Suicide assessment is one of the most important and challenging aspects of working in mental health. The combination of uncertainty and liability can be intimidating. For your own protection and peace of mind, assess and document carefully in this area: not a matter of writing a lot of words, but instead of writing the correct words. Aim to minimize the odds of suicide as much as possible, and to make it clear in the record that you did so. No one can perfectly predict or prevent all suicides, but we can do the best job possible. Remember, suicide is both common and lethal: tens of thousands of death in the U.S. every year.
Assessment aims at exploring the risk of an attempt, the dangerousness of such an attempt, and the available resources to mitigate risk. There are many pertinent questions, listed below (Stern et al 15-19). For many providers, the main need is to detect risk and steer patients at risk to a mental health specialist.
Ideation: are they thinking about it? How much? How seriously?
Intent? Do they plan to take action? When?
Somehow expressed intent precedes up to 80% of deaths by suicide
About 50% of people who kill themselves see a health care provider in the month prior. BUT of those who do see a provider first, only 60% express SI or intent at that time.
Can the patient contract for safety?
Is there a suicide plan? How viable is the plan, how lethal is it? How well thought out, how detailed? Are the means readily available, e.g. a gun (very high lethality).
Likelihood of rescue? If they were to make an attempt, would anyone be available to help them?
Hopelessness? Do they see any future for themselves? Anything and/or anyone to live for?
Impulsivity? Can they be trusted to stop themselves form harming themselves or others?
Mental status: E.g. Are they intoxicated? Psychotic? Psychiatric illness? Are they too impaired, or paranoid, etc. to keep themselves safe?
Risk factors, i.e. those that increase the odds of an attempt:
History: Any past Attempts: impulsive or premeditated? Any family history of suicide? History repeats itself:
50% of completed suicides have a prior attempt history
Of those with past attempts, 10-20% eventually die by suicide
Risk is esp. high for a year after most recent attempt, with elevated risk for 10 years
Any precipitants recently? Anniversaries of losses, job loss, break-ups, etc.
Stressors and supports? E.g.:
Widowed, divorced, separated
Financial and/or legal problems
Demographic risk factors? E.g. Elder white men are the single highest risk group demographic group, while married adults with young children are at lowest risk.
H/O Unstable childhood circumstances: parental death or separation, abuse, neglect. Raises level of risk.
All these factors help us gauge, however imperfectly, the risk of suicide and of death.
Care Planning for Suicidal People:
Finally, staff response is crucial: What do you plan to do to minimize risk?
In terms of care planning, it all boils down to trust, based on your assessment.
What is needed to maintain a person's safety?
Part of your trust involves your assessment regrading your patient as an historian:
- Are they competent?
Are they honest? Are they manipulative? Do they trust you enough to tell you the uncomfortable truth?
Who do they trust? Maybe you should seek information through more trusted sources
Are they threatening vs. others?
Are they cooperative?
The less you trust a patient's safety and/or predictability, the more protection you provide.
Aspects of your plan include:
- Patient contracting. A Contract for Safety (CFS) with the patient, promising to keep safe and come to staff if losing confidence in the contract. Can you trust the patient to keep such a promise?
- Setting and supports: e.g. locked inpatient unit, staying with friends or family, day programs, etc.
- Monitoring - checks: weekly, daily, 5 or 15 minutes, by phone or in person, one-to-one specials, a sitter, etc.
- Restrictions: locked unit, no sharps or flames, QR, restraints
- Ease suffering:
Medical care: esp. re. pain, anxiety, depression, and other suffering
Supportive education and counseling, e.g.
Depression cause hopelessness, and it is very treatable, given a bit of time. So we have every reason to expect things to look better, soon.
Build the rapport, maximize effective supports
Stern, T.A., Herman, J.B., and Slavin, P.L. The MGH Guide to Psychiatry in Primary Care. New York: McGraw-Hill.
Hope somebody out there finds this useful