How to write a suicide risk assessment that’s clinically sound and legally defensible

Suicidologists and legal experts implore clinicians to document their suicide risk assessments (SRAs) thoroughly. It’s difficult, however, to find practical guid­ance on how to write a clinically sound, legally defensible SRA.

The crux of every SRA is written justifica­tion of suicide risk. That justification should reveal your thinking and present a well-reasoned basis for your decision.

Reasoned vs right
It’s more important to provide a justifica­tion of suicide risk that’s well-reasoned rather than one that’s right. Suicide is impossible to predict. Instead of predic­tion, legally we are asked to reasonably anticipate suicide based on clinical facts. In hindsight, especially in the context of a courtroom, decisions might look ill-considered. You need to craft a logical argu­ment, be clear, and avoid jargon.

Convey thoroughness by covering each component of an SRA. Use the mnemonic device CAIPS to help the reader (and you) understand how a conclusion was reached based on the facts of the case.

Chronic and Acute factors. Address the chronic and acute factors that weigh heavi­est in your mind. Chronic factors are condi­tions, past events, and demographics that generally do not change. Acute factors are recent events or conditions that potentially are modifiable. Pay attention to combina­tions of factors that dramatically elevate risk (eg, previous attempts in the context of acute depression). Avoid repeating every factor, especially when these are documented else­where, such as on a checklist.

Imminent warning signs for suicide. Address warning signs (Table 1),¹ the nature of current suicidal thoughts (Table 2), and other aspects of mental status (eg, future ori­entation) that influenced your decision. Use words like “moreover,” “however,” and “in addition” to draw the reader’s attention to the building blocks of your argument.

Protective factors. Discuss the protective factors last; they deserve the least weight because none has been shown to immunize people against suicide. Don’t solely rely on your judgment of what is protective (eg, chil­dren in the home). Instead, elicit the patient’s reasons for living and dying. Be concerned if he (she) reports more of the latter.

Summary statement. Make an explicit statement about risk, focusing on imminent risk (ie, the next few hours and days). Avoid a “plot twist,” which is a risk level inconsis­tent with the preceding evidence, because it suggests an error in judgment. The Box gives an example of a justification that follows the CAIPS method.

Additional tips
Consider these strategies:
• Bolster your argument by explicitly addressing hopelessness (the strongest psy­chological correlate of suicide); use quotes from the patient that support your decision; refer to consultation with family members and colleagues; and include pertinent nega­tives to show completeness2 (ie, “denied sui­cide plans”).
• Critically resolve discrepancies between what the patient says and behavior that suggests suicidal intent (eg, a patient who minimizes suicidal intent but shopped for a gun yesterday).
• Last, while reviewing your justification, imagine that your patient completed suicide after leaving your office and that you are in court for negligence. In our experience, this exercise reveals dangerous errors of judg­ment. A clear and reasoned justification will reduce the risk of litigation and help you make prudent treatment plans.

Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this article or with manufacturers of competing products.