Suicide risk assessment: what is the standard of care?

It is said that there are two kinds of psychiatrists: those who have had patients commit suicide and those who will. Suicides of patients are the most frequent source of malpractice claims against psychiatrists. An examination of the parameters of what constitutes acceptable suicide risk assessment finds marked disagreement among respected clinicians, academics, and researchers who testify as experts in suicide cases. Studies of suicide in adults indicate that more than 90 percent of individuals who commit suicide are mentally ill. More than 30,000 people die by suicide each year. Many of these individuals will have seen a physician or a mental health professional the day of or a few days before committing suicide. In 1999, the Surgeon General’s “Call to Action to Prevent Suicide” emphasized that identification of “suicide risk and protective factors and their interactions form the empirical base for suicide prevention.” Psychiatrists cannot predict with certainty which patients will commit suicide. Suicide is a rare event. Attempts to predict suicide produce many false-positive and false-negative results. Thus, there is no professional standard of care for the prediction of suicide. No competent expert will disagree on this point. Moreover, few experts would disagree that the psychiatrist must gather sufficient information about the patient to perform an adequate suicide risk assessment that informs clinical interventions and management. The question is, what constitutes an adequate, clinically informative suicide risk assessment? My answer is that an adequate suicide risk assessment systematically considers the interplay between risk and protective factors. By systematic, I mean the identification and weighing of patient-specific risk and protective factors. Systematic suicide risk assessment is an inductive process, reasoning from patientspecific data to a clinical judgment about appropriate treatment and management. Systematic does not mean perfect or exhaustive assessment. When patients are at risk for suicide, nothing less than systematic risk assessment will do. Why do so many psychiatrists not perform or, having performed, not document even the semblance of a systematic (formal) suicide risk assessment? When posed to colleagues, this question receives a variety of answers: the psychiatrist never learned during training how to perform a systematic suicide risk assessment (I believe this to be true of many psychiatrists); the psychiatrist simply does not perform a systematic suicide risk assessment (the majority of cases); patients at risk for suicide evoke anxiety and denial in the psychiatrist who then minimizes or overlooks the risk; the psychiatrist actually performs a systematic suicide risk assessment but is rushed and fails to document it; the psychiatrist is fearful that documenting his or her thought processes creates legal exposure if the assessment is wrong and the patient commits suicide; or the psychiatrist delegates risk assessment and patient management to the treatment team or others, usually in managed-care settings. All of the above can play some role in the lack of performance or documentation of systematic suicide risk assessments. However, depending on the patient or in clinical situations such as ongoing psychotherapy, systematic suicide risk assessment may not be indicated. In the experience of one hospital quality assurance committee, which mandates documented assessment of suicide risk as a marker for review, there has been a complete lack of compliance. Repeated requests to perform risk assessments go unheeded by the attendDr. Simon is Clinical Professor of Psychiatry and Director, Program in Psychiatry and Law, Georgetown University School of Medicine, Washington, DC. Address correspondence to: Robert I. Simon, MD, 7921-D Glenbrook Road, Bethesda, MD 20814-2470. E-mail: [email protected]