The Suicidology Committee devoted its first year to exploring different aspects of suicide risk assessment (SRA). The committee worked to develop guidelines for SRA that would be useful to AAPL members. At the Baltimore meeting, four committee members, including Robert Simon MD, the committee's chair, participated in a panel discussion of suicide risk assessment.
Lucy Davidson MD opened the panel by discussing the process of suicide risk assessment. Dr. Davidson emphasized that the goal of SRA is not to predict suicide, but to identify modifiable risk factors that can be the focus of therapeutic interventions. Although we clearly can not predict suicide, we can do careful risk assessment, and tailor our interventions to address the identified risk factors. The goal of the assessment is treatment and intervention, which lowers the risk of suicide and may ultimately prevent suicide. Dr. Davidson also reviewed some of the risk factors for suicide, including impulsivity, depression, substance abuse, a family history of violence, and a personal history of violence.
Following Dr. Davidson, Holly Rogers MD discussed the special issues and concerns facing outpatient psychiatrists when assessing suicidal patients, Dr. Rogers noted that suicide assessments in outpatients are quite challenging because the outpatient psychiatrist has a very large patient population, most of whom are not at high-risk for self harm. The challenge for the outpatient psychiatrist is to identify those patients who are at high risk for self-harm and develop appropriate interventions for them. Carefully reviewing risk factors to determine if the patient is at low, medium, or high risk assists the psychiatrist in determining what level of intervention is needed. Dr. Rogers recommended that outpatient clinicians develop a systematic way of assessing suicide risk.
John Justice MD reviewed suicide risk assessment in psychiatric in- patients. Most psychiatric in-patients will initially be considered at high risk for self-harm, and will therefore require careful and frequent SRAs. Dr. Justice emphasized that SRA needs to be viewed as a process that continues throughout a patient's hospitalization. Suicide risk needs to be considered carefully anytime the patient's precautions are changed, passes are considered, and of course, at discharge. Dr. Justice reviewed a standardized risk assessment form that has been developed for use in his hospital, but cautioned that SRA has to be individualized for each patient.
Dr. Simon discussed the problems inherent in relying too heavily on "no harm contracts" with patients. Often clinicians rely on a contract with their patients instead of doing a careful assessment of suicide risk. In his experience, Dr. Simon has seen few charts with documented risk assessments. His advice to clinician's regarding risk assessment: "just do it."