The suicide prevention contract: clinical, legal, and risk management issues.

In the managed care era, mental health professionals increasingly rely upon suicide prevention contracts in the management of patients at suicide risk. Although asking a patient if he or she is suicidal and obtaining a written or oral contract against suicide can be useful, these measures by themselves are insufficient. "No harm" contracts cannot take the place of formal suicide risk assessments. Obtaining a suicide prevention contract from the patient tends to be an event whereas suicide risk assessment is a process. The suicide prevention contract is not a legal document that will exculpate the clinician from malpractice liability if the patient commits suicide. The contract against self-harm is only as good as the underlying soundness of the therapeutic alliance. The risks and benefits of suicide prevention contracts must be clearly understood.     

Clinical psychiatry and suicide prevention

People do not commit suicide all of a sudden. There is a suicidal process where negative life events are there in the beginning, and social support and help-seeking behavior play an important role in impeding the progress of the process. Mental disturbance would be deeply associated with the suicidal process around the final stage, thinking of the fact that approximately 90% of the suicides suffered from mental disorders at the time of suicide. In considering the strategies for suicide prevention, there are two perspectives: a community model and a medical model. A community model is thought to be related mainly to the first half of the suicidal process and a medical model to the latter half. It is an ideal that both community and medical approaches are put into practice simultaneously. However, if resources available for suicide prevention are limited, a medical-model approach would be more efficient and should be given priority. Starting from a medical model and considering treatment and social resources necessary for suicidal people, the range of suicide prevention activities would be expand more efficiently than starting from a community-model approach. Clinical psychiatry plays a greatly important role in preventing suicide. It is found that approximately 20% of seriously injured suicide attempters were diagnosed as adjustment disorder in Japan, which means that even the mildly depressed can commit suicide. Therefore, no one can take a hands-off approach to suicidality as long as he/she works in the field of clinical psychiatry. It is earnestly desired to detect and treat properly the suicidal patients, but there is no perfect method. It would be helpful to pay attention to patients' personality development, stress-coping style and present suicidal ideation. Besides, as suicide prevention is not completed only in a consulting room, it is important for psychiatrists to look for teamwork.     

Treating PTSD Within the Context of Heightened Suicide Risk

Because posttraumatic stress disorder (PTSD) is one of the few psychological conditions that predict suicidal behavior among those who think about suicide, many patients with PTSD present clinically with elevated suicide risk. Expert consensus and practice guidelines recommend against trauma-focused treatments for patients with elevated suicide risk, however. Research aimed at understanding the common mechanisms that underlie the association of PTSD and suicide risk has led to several advances in the effective care of suicidal patients diagnosed with PTSD. Based on these results, various combinations and sequences of suicide-focused treatments, risk management procedures, and trauma-focused treatments are implicated.     

Assessment and Intervention for the Suicidal Patient with Schizophrenia

The risk for suicidal behavior in schizophrenia is high with 10–15% committing suicide and 20–40% making suicide attempts. Due to the chronicity and complexity of schizophrenia and the multi-determined nature of suicidal behavior, the clinician must utilize a biopsychosocial approach to assessment and intervention. Clinical factors such as psychosis, depression and substance abuse increase the risk for suicidal behavior in schizophrenia. Social factors such as social adjustment and social supports also play a critical role. Ongoing assessment and intervention of suicidal behavior, clinical symptomatology, social environment and treatment issues are essential. Prediction and prevention of suicidal behavior are not always possible however. Treatment focused on the reduction of symptomatology and maintenance of an effective social environment may attenuate the risk for suicidal behavior in schizophrenia.     

The Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior: Study rationale,methodology, and baseline sample characteristics of a long-term,large-scale,multi-center,prospective, naturalistic,observational cohort study

BackgroundThe Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior (K-COMPASS) study is a prospective, naturalistic, observational cohort study, aiming to identify predictors of suicide attempt and suicide characteristics in the Korean suicidal population. The findings intend to contribute to a thorough understanding of suicidal phenomena and development of suicide prevention guidelines. The present cross-section study examines the study rationale, methodology, and baseline characteristics of the participants.MethodsParticipants were enrolled via the hospital and community gateways, establishing the hospital-based cohort (HC) and community-based cohort (CC), respectively. Baseline assessment was conducted on sociodemographic, clinical, diagnostic, and psychopathological aspects. The Columbia-Suicide Severity Rating Scale was used to investigate suicidality.ResultsA total of 800 suicidal people aged 15 years or older were enrolled from 8 university hospitals and 8 community mental health welfare centers (CMHWCs), among whom 480 (60%) were suicidal ideators and 320 (40%) were attempters. The ideators comprised 207 CC and 273 HC participants, whereas the attempters, 34 CC and 286 HC participants. Despite their lower severity in some measures, including suicidal ideation, compared with their HC counterparts, the CC participants within each group of ideators or attempters presented clinically significant psychopathology. Moreover, alcohol use problems and past suicide attempt were more likely to be found in CC participants. Only 11.1% to 21.6% of the participants in each of the four groups (defined by the cohorts and the ideators/attempters) were on any type of psychiatric treatment.ConclusionsSuicidal visitors to CMHWCs need to be as closely monitored as suicidal patients in university hospitals, especially considering their association with problem drinking and past suicide attempt. A cautious assumption is that the high suicide rate in Korea might be partly attributable to the low proportion of patients receiving psychiatric services.     

Evaluation of official procedures for suicide prevention in hospital from a forensic psychiatric and a risk management perspective

Abstract

Background: Suicide is a severe public health problem, in 2008 the Italian ministerial recommendation n° 4 on the management of suicide defined key areas for the identification of suicidal risk in hospital wards. The guidelines are important in defining professional liability issues, in line with Law 24 of 8/3/2017 ‘Gelli-Bianco’. Our study aimed to investigate the appropriateness of the official documents on suicide prevention delivered by Italian hospitals and their compliance with the ministerial recommendation.

Methods: The Italian hospitals’ public procedures on suicide prevention issued between 2008 and 2019 (n?=?33) were retrieved thorough web search and further evaluated according to their compliance with the 2008 Italian ministerial recommendations.

Results: The guidelines documents were generally in line with the ministerial recommendation. However, we found a lack of implementation in the specific training of health professionals. Most guidelines provided no risk stratification, nor specific procedures for different risk degrees or diagnoses. More than half of the documents did not report standardised tools for the assessment of suicidal risk.

Conclusions: The public procedures on suicide prevention in Italian hospitals present general indications, leaving room for interpretation. Public procedures should be implemented with greater attention to the elements of judgement in the assessment of suicidal risk.

• KEY POINTS

• Procedures for suicide prevention are of uttermost importance for psychiatrist working in hospital.

• Standards in suicide risk evaluations are needed.

• Comparison between procedures can improve risk assessment and evaluation

     

Teaching health care professionals about suicide safety planning

The suicide safety plan is a plan of action created by the clinician and patient that essentially charts the course of what the patient should do if he/she begins to experience suicidal urges. It is important for clinicians to learn how to implement a safety plan so that they can offer this service to their patients and teach their colleagues and associates about suicide safety planning. The safety plan is a great tool employed to help patients with suicidal urges, but trainees-clinicians and clinician associates alike - should fully understand that it is not a form of treatment. However, since an effective treatment for suicidality does not exist, practitioners should definitely use suicide safety planning. Although more resources are now being provided to individuals with suicidal behavior, more research needs to be done to develop new, effective methods of treatment and prevention of suicidal behavior.     

Community-based Suicide Prevention Research in Remote On-Reserve First Nations Communities

Suicide is a complex problem linked to genetic, environmental, psychological and community factors. For the Aboriginal population more specifically, loss of culture, history of traumatic events, individual, family and community factors may also play a role in suicidal behaviour. Of particular concern is the high rate of suicide among Canadian Aboriginal youth. While the need to develop interventions to reduce suicidal behaviour for First Nations on-reserve populations is evident, there may be an element of distrust of researchers by Aboriginal communities. Furthermore, research in mental health and specifically suicide is much more sensitive than studying medical illnesses like diabetes. Clearly, this issue requires a unique and insightful approach. While numerous suicide prevention/intervention plans and guidelines have been published specifically for work involving Aboriginal people, the literature lacks a comprehensive discussion of the methodological and logistical issues faced by research teams and Aboriginal communities attempting to develop culturally-grounded and community-specific suicide prevention and intervention strategies. This paper outlines the research process, key challenges and lessons learned in a collaborative University-First Nations suicide prevention project conducted with eight north-western Manitoba First Nations communities (Canada).     

High-risk management guidelines for elderly suicidal patients in primary care settings.

Older adults, especially older white men, are more likely to commit suicide than other age-groups. The assessment and management of suicide ideation and behavior for the elderly is especially relevant for primary care physicians because many patients visit their physician shortly before committing suicide. In 1993, the Agency for Health Care Policy and Research (AHCPR) released clinical practice guidelines for the treatment of depression in primary care settings. The AHCPR guidelines offered some assistance with respect to detecting and treating patients who are suicidal. However, these guidelines lacked detailed and specific instructions for managing high-risk patients within the context of intervention research. The current set of guidelines builds upon this previous work by describing (1) a general approach for interacting with suicidal patients; (2) structured assessments for determining the degree of risk for suicide; (3) crisis intervention strategies; and (4) ongoing management procedures for working with suicidal patients in primary care settings.     

Parasuicide online: Can suicide websites trigger suicidal behaviour in predisposed adolescents?

The present case report describes a 17-year-old female who explicitly visited suicide web forums, where she researched reliable suicide methods, contacted an anonymous user and purchased substances for the implementation of suicide. The risk of Internet use by vulnerable youth is discussed. Psychiatric exploration should include questions of manner and frequency of media use. The application of media guidelines for suicide prevention is demanded for websites, as are accessible self-help sites for suicidal persons targeted to youthful users.     

Årsmøte 1953

The present case report describes a 17-year-old female who explicitly visited suicide web forums, where she researched reliable suicide methods, contacted an anonymous user and purchased substances for the implementation of suicide. The risk of Internet use by vulnerable youth is discussed. Psychiatric exploration should include questions of manner and frequency of media use. The application of media guidelines for suicide prevention is demanded for websites, as are accessible self-help sites for suicidal persons targeted to youthful users.     

Dilemmas in the management of suicidal behavior in individuals with borderline personality disorder

Managing suicidal behavior of individuals with borderline personality disorder presents both therapeutic and ethical/legal dilemmas. It is argued in this paper that clinicians treating borderline individuals need to carefully discriminate "acute" from "chronic" suicidal states. For "acute" suicidal situations, traditional management approaches are appropriate. However, for "chronic" situations, common among borderline individuals, traditional management approaches may be therapeutically counterproductive. A number of proposals for managing chronic suicidal behavior are reviewed. Unfortunately, current ethical standards and laws have evolved from considering suicide in an "acute" context and are insensitive to the "chronic" situation. Recommendations are made for clinicians to effectively manage chronic suicidal behaviors within present ethical and legal guidelines, and some suggestions for legal reform are offered.     

Managing Suicide Attempts: Guidelines for the Primary Care Physician

The management of patients who have made suicide attempts is a responsibility that frequently falls to the primary care physician. For this reason, it is important that the physician have a clear strategy for dealing with the suicidal patient in the office, hospital, and emergency room. In the acute situation, the first priority is to stabilize the patient and ensure his or her medical safety. Once this is accomplished, history and circumstances of the attempt can be assessed, along with likelihood of recurrence of the attempt. This article reviews guidelines for evaluating suicide risk. The importance of the patient-physician relationship is noted, particularly in regard to prevention of future suicide attempts. With a focused, thorough approach to the suicidal patient, which incorporates both medical and psychiatric considerations, the primary care physician can ameliorate the patient's acute situation and facilitate the coordination of care with appropriate psychiatric resources.     

Suicide and violence assessment in psychiatry

Psychiatrists are increasingly expected to predict and prevent the suicidal and violent/homicidal impulses of their clients. This article reviews the current literature and research in these areas. While the debate continues on whether the clinician can successfully predict either violence or suicidal behavior in their patients, the preponderance of studies weighs in that predicting suicide and violence in the individual may not be possible currently given present knowledge. To compensate for forecasting limitations, conservative clinicians deliberately overpredict suicide or violence to help insure the safety of their patients and the greater communities in which they reside. In addition, clinicians need to perform thorough assessments and make logical clinical decisions that are in line with the perceived risks. Preventive measures for violence remain complex, but clinicians can maximize treatment effects by following specific intervention guidelines. Minimally, documentation concerning violence needs to focus on the rationale for why treatment interventions were or were not implemented. The chart does not require lengthy notations but should include a reasonable assessment of risk and the delineation of a prudent course of action.     

The assessment and management of the suicidal patient.

This chapter will be oriented toward the problem faced by the clinician in attempting to prevent suicide in patients under treatment. It will focus on the clinician's difficult task of assessing suicide potential and initiating interventions to prevent suicide in patients at high risk. Specifically, the state of the art in identifying the suicidal patient will be reviewed, and various interventions available to the clinician will be discussed.     

Suicidal ideation and risk factors in primary care patients with anxiety disorders

The presence of an anxiety disorder is associated with greater frequency of suicidal thoughts and behaviors. Given the high personal and societal costs of suicidal behaviors, suicide prevention is a priority. Understanding factors present within individuals with anxiety disorders that increase suicide risk may inform prevention efforts. The aims of the present study were to examine the prevalence of suicidal ideation and behaviors, as well as factors associated with suicide risk in patients with anxiety disorders in primary care. Data from a large scale randomized controlled study were analyzed to assess prevalence of suicidal thoughts and behaviors, as well as factors associated with suicide risk. Results revealed that suicidal ideation and behaviors were relatively common in this group. When examining mental and physical health factors jointly, presence of depression, mental health-related impairment, and social support each uniquely accounted for variance in suicide risk score. Methodological limitations include cross-sectional data collection and lack of information on comorbid personality disorders. Moreover, patients included were from a clinical trial with exclusion criteria that may limit generalizability. Results highlight the complex determinants of suicidal behavior and the need for more nuanced suicide assessment in this population, including evaluation of comorbidity and general functioning.     

Routine use of the Beck Scale for Suicide Ideation in a psychiatric emergency department

BACKGROUND: U.S. suicide rates are estimated to be 11 per 100,000 people, and improved screening in emergency departments may reduce suicide rates. METHOD: This study examined the relationship between clinician rating of suicide ideation and Beck Scale for Suicide Ideation (BSI) scores when clinicians had access to the BSI results and whether BSI scores and/or clinician ratings of suicidality are associated with patient disposition from the psychiatric emergency department. RESULTS: Of 735 patients, 665 (90%) had documentation of suicide ideation in the chart; 246 (37%) were rated as suicidal; 487 (66%) patients completed the BSI forms; 300 patients (62%) scored positive on the BSI. Logistic regression analysis for BSI scores and clinician ratings of suicidality showed similar results, except clinicians were more likely to rate males as suicidal, while BSI scores did not vary according to sex. Hospitalization occurred more often for patients with mood disorder who had positive BSI scores, while hospitalization occurred more often for patients with a diagnosis of bipolar disorder or schizophrenia who were rated by clinicians as suicidal. CONCLUSIONS: There were important demographic and diagnostic differences revealed by logistic regression analysis of BSI scores and clinician-rated suicidality, and these differences may be associated with disposition for patients presenting with suicide ideation.     

Recent trends in suicidal behavior in Japan

Abstract This paper reviews the present situation of suicidal behavior in Japan. Although the suicide rate among the younger generation has been decreasing steadily, that among elderly Japanese has been high. In addition, it is expected that the elderly population in Japan will increase more rapidly than in other countries in the 21st century. This paper highlights the problems of suicidal elderly in Japan, by focusing on characteristics of their psychopathology, and it proposes an integrated model for suicide prevention. Accurate knowledge about suicide crisis in the elderly and appropriate countermeasures should be acquired by every individual in the community, and efficient social support networks should be established. The long-term objective should be to create an environment in which senior citizens can contribute to the community to the best of their ability, and every effort should be made to decrease the social stigma against old age and suicide.     

A psychodynamic approach to suicide prevention

This paper sets forth a new theoretical approach to understanding the psychological etiology of suicide. The theory is demonstrated by an in-depth clinical case example, and its implications for the management of the suicidal candidate in his acute interim and long-term care are described. The theory assumes that the primary motivation to suicide comes from a clinically characteristic, unremitting psychological pain. The role of the suicidal prevention center is discussed with specific emphasis on the quality of the engagement between a center staff person and the suicidal patient. A future course for suicide centers is suggested based on the theory.     

Adolescent Suicide

Suicide is an increasing problem among adolescents. Developmental concerns and inability to resolve problems stemming from feelings of alienation are often at the core of an adolescent's suicide attempt. Nurses can be instrumental in primary prevention by educating the public about persons at risk for suicide, in helping parents deal more effectively with children's growth, and by supporting programs in the school system and other agencies that help young people communicate with others and resolve problems before they become crises. The nurse can also play an important role in secondary prevention through participation in or referral to hotline services, through intervention in the emergency service, or in community mental health programs or inpatient treatment programs. The psychiatric nurse specialist, in particular, can play a very significant role in the treatment of the adolescent in a suicidal crisis and also in consultation with other nurses and professionals who may assess suicidal risk in young people in the community. Finally, tertiary prevention may be necessary to help families and friends resolve their grief over the loss if a family member or close friend has succeeded at a suicide attempt. Feelings of guilt, anxiety, anger, and depression are usually present in the surviving family members of a successful suicide. They need to be given the opportunity to talk about the events leading up to the suicide, their feelings about the persons involved, especially the lost person, and to ventilate their anger, guilt, and sadness. The rising rate of suicide or suicide attempts among this country's adolescents--the third cause of death among adolescents--cries out for stronger support systems for our young people.(ABSTRACT TRUNCATED AT 250 WORDS)