Suicide risk assessment forms: form over substance?

Suicide risk assessment is a core competency that informs patient treatment and management. It is a process of analysis and synthesis that identifies, prioritizes, and integrates acute and chronic risk and protective factors into an overall assessment of the patient’s suicide risk. Psychiatrists assess suicidal patients who present life-threatening emergencies. Unlike other physicians, psychiatrists do not have laboratory tests and sophisticated diagnostic instruments to assess patients at risk for suicide. For example, when evaluating an emergency cardiac patient, the physician orders several diagnostic tests and procedures (e.g., electrocardiogram, serial enzymes, imaging, and catheterization) to provide clinical data that are analyzed and synthesized into an overall treatment and management plan. The psychiatrist’s diagnostic instrument is systematic suicide risk assessment. Suicidal patients can evoke a variety of troubling emotions in the clinician that cause anxiety, sleep disturbances, and distraction. Countertransference anger, hate, and a reaction formation of solicitude toward the suicidal patient can threaten the clinician’s ability to assess and treat the patient competently. A patient’s suicide is devastating, arousing powerful feelings of grief, guilt, betrayal, anger, depression, and loss of clinical confidence. Charles and Kennedy have described the serious personal and professional consequences of a lawsuit following a patient’s suicide. Thus, clinicians may resort to use of suicide risk assessment forms as a risk management technique, in the illusory belief that a form can provide a defense or deterrence against a malpractice suit. Unfortunately, assessment forms merely cast a spell of reassurance, often masquerading as competent clinical assessment and judgment. The clinician is left with the false notion that further clinical assessment of suicide risk is unnecessary, paradoxically exposing the clinician to increased liability risk. In suicide malpractice cases, plaintiffs’ attorneys will closely scrutinize a suicide risk assessment form. Invariably, the patient who attempts or completes suicide is alleged to have displayed risk factors not included on the form. The attorney’s expert will testify that, instead of relying on an assessment form, had the clinician performed a competent suicide risk assessment, the patient’s increased suicide risk would have become apparent.