Suicide assessment and management self-test: How do you score?

The best response option is D
The length of stay in many acute care psy­chiatric facilities is <7 days. The goal of hospitalization is to stabilize the patient and discharge to appropriate community mental health resources. Discharge plan­ning begins at the time of admission.

Reducing Ms. G’s suicide risk to low or moderate is unlikely because of her diagnoses, frequent hospitalizations, and acute high risk for suicide on admission. After acute, high-risk suicidal patients are treated, many revert to chronic high risk for suicide.

Patients at chronic high risk for suicide often are treated as outpatients, except when an acute suicidal crisis requires hospi­talization.⁵ At discharge from the hospital, the goal is to return the patient to outpatient treatment.

A discharge note identifies the acute sui­cide risk factors that have abated and the chronic (long-term) suicide risk factors that remain. The discharge note also addresses a patient’s chronic vulnerability to suicide. For example, a patient can become acutely suicidal again, depending on a number of factors, including the nature and cause of the psychiatric illness, adequacy of future treat­ment, adherence to treatment recommenda­tions, and unforeseeable life vicissitudes.

Question 12
A 20-year-old college student is hospitalized after an overdose suicide attempt. Failing grades, panic attacks, and depression precipitated the suicide attempt. After 8 days of hos­pitalization, she is much improved and ready for discharge. She is assessed to be at low to moderate suicide risk. The treating psychiatrist and social worker convene a family meet­ing with both parents and an older brother. The family’s role after discharge is discussed.

All of the following options are helpful family roles except:
a) provide constant 24-hour family supervision
b) provide emotional support
c) observe and report symptoms and behaviors of concern
d) encourage adherence with treatment
e) provide helpful feedback about the patient’s thoughts and behavior

The best response option is A
The family’s role is important, but it is not a substitute for constant safety management provided by trained mental health profes­sionals on an inpatient psychiatric unit.⁵ Early discharge of an inpatient by relying on family supervision can be precarious. Most inpatients are discharged at some level of suicide risk, given the short length of hos­pital stay. If an outpatient at risk of suicide requires constant 24-hour family supervi­sion, then psychiatric hospitalization is indicated.

Patients who are intent on killing them­selves can find ingenious ways to attempt or commit suicide. Asking family members to keep a constant watch often fails. Most family members will not follow the patient into the bathroom or be able to stay up all night to observe the patient. Moreover, fam­ily members find reasons to make exceptions to constant surveillance because of denial, fatigue, or the need to attend to other press­ing matters.

Question 13
During the initial evaluation of a patient, it is the psychiatrist’s practice to routinely inquire about current and past suicide ideation. An affirma­tive answer prompts a systematic suicide risk assessment. In the absence of current risk, if exploration of the patient’s history reveals chronic suicide risk factors, the psychiatrist con­ducts a systematic suicide risk assessment.

The chronic risk factor that has the highest association with suicide is:
a) family history of mental illness or suicide
b) childhood abuse
c) history of a suicide attempt
d) impulsivity or aggression
e) prior psychiatric hospitalization

The best response option is C
A comprehensive suicide risk assessment may not be required at the initial outpatient evaluation in the absence of acute suicide risk factors. However, chronic suicide risk factors may be present.

The Standard Mortality Ratio (SMR) for prior suicide attempts by any method was 38.61.⁶ Suicide risk was highest in the 2 years after the first attempt. The SMR is a measure of the relative risk of suicide compared with the expected rate in the general population (SMR of 1).

Some chronic suicide risk factors are static: for example, a family history of psy­chiatric illness or earlier suicide attempt. Other chronic risk factors, usually a trait characteristic, can become acute: for exam­ple, impulsivity or aggression, or deliberate self-harm. The presence of chronic suicide risk factors should prompt a systematic sui­cide risk assessment. Evaluation of chronic suicide risk factors is an essential component of comprehensive assessment.5

Question 14
A psychiatrist is treating Dr. R, a 43-year-old physician, for anxiety and depression. The psychiatrist sees Dr. R twice a week for psy­chotherapy and medication management. A recent lawsuit filed against Dr. R has severely exacerbated her symptoms. She can sleep for only a few hours. Suicide ideation has emerged, frightening Dr. R and her family. The psychiatrist performs a systematic suicide risk assessment and determines that Dr. R is at acute high risk for suicide.

The psychiatrist recommends immediate hospitalization, but Dr. R adamantly refuses. The psychiatrist decides not to involuntarily hospitalize her because she does not meet the substantive criteria of the state involun­tary commitment statute (eg, overt suicidal behaviors). The psychiatrist chooses to con­tinue outpatient treatment.