Management of suicide risk

Against a high-risk strategy in the prevention of suicide

Standard approaches to the prevention of suicide have concentrated on the rigorous assessment and management of suicidal risk. Using deliberate self-harm as a specific example, we discuss the relative merits of this ‘high-risk’ strategy and compare it with a population-based preventive strategy. We conclude that a combined approach offers the best hope for reducing the rate of suicide, although it may not fit easily with medical models of care.

The assessment and management of risk in psychiatry: can we do better?

This is the final contribution to a five part series on risk in psychiatry. Bowden (1997) has cast a bleak eye on the realities of making risk decisions about difficult and dangerous patients, identifying the essential subjectivity of these decisions and the cognitive distortions that psychiatrists can undergo to make them apparently easier; distortions that can blind the clinician to impending disaster. Morgan (1997) emphasised the limitations of a simplistic ‘risk factor’ approach to the management of potentially suicidal patients, concluding that the priority is the refinement of our basic clinical skills (and by implication deployment of successful treatments for our patients' illnesses). Prins (1997) analysed the particular difficulties faced by mental health review tribunals hearing the cases of Restricted patients. The perhaps unsurprising conclusion is that tribunals make bad decisions when presented with inadequate information (which begs the question why not adjourn and seek the information required before proceeding?). Roy (1997) has addressed a range of risks faced by Trusts and the clinicians who work for them. There is a clear demand that Trusts develop risk management strategies: of necessity these strategies will discourage inherently risky behaviour such as inadequate staffing of in-patient units and the devolution of inappropriate levels of responsibility to staff who are inadequately trained or supported.

Changeability, confidence, common sense and corroboration: comprehensive suicide risk assessment

OBJECTIVE

The authors, in collaboration with NSW Health, have recently developed a comprehensive suicide risk assessment framework. The present paper describes key concepts in the assessment of suicide risk by mental health professionals.

METHODS

A framework for conducting a comprehensive suicide risk assessment was derived from the literature, incident analysis and clinical experience. The framework underwent a consultation process involving clinicians in NSW area mental health services. The aim was to provide clinicians with a standardized conceptual map for the assessment of suicide risk. A MEDLINE search was conducted for publications dealing with 'suicide' and 'suicide risk assessment' from 1980 to 2002. The recommendations from sentinel event reviews conducted in a NSW area mental health service in the period 1999-2002 were reviewed. The lessons from a visit to a coroner's relatives support group for people who had been bereaved by suicide also informed the development of the guidelines.

RESULTS

A framework is proposed for the assessment of suicide risk. The framework promotes a reflective style of practice, encouraging clinicians to evaluate their assessment and its limitations. Risk assessment is always undertaken as part of a full clinical assessment and an evaluation of the person's current predicament and psychosocio-cultural context. The concepts of changeability, assessment confidence, common sense and the importance of corroboration are incorporated in the framework.

CONCLUSIONS

Mental health clinicians can be guided by a framework in suicide risk assessment and documentation. The assessment of suicide risk can generate a suicide risk rating for which minimum standards of care can be mandated.