Can suicide risk assessments prevent your patients from dying by suicide?

David is a 60 yo man with a history of chronic low back from severe disc disease on long-term opioids, PTSD, alcohol use disorder, and major depression. After his husband died 30 years ago, he tried to kill himself twice by hanging and was psychiatrically hospitalized for severe depression after each attempt. Since that time, he has had intermittent thoughts that he would be better off dead, but he has not had thoughts of suicide, a plan, or the intent to kill himself.  

David calls your primary care clinic 1-2x/month and tells whoever answers the phone that his pain is out of control. If he doesn’t get some relief, he will have to kill himself because he can’t live like this. He lives alone and has a close network of friends. He saw a psychiatrist 20 years ago but has declined to meet with a therapist or a psychiatrist since. 

The most recent time that he called the clinic, you called him back during your lunch break. You learned that he was with a friend and he didn’t intend to kill himself. If the pain didn’t get better, however, he might take all 50 pills in his bottle of oxycodone to get some relief. You review other non-pharmacologic strategies for managing pain and recommend that he call 911 or go to the nearest emergency room if his pain is unmanageable at home. You also confirm that his friend is aware of the naloxone that he has at home. You review the National Suicide & Crisis Lifeline (988) which he has previously called at night when he is lonely and confirm your next scheduled appointment together in 2 weeks. 

As your afternoon clinic progresses, you find yourself distracted by intrusive thoughts: Is David going to kill himself? Am I doing enough? Am I liable if kills himself? You notice your fear and frustration – it is really hard to care for this patient alone!

In this PsychSnap, I aim to shift the conversation from “How do I prevent my patient from dying by suicide?” to “How do I care for a patient who is chronically suicidal in the outpatient setting?”  

Patient deaths from suicide feel different than deaths from cancer or cirrhosis because the person who dies by suicide, by definition, has chosen to die. The question always lingers, “What could I have done differently?”

There are things we can do that are helpful in working with people with chronic suicidal thoughts and behaviors AND none of our suicide risk assessment tools predict who will die by suicide well-enough to be useful in guiding clinical decision making. Put another way, there are things we can do to support patients, but we as clinicians cannot hold ourselves responsible for preventing suicide in our patients. If we work with people who are psychiatrically ill, some people will tragically die by suicide. 

If you have lost a patient or a loved one to suicide, consider taking a moment to remember them with a few deep breaths.

What about suicide risk assessments?

Structured suicide risk assessment tools are widely used, sometimes mandated (for example, by the Joint Commission in US hospitals beginning in 2019), considered essential in caring for a patient with suicidal thoughts or a history of self-harm, and definitely helpful in reducing medical liability. There are several available instruments, like the Columbia-Suicide Severity Rating Scale, that ask structured questions about a patient’s current and past suicidal ideation, plans, preparation, and suicidal intent, and assign a low, medium, or high-risk score based on a series of questions.  

Unfortunately, the suicide risk scores generated from these structured suicide risk assessments are too inaccurate to be clinically useful. A meta-analysis of 70 studies of suicide risk prediction scales looked at how many people classified as “high-risk for suicide” later died by suicide. The pooled positive predictive value was 5.5% (95% CI 3.9 – 7.9%), meaning that for every 100 people classified as high risk for suicide, only 5 went on to die by suicide. Because death by suicide is a low prevalence event, most people classified as high-risk for suicide will not die by suicide, even if the sensitivities and specificities of a suicide risk scale are high (Carter 2017). Furthermore, in clinical populations, the sensitivity of the high-risk for suicide category for future completed suicide was only 56%. Just over half of the people who died by suicide were classified as high-risk, and just under half the people (44%) who died by suicide were classified as low risk (Large, 2016).  Chan et al concluded her meta-analysis of suicide risk scores for people who have self-harmed by saying, “The idea of risk assessment as risk prediction is a fallacy and should be recognized as such. We are simply unable to say with any certainty who will and will not go on to have poor outcomes.” (Chan, 2016)

The National Institute for Health and Care Excellence (NICE) in the UK has cautioned specifically against structured risk assessment tools. The 2022 NICE Guideline Self-harm: assessment, management and preventing recurrence reads, “Do not use [risk assessment tools/scales, or global risk stratification into low, medium, or high risk to predict future suicide, repetition of self-harm, or determine who should be offered treatment or who should be discharged].” Instead, do a thorough psychosocial evaluation of people at elevated risk for suicide, and create a safety plan with the patient that focuses on the individual modifiable risk factors and needs. A psychosocial evaluation is broader than a quick structured suicide risk assessment and looks at an individuals’ history, needs, strengths, and vulnerabilities. 

Two PsychSnaps will follow on related topics: 1) How to talk with patients with suicidal thoughts and behaviors, and 2) Clinical interventions (including safety plans) for patients with suicidal thoughts and behaviors.

Returning to the question: “Is David going to kill himself?” None of us can know. From a clinical perspective, we certainly should not look back after a patient death by suicide and wonder if we should have done more risk assessments.


Key Points

  1. Suicide risk assessment tools are widely used and mandated in some systems of care. They do not predict who will die by suicide well-enough to be useful in guiding clinical decision making and are explicitly cautioned against in other systems of care.
  2. Unfortunately, and tragically for some, the tools we have to assess suicidal risk are faulty and inaccurate; we as clinicians cannot hold ourselves responsible for preventing suicide.

References:

Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ. Predicting suicidal behaviours using clinical instruments: Systematic review and meta-analysis of positive predictive values for risk scales. British Journal of Psychiatry. 2017; 210(6):387-395. 

Chan, Melissa KY, et al. “Predicting suicide following self-harm: systematic review of risk factors and risk scales.The British Journal of Psychiatry 209.4 (2016): 277-283.

Large, Matthew, et al. “Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time.” PloS one 11.6 (2016): e0156322.

Mulder, R., Newton-Howes, G., & Coid, J. W. (2016). The futility of risk prediction in psychiatry. The British Journal of Psychiatry, 209, 271–272.

National Patient Safety Goal for Suicide Prevention.” The Joint Commission. (2018)

Self-harm: assessment, management and preventing recurrence. National Institute for Health and Care Excellence Clinical Guideline. (2022).


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