CLINICAL PEARLS: RESPONDING TO PATIENTS WITH SUICIDAL THOUGHTS
Journal of Psychiatry Reform Vol 4 #2, November 2018
Alan Eppel MB, MRCPsych, FRCPC
With this issue the Journal of Psychiatry Reform introduces a new section entitled Clinical Pearls. Clinical pearls are succinct items of information derived from careful clinical observation over years of practice and which may not be widely known. Clinical pearls can be used to solve everyday clinical problems.
- Completed suicide cannot be predicted. Because suicide is a rare event reliable probabilities cannot be determined statistically
- There are no checklists or questionnaires that can predict suicide
- Risk assessments do not correctly identify those that may complete suicide
- The focus should be on providing the right care and support for individuals with suicidal thoughts
- The first step in responding to a person contemplating suicide consists of listening and attending to the person’s distress.
- Understanding the patient’s predicament is critical
- Focus on providing connection, support, care and treatment
In 1983 Alex Pokorny studied a cohort of 4800 patients admitted to the Veterans Administration Medical Center in Houston Texas. Of these 803 (17%) were categorized at high risk for suicide. 30 of these patients (3.7%) died by suicide. Of the 3997 patients classified as low risk 37 completed suicide (0.9%). In other words 96.3% of the patient’s labelled as high risk were false positives and did not complete suicide while 0.9% of the total cohort where false negatives.
Kessler and colleagues undertook a study of over 53,000 American soldiers examined factors associated with suicide in the 12 month period following discharge from military psychiatric hospitals. There were 36 completed suicides among 2689 patients identified as high risk. Almost 50% of the suicides occurred in the 51,000 patients classified as low risk. Again the false positive rate in the study with was over 98%.
Helen Stallman at the Centre for Social Change, School of Psychology, Social Work and Social Policy, University of South Australia, has developed a comprehensive approach to suicidality emphasizing that the focus should shift from attempting to predict risk to one that is based on the provision of care and treatment for the patient:
“Managing this risk is the dominant paradigm in responding to suicidality. Its focus is on ensuring the patient’s safety and preventing death. A risk perspective reflects a society that is motivated by a commonality of anxiety about the future, rather than a commonality of need in the present.
……the needs of the patient, as expressed through seeking help and disclosure, have been neglected. By reacting to disclosures using a risk management approach, health professionals were seen to lack empathy for and dismiss their distress, and instead overreact to the potential for danger these individuals describe feeling mistrusted and full of shame after disclosing suicide, and are often motivated to hide any future suicidality..”
The Patient’s Predicament
Isaac Sakinofsky the well-known Canadian suicidologist has written about the importance of understanding the patient’s “predicament”.
“It is the personal predicament and how the person sees and responds to it that determines the degree of suicidality………the clinical condition creates the vulnerability to the impact of the personal predicament.”
Sakinofsky states that the “you must think yourself into the patient’s shoes” and try to understand the predicament and its appraisal from the patient’s point of view. This will be influenced by socio-cultural and environmental factors as well as the clinical disorder.
The predicament may be in the form of extreme mental or physical pain; unbearable loss; or catastrophic social, legal or financial situations. The patient may feel that there is no way out other than suicide.
Connecting With Patients
Siv Hilde Berg at Stavanger University Hospital in Norway has investigated suicidal patients’ experiences during psychiatric inpatient care.
Connections with health care professionals were vital for patient recovery and feelings of safety. Patients want to feel understood and respected. They want to express their feelings and to be able to talk about their suicidality. Some patients said that their health care providers did not spend much time with them and had little compassion.
The quality of the patient-physician relationship depended on patients’ experience was dependant on empathy, respect, understanding and willingness to talk about emotions and the circumstances leading to a suicide attempt.
When patients were placed on constant observation they cited receiving support from the staff assigned to observe them as extremely important.
Patients felt that supportive observers as vital for decreasing their suicidality during constant observation.
In summary the approach to patients with suicidal thoughts or attempts should be on connection, care and treatment.
Lorin M, Palazzi D, Turner T, Ward M. What is a clinical pearl and what is its role in medical education? Medical Teacher 2008: 30, 870-874
Nielssen O, Wallace D, Large M. Pokorny’s complaint: the insoluble problem of the overwhelming number of false positives generated by suicide risk assessment. BJPsych Bulletin 2017: 41, 18-20.
Pokorny A. Prediction of suicide in psychiatric patients. Report of a prospective study. Archives Gen. Psychiatry 1983: 40, 249-257.
Kessler R, Warner C, Ivany C et al. predicting suicides after psychiatric hospitalization in US Army soldiers. JAMA Psychiatry 2015:31, 125 – 140.
Mulder R, Newton-Howes G, Coid J. The futility of risk prediction in psychiatry.
Brit J Psychiatry 2016, 271-272.
Pereira S, Woollaston K. Therapeutic engagement in acute psychiatric inpatient services. Journal of Psychiatric Intensive Care 2007,v.31:3-11
Stallman H, Ohan J. The alignment of law, practice and need in
suicide prevention. BJPsych Bulletin (2018) 42, 51–53,
Stallman HM (2017) Coping planning: A patient- and strengths-focused
approach to suicide prevention training. Australasian Psychiatry
2018, Vol 26(2) 141–144 ps://doi.org/10.1177/1039856217732471
Pisani A, Murrie D, Silverman M. Reformulating suicide risk formulation:
from prediction to prevention. Academic Psychiatry 2016, 623-629.l
Sakinofsky I. Suicide and Suicidality in: Psychiatric Clinical Skills. Ed. Goldbloom DS. Mosby
Berg S, Rørtveit K, Aase K. Suicidal patients’ experiences regarding their safety during psychiatric in-patient care: a systematic review of qualitative studies. BMC Health Services Research (2017) 17:73