide. I never used no-suicide contracts because well before the time I entered professional practice, most experts agreed that they don’t prevent suicide.
What was more useful for me as a clinician was to sit down at the patient’s bedside and, after getting the details about what the patient actually did in the suicide attempt and the events connected with it (along with a comprehensive and thorough history), I would get the safety plan from my clipboard, hold it up so they could see it and say, “Now let’s work on this; it’s your safety plan.”
I can’t tell you how often working on those plans, frequently for more than half an hour, led to laughter as well as tears from the patient. When it worked, meaning the relationship between us deepened, I sometimes did not find it necessary to admit the person to the psychiatric ward. While this occasionally alarmed the ICU nurses, things usually turned out fine later.
Go Retire Psychiatrist 
Great piece Jim. With the way the EHR slices and dices up our specialty and past critiques about the lack of phenomenology – I have the thought that these suicide assessments are the ideal area to focus on that issue. One of my early attendings taught me the important of looking at all of the fine details and specifics of suicidal ideation but especially suicide attempts. When you talk in detail to the survivors it is often a very long conversation.
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Thanks, George! I remember being told that only consulting psychiatrists could order and cancel all suicide precautions on inpatient general medicine units, and the ER. A committee drove that, which in turn was partly driven by an anticipated upcoming routine visit from Joint Commission. Part of the issue was that some medically ill patients who expressed suicide ideation could not be admitted to either our general psychiatry units or even the medical-psychiatry unit. I tried to convey how difficult suicide risk assessments can be. As you and I both know, suicide ideation is a moving target and can change quickly. While I could order suicide precautions, that did not stop med-surg attendings from canceling them for various reasons. Patients can tell the ER staff physician they’re having thoughts of suicide. And when a C-L psychiatrist conducts a suicide risk assessment later, the patient can deny suicide ideation and say the reason, e.g., is to keep a beauty parlor appointment.
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