Across Bluegrass, from the out-patient clinics to the hospital and even at Oakwood, our protocols for assessing and managing suicidal ideation and behavior are under review. In part, this effort is driven by Joint Commission’s National Patient Safety Goal to “Identify individuals at risk for suicide”. Whenever Joint Commission gets involved, we all know that a documentation trail can’t be too far behind. However, working with Aaron Dowdell and his Clinical Leadership Committee’s team on suicide assessment, with David Susman and David Riggsby at the hospital, and with David Lanier at Oakwood, I’ve been impressed by the clinical knowledge going into this work. Here are some observations:
·Suicide risk, even high or critical risk, does not require that the client be voicing suicidal ideation. The presence of risk factors, such as psychiatric diagnosis, chronic pain, history of previous attempts, etc. can be sufficient for a clinical judgment of elevated risk.
·The involvement of collateral sources of information is especially important when risk may be high and we do not know the client well. Staff conducting 202A or jail triage evaluations or working in the Central Triage Unit (CTC) should not hesitate to contact available collateral sources if any question exists as to the client’s risk.
·The use of a checklist or form cannot substitute for a sensitive clinical interview and intervention. I’m grateful to David Susman for passing on to me an interesting discussion from the American Association of Suicidology’s listserv. Although forms and checklists may help clinicians remember all the points that need to be covered in an assessment, the completion of a form should never control the clinical interaction.
·“No suicide contracts” have no demonstrated benefit in preventing suicides, but they may be useful as a clinical tool for evaluating the client’s level of intent and sense of control.
·Although some groups are not ordinarily considered at elevated risk for suicide, ultimately the assessment has to take into account the unique circumstances and characteristics of the client’s life. For example, David Lanier at Oakwood has been looking into assessment and management of suicide risk with residents with intellectual disabilities (not usually considered at high risk) who also have co-morbid psychiatric disorders.
·The relationship between suicide attempts and suicide completions is complex. Some researchers estimate that a ration of 300:1 exists for suicide attempts to completions and individuals who attempt suicide unsuccessfully are at greater risk for a fatal attempt later. However, most completed suicides occur on the first attempt, often with little or no warning to family or friends.
In the coming months, I hope that this column will become a place to share information and ideas across our organization. I would like to hear your comments and questions. In the meantime, I’ve posted a couple of articles related to the assessment and management of suicide on the H drive in the folder “Chief Clinical Officer – MH & SA” in the folder labeled “Suicide”.
