CIGNA Behavioral Health Practitioner Connection

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CBH Practitioner Conection
Volume XXIV, 4th Quarter

The right help at the right time!

ASSESSING SUICIDALITY

In reviewing some of the literature regarding suicidality assessment, including the APA practice guidelines (http://www.psych.org/psych_pract/treatg/pg/SuicidalBehavior_05-15-06.pdf), one common theme found is that we cannot predict suicide. We can, however, gather information in an attempt to decrease the risk of suicide and understand the reasons for suicidal thinking. The goal of a good assessment is to help identify the status of participants’ risk factors followed by developing a treatment plan, identifying the treatment setting needed, and then making attempts to decrease those risk factors which can be modified.

According to the APA practice guidelines, the psychiatric evaluation is the “core element” of the suicide risk assessment. Although the psychiatric assessment and approach to a suicidal assessment are similar, assessments may vary based on many factors, such as the participant’s IQ, age, ability to comprehend, cooperation, severity of symptoms and mental status. The psychiatric assessment will provide information about the participant's psychiatric symptoms, mental status, stressors, cooperation, psychosocial issues, current circumstances, personal and family history, and even their desire or willingness to get help. It is important to keep in mind that not reporting suicidal thinking does not necessarily predict suicide; however it is still important to ask direct questions about suicidal thinking, intent, plans or means as that information can be valuable in helping to formulate a treatment plan and in decision making on the treatment setting needed.

When assessing a participant, it is important to establish a diagnosis, including substance abuse and medical conditions that can increase risk of suicide. There is a higher risk for suicide with certain psychiatric conditions such as major depression, bipolar disorder, schizophrenia and substance abuse. There are symptoms that can also increase the risk for suicide, including command hallucinations to harm self, anxiety, agitation, hopelessness, and persistent or intense suicidal ideation. It is important to assess past history (past diagnoses, past treatment, compliance, history of any therapeutic alliances, ability to seek out help, suicide attempts and circumstances, and family history), psychological stressors, support systems and availability of friends and family. Psychosocial issues, such as being single, living alone, no friends or family, recent job loss, financial difficulties, or relationship issues, can increase the risk of suicide. Comorbid conditions, medical conditions and substance abuse can increase the risk of suicide as well.

Risk factors can be categorized as static or dynamic. Static risk factors are non-modifiable factors that can determine an increased risk of suicide such as being male, having a past history of suicide attempts or a family history of suicide. However, it is the dynamic risk factors that are modifiable, such as having mental illness with treatable symptoms. Symptoms of anxiety, hopelessness, hearing command hallucinations, insomnia and even pain are some examples of modifiable risk factors. Other modifiable risk factors include psychosocial stressors. Some psychosocial stressors, such as a recent divorce, being unemployed or having financial difficulties, are modifiable risk factors, but they can be difficult to modify on an acute basis. Protective factors such as cultural or religious beliefs, fears of hurting family or feelings of guilt if one should commit suicide should also be identified.

Although we know that we cannot predict suicide, a good psychiatric evaluation and suicidality assessment will help to identify either risk factors or protective factors, which can then be used to develop a specific treatment plan to deal with present safety concerns. Ongoing treatment interventions may then be formulated, opportunities to begin working on a treatment alliance identified, and a treatment options discussed with the participant.