Acad Psychiatry (2014) 38:526–537 DOI 10.1007/s40596-014-0200-1

IN DEPTH ARTICLE: SYSTEMATIC REVIEW

Training for Suicide Risk Assessment and Suicide Risk Formulation Morton M. Silverman & Alan L. Berman

Received: 2 April 2014 / Accepted: 2 July 2014 / Published online: 25 July 2014 # Academic Psychiatry 2014

Abstract Suicide and suicidal behaviors are highly associated with psychiatric disorders. Psychiatrists have significant opportunities to identify at-risk individuals and offer treatment to reduce that risk. Although a suicide risk assessment (SRA) is a core competency requirement, many lack the requisite training and skills to appropriately assess for suicide risk. Moreover, the standard of care requires psychiatrists to foresee the possibility that a patient might engage in suicidal behavior, hence to conduct a suicide risk formulation (SRF) sufficient to guide triage and treatment planning. An SRA gathers data about observable and reported symptoms, behaviors, and historical factors that are associated with suicide risk and protection, ascertained by way of psychiatric interview; collateral information from family, friends, and medical records; and psychometric scales and/or screening tools. Based on data collected via an SRA, an SRF is a process whereby the psychiatrist forms a judgment about a patient’s foreseeable risk of suicidal behavior in order to inform triage decisions, safety and treatment plans, and interventions to reduce risk. This paper addresses the need for a revised training model in SRA and SRF, and proposes a model of training that incorporates the acquisition of skills, relying heavily on case application exercises. Keywords Suicide . Teaching methods . Psychiatry residents . Interviewing . Supervision Suicide is a significant public health problem. Suicide rates increased 15 % in the USA in the 2001–2010 decade [www. M. M. Silverman (*) The University of Colorado Denver School of Medicine, Aurora, CO, USA e-mail: [email protected] A. L. Berman American Association of Suicidology, Washington, DC, USA

cdc.gov/injury/wisqars/fatal_injury_reports.html]. This overall rise in rates hides the fact that rates have declined in certain age groups. Much attention has been paid to developing and implementing suicide prevention programs for these subpopulations with high rates. Rates have risen, however, in other demographic groups that had previously received little attention—for example, White middle-aged men. What is now understood is that specific suicide risk assessments and prevention efforts must be tailored for different at-risk populations. Suicide is a behavior that is multi-determined and highly associated with psychiatric disorders. Clinical populations have elevated lifetime risk for death by suicide more than four times that of the general population [1]. Moreover, specific psychiatric disorders, such as major depressive disorder, have rates of lifetime risk as much as 20 times those of the general population [2]. Risk of suicide is also elevated in a number of medical disorders, notably mediated by psychiatric disorders and acute psychiatric symptoms [3]. Hence, recognizing and responding to risk for suicide are everyday issues faced by psychiatrists (and other medical specialists). Approximately one in three American, and one in four British, citizens contact a mental health care provider or service in the year before dying by suicide [4, 5]. About one in ten patients are seen in emergency departments within 2 months of dying by suicide [6, 7]. A conservatively estimated 31.3 % of Americans who died by suicide were receiving mental health treatment at the time of their deaths [8]. Tragically, the Joint Commission denotes that suicide has regularly been among the five most frequently reported sentinel events in recent years (i.e., an unexpected event in a hospital that caused serious injury or death [9]); insufficient or absent patient assessment is reported as the root cause in over 80 % of suicide deaths in these reported sentinel events [10]. Clearly, health care providers have significant opportunity to identify at-risk individuals and engage them in treatment to

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reduce the risk of suicidal behavior. In spite of marked advances in understanding suicide risk, the academic training offered to psychiatrists-in-training in assessing and formulating suicide risk has not kept pace. Suicide risk assessment is a core competency that a psychiatrist must possess, informing the treatment and management of all patients [11, 12]. A core competency is defined as “those skills and abilities that are central to, or ‘at the core’ of, a given field” [12, (p. 1)]. In patients at risk of suicide, the standard of care requires that the psychiatrist perform reasonable suicide risk assessments [13, 14]. Many psychiatrists lack the requisite training and skills to assess for suicide risk appropriately [15, 16]. It should not be surprising, then, that patients who have died by suicide were more likely to have been formulated to be at low risk when last assessed before their deaths [17]. Rather than enhancing practitioner competencies in suicide risk assessment and suicide risk formulation by mandating certain levels of training, the mental health professional organizations and managed care companies have, instead, chosen to develop and publish guidelines [18–20] [https://www. magellanprovider.com/MHS/MGL/pprvidingcare/clinical_ guidelines/clin_prac_guidelines/suicide.pdf] [http:// download.journals.elsevierhealth.com/pdfs/journals/08908567/PIISP890856709603555.pdf]. Many of these guidelines have not been updated since they were originally developed; hence, they are no longer current regarding research advances made in identifying risk factors, protective factors, and warning signs. Most important, guidelines continue in the tradition of passive educational tools, not to be confused with training to desired levels of competency. Adherence and implementation will forevermore be inadequate if we do not recognize that guidelines are not synonymous with training. This is akin to a professional football coach who, after working up the greatest playbook ever, tells his players to read it and, rather than repeatedly having his team practice and be coached in executing the plays as designed, simply expects his team to run these plays to sure victory on game day.

Suicide Risk Assessment and Risk Formulation The standard of care in working with patients at-risk for suicide requires that the clinician first assess that patient’s relative risk. We see the assessment process actually as a two-part process: first to determine whether an individual has risk factors associated with increased risk for suicide; second to formulate the level of risk. These steps then inform appropriate triage decisions, safety and treatment plans, and interventions (ideally evidence-based) to reduce the level of risk for that specific individual and setting. A suicide risk assessment (SRA) gathers data about observable and reported symptoms, behaviors, and historical factors presented by a patient that are associated with suicide

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risk and protection, ascertained by way of psychiatric interview; collateral information from family, friends, and medical records; and psychometric scales and/or screening tools. A suicide risk formulation (SRF) is a process by which the clinician forms a judgment about a patient’s foreseeable risk of suicidal behavior on the basis of data collected via an SRA [21]. A formulation involves some understanding of how risk factors combine, interact, fuel, or otherwise contribute to a “recipe” for heightened risk for suicidal behavior. Moreover, the formulation of level of suicide risk requires clinical acumen, experience, and judgment. The SRA, therefore, is a precursor to an SRF, and the reliability and validity of the SRF depends on the robustness of the SRA. There is a need to present a clearly articulated approach to doing an SRA and an SRF that utilizes the SRA findings, leads the clinician to treatment interventions, and clarifies which interventions are aimed to modify which risk factors. In this paper, we address the need for a revised training model in suicide risk assessment and suicide risk formulation. First, we will briefly discuss previous actuarial models for suicide risk assessment and suicide risk formulation

The Movement Toward Empirical Scale Development Soon after the middle of the last century, suicidology researchers attempted to build instruments for evaluating “suicide potential.” In the 1960s, clinicians at the Los Angeles Suicide Prevention Center constructed a “suicide potential scale” to evaluate a patient or caller who identified himself or herself as suicidal [22]. Ten categories of observations, including more than 60 individual, weighted items, constituted a summated score and relatively differentiated risk ratings ranging from low to high. High risk was conceptualized as “a prediction of suicide probability” of 10,000 per 100,000. Contemporaneously, Tuckman and Youngman [23] developed a scale for differentiating high versus low suicide risk among those who had made an attempt (defining high risk operationally as death from suicide within 1 year of the attempt). Using a dataset of more than 1,000 nonstandardized police death investigations, these researchers ultimately presented 14 risk factors associated with high risk. Neither of these early efforts was ever replicated or validated. Cohen et al. [24] classified suicide attempts of 193 inpatients into one of four grades of seriousness and followed up on these patients over a 5–8-year period to identify those who were at high risk, that is, who made a subsequent attempt or died by suicide. Ultimately, they derived a 15-item Suicide Risk Assessment Scale (SRAS) with weighted scores totaling over 800 and a “table of risk,” ranging from “very low” to “very high” (defined as a score >555, having an approximated suicide rate of over 10 % over the next 2 years). The SRAS was intended to supplement, not substitute for, clinical

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judgment, and “when the Scale [was] not consistent with clinical judgment, clinical judgment [was to] be given precedence” [25]. Perhaps the most significant contribution to developing an SRF was offered by Lettieri and colleagues at the National Institutes of Mental Health (NIMH) in the early 1970s. These researchers developed sophisticated models for formulating risk among four demographic groups defined by age and gender (old–young, male–female) and, similar to earlier scales, ratings of risk with scaled scores above 7 indicating high risk or the likelihood of being dead by suicide within 2 years [26]. That none of these, as well as other, attempts to predict suicide via research-based scales has survived to offer a standard for clinicians was presaged by Diggory in the same volume: The intuitive, common sense combination of plausible suicide predictors into scales for evaluating risk without systematic, empirical testing or verification has been tried…But, I believe that at present hardly anyone seriously believes that such a procedure is likely to fill the need for better prediction. [27, p. 62] Clinicians, however, are not expected to predict suicidal outcomes, no less specific acts such as a nonfatal attempt or an attempt sufficiently lethal to lead to death. Suicide risk formulations involve assigning an ordinal level of risk in line with what is best understood about various risk groups. In some instances, that level of risk can be quantified, hence translated into a greater than low level of risk but, in general, only for elevated risk across that risk group member’s lifetime, for example, for those with a major depressive disorder (see above). Although it is tempting to seek actuarial models for predicting a patient’s risk of violence (in contrast to relying on purely clinical judgment), there is evidence to suggest that these models may not be superior [28]. Further, the question remains as to whether suicidology will ever be able to model statistically those decision rules that would better inform the accuracy of clinical judgments [29–31]. As Nakash and Alegria [32] have suggested, the cognitive processes involved in clinical judgment include an appreciation of nonverbal cues and affective communications from patients (and hence have termed these processes “implicit clinical judgment”); the potential to create a viable actuarial model that fails to capture these inputs, we believe, is questionable. Nevertheless, attempts continue to this day to develop risk assessment instruments [33, 34]. As most commonly implemented, these are checklists of risk and protective factors, often presented with an ordinal scaling from low to high risk, on the basis of what appears to be common sense, not necessarily empirical support [1]. For example, as we discuss

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below, active suicidal ideation has not been found to be any more associated with risk for death by suicide than has passive ideation, yet almost universally is believed by clinicians to point to greater risk for suicide [35]. Table 1 offers an example of one hospital’s intake assessment of suicide ideation and its proposed scaling of relative risk, which incorporates this misconception. The latest suicide risk assessment instrument, and one that has rapidly gained widespread use, is the Columbia-Suicide Severity Rating Scale (C-SSRS) [36]. The C-SSRS is a semistructured questionnaire that continues in the tradition of guiding the clinician toward capturing data/observations associated with risk but, as discussed below, suffers from its reliance on assessing ideation, and especially active ideation, as a threshold for further inquiry. Moreover, the C-SSRS does not guide the clinician to a formulated level of risk based on a trained understanding of the import of, and interaction among, observed risk factors.

Assessment and Screening Are Not Synonyms Given the low base rate of suicide, it has been intuitively understood by suicidologists that predictive scales, no less any attempt to actuarially derive levels of risk for death by suicide, would produce far more false positives than could be clinically tolerated. To illustrate this, were we to have a scale that was 95 % accurate at predicting imminent risk (defined as death by suicide within the next 48 hours) and to apply this scale to 100,000 individuals, the scale would correctly find almost all those who, indeed, would die by suicide, but would simultaneously and falsely identify almost 5,000 individuals as imminently at risk! The US Preventive Services Task Force has found insufficient evidence that screening for suicide risk in the primary care setting reduces suicide attempts or deaths by suicide [37, 38]. This may well be an indication that the questions asked in screenings are imprecise, vague, and nonspecific to the task at hand—identifying those at risk of suicidal behaviors in the short- and near-term. However, because of the pressing need to identify and address suicidal behaviors in adolescents, and the fact that suicidal behavior is a sentinel event in hospitals, both the American Academy of Pediatrics and the Joint Commission have called for suicide screening for all patients in health care settings [39] [http://www.jointcommission.org/ assets/1/18/SEA_46.pdf].

How Are Psychiatrists Trained to Do a Suicide Risk Assessment? In 1983, the Training Committee of the American Association of Suicidology surveyed psychiatric residency programs

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Table 1 A typical relative risk-scaling model for suicide ideation Risk factor

Nominal

Low

Moderate

High

Ideation

None reported

Passive wishes/fleeting thoughts

Some thoughts/moderate amount

Active or pervasive thoughts

regarding the amount and format typically offered in the way of training in suicidology [40]. Responses were received from almost two thirds (63 %) of 151 residency program directors to whom a postcard survey was sent. Results indicated that psychiatric residents were being taught through essentially informal teaching mechanisms: supervised clinical experiences, preceptors, clinical tutorials, and case discussions. Didactic teaching through seminars and lectures occurred but primarily were embedded in curricula offerings regarding, for example, emergency psychiatry, psychopathology, and psychodynamics. In 1986, Lomax [41] proposed a psychiatry residency curriculum of the requisite knowledge, attitudes, and skills for suicide care. Ellis et al. [42], in a survey of directors of training in psychiatry, reported that almost all of the responding directors (94 %) identified some form of training in a suicide risk assessment in their residency programs, but again, most of the reported formats were passive (e.g., therapy supervision, journal clubs, and seminars). About one in four (27.5 %), however, did report training via skill-development workshops. Coverdale et al. [43], in an editorial focusing on the associated ethical and policy issues surrounding residents’ experiences and psychiatry training program responses when a patient dies by suicide, called for residency programs to teach suicide care as an early component of residency training and prepare for the possibility of the suicide of a patient treated by a resident. More recently, Melton and Coverdale [44] found that 91 % of residency programs offered some sort of teaching on the care of suicidal patients, mostly via an average of 3.6 lectures, but the specific content delivered was described as “vague and nondescript.” Many of their respondents opined that there was insufficient focus on suicide intervention. It is critical to note that didactic training is not necessarily synonymous with effectively building the skills needed to conduct adequate suicide risk assessments and treat suicidal patients. Providing information to trainees is necessary, but not sufficient, because trainees must also be given opportunities to translate this information into competent practice by assessing and treating suicidal patients with proper supervision. From our perspective, this differentiates educating about suicide from training in suicide risk assessment and risk formulation. To our knowledge, there have not been national surveys regarding the extent of education and training in suicide risk assessment and risk formulation provided to medical students, either as part of their pre-clinical didactic courses or during their clinical rotations. At a few medical schools, however, curricula

have been developed to teach guidelines to do an assessment [45]. For the most part, in-depth education about suicide is not a requirement in psychiatry residency training programs; hence, there are no preferred protocols for SRA or SRF or treatment planning. To date, there has been significant variability in the material that is taught to residents and the manner in which this material is presented. There are only very limited standardized curriculum recommendations in the literature [46, 47]. As Simon has noted, “Risk and protective factors must be pulled together into the process of analysis and synthesis. Suicide risk assessment allows the clinician to piece together (identify and prioritize) risk and protective factors to construct a clinical mosaic (synthesis) of the suicidal patient” [48]. Existing SRA protocols offer little to no guidance on how to organize, integrate, conceptualize, or prioritize the data obtained, that is, to derive an SRF. Some offer checklists and/or scales (Likert scales) for each item believed to be essential in conducting a SRA (Table 1), but there are no formulas that translate these individual risk factor ratings into an overall formulation of level of risk. It is our contention that the literature on SRA does not address the critical role of SRF and rarely discusses the techniques, tools, approaches, and concepts involved in formulating the level of suicide risk on the basis of the data acquired during the SRA.

Recent National Recommendations The need for change has been apparent for years and increasingly called for by suicidologists. When the first iteration of the National Strategy for Suicide Prevention was released in 2001, it set as an objective (6.2) “By 2005, increase the proportion of…medical residency programs that include training in the assessment and management of suicide risk and identification and promotion of protective factors” [49]. With the release of the second edition of the National Strategy in 2012, this objective was broadened to address training in all health professions and an additional objective (7.4) was added to promote the adoption of core evidence-based and best practice training guidelines by credentialing and accreditation bodies, in addition to encouraging a requirement that licensing exams test on this content [50]. The Liaison Committee on Medical Education (LCME), the accrediting body for US medical schools, recently updated

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its education program guidelines, providing the following guidelines [www.lcme.org/pubications.htm#guidelines]: ED-6: The curriculum of a medical education program must incorporate the fundamental principles of medicine and its underlying scientific concepts; allow medical students to acquire skills of critical judgment based on evidence and experience; and develop medical students' ability to use principles and skills wisely in solving problems of health and disease. ED-28: A medical education program must include ongoing assessment of medical students’ problem solving, clinical reasoning, decision-making, and communication skills. We are thankful that the Psychiatry Resident-in-Training Examination (PRITE) has addressed this goal by including suicide-specific questions within the emergency psychiatry domain [www.acpsych.og/prite]. As one of our colleagues has remarked, however, “I don’t go to an oncologist hoping they know about cancer; I go because I want to get help and to get better.” At the turn of this century, the Institute of Medicine critically evaluated and reported on the state of suicide prevention in the USA. As one of their recommendations, they argued [51]: Professional medical organizations should provide training to health care providers for assessment of suicide risk and provide them with existing tools… encourage[ing] (or require[ing], when appropriate) their memberships to increase their skills in suicide risk detection and intervention. A decade later, a Task Force on Training, established by the American Association of Suicidology, called the relative lack of required training “an egregious, enduring oversight” and recommended that accrediting organizations require verified skill acquisition. Going further, the Task Force recommended that professionals without such training “not be entrusted with the assessment and management of suicidal patients” [15]. Although enforcing this may seem implausible, establishing a demonstrable level of skill in formulating risk for a standardized patient as part of board certification may well serve to sufficiently raise the bar.

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might engage in suicidal behavior, hence to conduct a suicide risk assessment and make a suicide risk formulation sufficient to guide triage and treatment planning. Elsewhere, we have articulated that traditional guidelines for conducting an SRA have overemphasized long-standing approaches that have little empirical support [53]. Among these unquestioned approaches is that the presence of communicated suicidal ideation has traditionally been the gateway to the investigation of whether an individual might be “suicidal.” As noted above, the C-SSRS, as but one example of a risk assessment questionnaire, continues this tradition, however: 1. Among those who die by suicide, suicidal ideation is more likely to be denied than admitted to on clinical inquiry that is conducted reasonably proximate to the date of death. Neither does the absence or denial of suicidal ideation indicate the absence of suicide risk or potential to engage in suicidal behaviors in the near-term, nor does the absence or denial of suicide ideation equate to no “imminent” or “acute” risk [52]. 2. Active suicide ideation, although important in leading to further assessment and risk formulation, is no more associated with death by suicide than is “passive” suicide ideation [35, 54, 55]. 3. Although there is strong evidence of a relationship between suicide attempts and subsequent death by suicide, the association between currently expressed suicide ideation and subsequent death by suicide is less clear and the presence of suicide ideation, in the absence of a suicide attempt, has not been demonstrated to be a risk factor for death by suicide [56, 57]. 4. The reporting of current or recent suicide ideation has very little correlation with the development or expression of suicidal intent, the progression from suicide ideation to suicide attempts, or to death by suicide in the near-term [58–62]. 5. Current or recent suicide ideation is not the best predictor of eventual death by suicide. Rather, Beck et al. [56] found that a retrospective report of suicidal ideation at its worst point in a patient’s life was a better predictor of eventual death by suicide than was current suicide ideation or hopelessness.

Suicide Risk Assessment

Suicide Risk Formulation

No method of conducting an SRA or an SRF has been empirically tested for reliability and validity or has sufficient sensitivity and specificity to be effective [1, 52]. Yet, as noted above, the standard of care requires mental health professionals to recognize and foresee the possibility that a patient

Formulating a patient’s level of suicide risk requires an understanding of how risk factors interact, exacerbate, and otherwise contribute to heightened or lowered risk for suicide. Impressive gains have been made in identifying lifetime, or long-term, risk and protective factors for suicidal behavior.

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However, one of the most important jobs of clinicians is to determine who is at near-term, or imminent, risk for suicidal behavior. Despite decades of research devoted to the study of risk and protective factors for suicide and suicidal behavior, surprisingly little is known about near-term risk factors for these behaviors. Warning signs have been identified by their association with death by suicide over the subsequent 12 months, not the next 30 or 7 days or, for that matter, 48 hours [63]. There is a pressing need for this research to be conducted. In fact, the Research Task Force of the National Action Alliance for Suicide Prevention has prioritized the assessment of who is at risk for suicide in the near future as one of its 12 aspirational goals (http://actionallianceforsuicideprevention.org/taskforce/research-prioritization). Accordingly, there is currently no empirically supported method for incorporating objective markers of near-term risk in a way that informs our determination of an individual’s risk for future suicidal behavior (i.e., low, moderate, high, or imminent risk). In the absence of a tool for synthesizing this information, clinical judgment or intuition is currently used, rather than science, to combine details about risk factors. Hence, we advocate for training that is based on clinical vignettes, supervision, and active interaction with suicidal patients. What is needed are prospective studies aimed at identifying novel, near-term predictors; examining methods of synthesizing this information; and testing the ability to predict and prevent suicidal events. The take-home message here is that research findings such as these have not yet translated into clinical understandings of—and better formulated approaches to deriving—a suicide risk formulation. The need for upgrading the understanding and skills of psychiatrists, built upon evidence-based research findings rather than clinical folklore, is palpable. The clinical literature abounds with references to a suicide risk formulation as an intuitive enterprise. Surprisingly, there is little in the clinical literature that trains to the development of clinical judgment either via a model for a suicide risk formulation or an extended guideline for establishing levels of risk. Furthermore, the literature lacks studies on the reliability and validity of clinical judgment as it relates to a suicide risk formulation. Regarding the formulation of suicide risk, Motto wrote in 1992, “…there is no avoiding subjectivity…leaving us with what I have referred to above as an intuitive judgment” [64]. That same year, Maltsberger wrote, “Because no one knows how to do this [integrate a large mass of data] precisely and with empirical certainty, the clinician is forced to rely on clinical experience and on inductive reasoning. He does not know how important each datum may be in comparison to the others that have been collected” [65]. What was noted by Motto in 1989 remains true a quarter century later:

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…to date we have no established and generally accepted procedure to guide us… Innumerable decisions regarding risk are made and implemented every day—the job gets done—but how it gets done is determined primarily by the skills and philosophy of the individual clinician. [66]

What Does “Levels of Suicide Risk” Mean? Clinical professionals generally evaluate a patient’s risk on a quasi-Likert Scale ranging from no risk to low risk to moderate risk to high risk, and whether high risk might actually be acute or imminent risk. However, standardized, operational definitions of these levels of risk are difficult to find. As noted by Simon [11], models and strategies for making judgments of levels of risk have been proposed, but there is no research that has specifically examined the relative validity of any of these schemas, no less the process and outcome of clinical decision-making that is intended to result from an assignment of a level of risk. What is generally understood by the clinician is merely that these levels of risk exist on an ordinal scale, that higher versus lower levels of judged risk carry more significant demands for aggressive treatment planning, triage, and intervention, and that a determination of “imminent risk” is a statutory requirement criterion for civil commitment and potentially a clinician’s duty to warn [67]. Imminent Risk US statutes for assisted treatment (involuntary hospitalization) vary considerably [68] but, typically, employ language to guide the clinician as follows: & & & &

Real and present threat of substantial harm to self or others Likely to injure if not thwarted Unable to care for self …in the reasonable future

These statutory provisions offer language that leaves the determination of imminent risk entirely up to the clinician’s best judgment applied to a subjectively determined timeline (i.e., some undefined number of hours into the future, e.g., 24, 48, or 72 hours) [69].1 Hence, imminent risk determinations are clinical and temporally related predictions of behavior in the near future (with no agreed-upon operational definition of what is meant by the “near future”). In 2006, Simon was correct when he wrote that this near-term prediction of imminent risk “imposes an illusory time frame on an unpredictable act” [70]. An oft-quoted reference (Hirschfeld and Russell 1997) defines “imminent risk” as a suicide attempt occurring within 48 hours of the time that the patient is seen, “short term risk” within days or weeks, and “long term risk” within weeks to years.

1

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In making a judgment of imminent risk, the clinician is asked to anticipate reasonably the possibility of a patient’s potentially lethal suicidal behavior in the very near future and hence to act to protect the patient. Therefore, this judgment is central to determining legal liability (whether a breach in the standard of care occurred) in the assessment and treatment of a patient who has died by suicide. In the legal context, this judgment is one of “foreseeability.” Again, if the court holds clinicians accountable for formulating a patient’s imminent risk for suicide, should we not try to base this judgment on something more than intuition [53]?

Just How Reliable Are Clinicians’ Judgments of Levels of Risk? Recently, Cahill and Rakow investigated differences in clinical judgment, using 35 hypothetical case examples provided to seven practitioners by regressing 10 case variables onto their judgments, and found all but two potential risk factors were related to risk and priority judgments [71]. Further, they observed that “low risk” might be particularly subject to variability in its interpretation. Even the term risk could be ambiguous, as they noted, “reflecting the probability of occurrence for some” and “the severity of occurrence to others.” Perhaps, then, it should not surprise us that Appleby et al. [5, 72] reported that, at the last clinical contact, the therapist assessed no suicide risk in 30 %, and low risk in 54 %, of patients who then died by suicide. As noted, there are no uniform criteria or definitions for the determination of low, moderate, or high risk. Clinicians tend to believe that clinical judgment improves with increased education, training, or experience. Clinical experience and “expertise,” however, add little to the accuracy of clinical judgment [73]. If critical clinical thinking is influenced by knowledge and experience, we have yet to validate it [74]. Indeed, a meta-analysis of 75 clinical judgment studies involving more than 4,600 clinicians concluded that education and clinical experience have a very small effect (only 13 %) on the accuracy of clinical judgments [75]. Experience, unto itself, does not equate to competence, and competence can only develop with extensive deliberate practice and corrective feedback [76, 77]. Clinical errors are both universal and inevitable; clinical judgments, however, particularly those made under the stress of seeking to be lifesaving, may be especially prone to error. In one study, for example, researchers were unable to predict nearly two thirds of the violent crime that ultimately occurred and nearly two thirds of the persons whom they predicted would be violent were not [78]. A recent systematic meta-analysis of controlled studies investigated risk factors for suicide within 1 year after discharge from a psychiatric hospital [79]. Factors weakly associated with post-discharge suicide were reports of suicidal ideas (OR=

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2.47) and a diagnosis of major depression (OR=1.91). Patients deemed to be “high risk” were more likely to die by suicide than other discharged patients, but the strength of this association was not much greater than the association with some of the individual risk factors. These authors concluded that no one factor, or combination of factors, was strongly associated with suicide in the year after discharge and, further, that risk categorization is of no value in efforts to decrease the numbers of patients who will die by suicide after hospital discharge. Our interpretation of this meta-analysis is that the “low risk” patients may have been misdiagnosed or poorly assessed, in part because once they denied suicidal ideation they were deemed to be free of suicide risk and ready for discharge [53].

Limitations and Barriers to Training for Suicide Risk Assessment, Suicide Risk Formulation, and Level of Risk Determinations As noted, there are a number of limitations to our current reliance on some standard components of the SRA, such as suicide ideation. Furthermore, there is no agreed-upon listing of elements that should be included in an SRA. As a result, there is no standardized SRA, and Simon has admonished clinicians not to rely on forms in conducting a suicide risk assessment [80]. There has been no empirical study of the criteria used for determining the level of risk or ranking of low, moderate, or high. In fact, there is no agreement of the ranking designations because beyond the commonly used low-moderate-high rankings, other designations are used, such as, very low, immediate, very high, emergent, and imminent. The meaning and criteria for these rankings are not standardized. There have been very few empirical studies of the shortand long-term outcomes of those patients who were labeled as low, moderate, or high risk. Many studies only followed up with those who have been hospitalized for a “medically serious suicide attempt” [81]. The assumption is that a medically serious suicide attempt indicates that the patient was at high, imminent, acute, or immediate risk. There have been virtually no empirical studies that link treatments or interventions with specific levels of risk. Hence, we really do not know much about what works best, or is most effective or cost-efficient, for low versus moderate versus high-risk individuals. Clinicians deserve a better roadmap or clinical tool to assist in assigning a level of suicide risk to an individual. Without such a guide, the clinician is left to his or her education, training, intuition, judgment, and previous experience to determine how best to intervene and manage the patient. Clinical judgments and intuitions are influenced by knowledge and experience, but greater experience does not necessarily equate to better judgment [74]. Clinical “expertise” adds little to the accuracy of clinical judgment [73]. No doubt that sound clinical judgment must be brought to the task of formulating

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risk, but the questions of whether good clinical judgment can be improved upon, no less trained, remain outstanding. Moreover, despite the obvious appeal, it remains dangerous and unpredictable to rely on “clinical intuition” in arriving at a judged risk level for an individual, especially when life or death hangs in the balance. In the end, actuarial models for predicting a patient’s risk of violence, in contrast to clinical judgment, may not be superior [82]. The need now is to bring as much science into this process as is possible to arrive at the best possible approach to risk formulation. Indeed, there is evidence that this is possible [83].

Is Clinical Judgment Trainable? A major goal of medical school and residency training is to achieve clinical competency in trainees. Clinical judgment is a competency-based skill. In a recent JAMA editorial [84], Cohen outlined major revisions of the Medical College Admission Test (MCAT) and of the United States Medical Licensing Examination (USMLE). He stated that both of these revisions “are designed principally to sharpen the assessment of the scientific knowledge and the reasoning skills deemed necessary to provide safe and effective care” [84, p. 2253]. In the case of the USMLE, the aim is to “ensure that entrants into supervised residency training and ultimately into independent practice have actually acquired the ‘ability to obtain, interpret, and apply scientific and clinical information’ to the care of patients” [85, p. 2245]. In revising the MCAT, “there was consensus that applicants should demonstrate their use of theory and evidence to draw conclusions about the influence of psychological, sociocultural, and biological factors on behavior and behavioral change” [86, p. 2243]. This focus toward a greater emphasis on critical analysis and reasoning skills “parallels the adoption of competency-based curricula in medical schools” [86, p. 2243]. Both tests “will shift the focus from how knowledgeable examinees are to how competent they are in using their knowledge” [84, p. 2253]. There have been concerns raised in the past regarding the effectiveness of continuing education programs in impacting providers’ behaviors or changing patient-related outcomes [87]. Recent research has suggested that interactive continuing medical education training programs, especially those that included supervised skill demonstration and rehearsal, significantly affected health care providers’ behavior [88]. However, a recent review has raised questions about the efficacy of training in workshop formats for improving the clinical care of the suicidal patient [89]. Despite this review, studies have shown improvements in knowledge and skills because of continuing education programs. The scientific literature is beginning to demonstrate that empirically based skills taught in a brief continuing education format can change clinic policy, confidence in risk

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assessment, and confidence in management of suicidal patients, with changes sustained at a 6-month follow-up [90, 91]. Findings such as these, in conjunction with the known elements that facilitate the translation of continuing education training into clinical practice [88], suggest that suicidespecific continuing education can “meaningfully impact professional practices, clinic policy, clinician confidence, and beliefs” [91, p. 21]. As for whether education and/or training can improve the accuracy of clinical judgments, the jury is still out [75] but the need is still there. As noted by Karthikeyan and Pais, “Clinical judgment conjures up visions of the archetypal clinician endowed with infinite wisdom and breathtaking clairvoyance” [92, p 623]. We recognize that creating clinicians in this mold is an unattainable goal. Further, the question remains as to whether suicidology will ever be able to model statistically those decision rules that would better inform the accuracy of clinical judgments [83, 93, 94]. As Nakash and Alegria [95] have suggested, the cognitive processes involved in clinical judgment include an appreciation of nonverbal cues and affective communications from patients (they have termed these processes “implicit clinical judgment”), hence the potential to create a viable actuarial model that fails to capture these inputs is questionable. Nevertheless, the American Association of Suicidology’s Task Force on Training has made multiple recommendations for preventing suicide through improved training (in this case to make a clinical judgment of level of risk) focused on building essential skills [15]. The question remains as to whether training can improve these skills and, if so, through what methods of training.

A Proposed Model for Formulating Suicide Levels of Risk At the present time, only a few training programs have been recognized for disseminating content that is consistent with the core competencies identified for SRA and SRF and have been demonstrated to be effective in increasing suicide specific knowledge and skills. The depth and breadth of these evidence-based training programs vary in length from 6 hours and a focus on knowledge competencies (i.e., Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals) [96]) to 13 hours (i.e., Recognizing and Responding to Suicide Risk) with a focus on behavioral competencies [97]. Outcome data regarding behavior change in response to the latter training are emerging, with changes documented up to 4 months after training [98]. The American Association of Suicidology’s Recognizing and Responding to Suicide Risk (RRSR) [97] clinical training program’s model for conducting a suicide risk formulation asserts that the presence of chronic risk factors establishes the patient’s vulnerability to be suicidal across his or her lifetime, whereas the presence of one or more warning signs (acute risk

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factors) [63], in that context of lifetime vulnerability, establishes a basis for the foreseeability of near-term risk [www. suicidology.org]. The RRSR model for conducting a suicide risk formulation builds upon Litman’s conceptualization of a “suicide zone” [99] in which he proposed that vulnerable individuals move in and out of periods of heightened risk, when a number of things go wrong at once. The model further assumes that the greater the number of acute risk factors, the greater the risk for death by suicide, although no actuarial statement is made about cutoff scores (e.g., number of acute risk factors needed to define imminent risk) [68]. Further, the RRSR approach asserts that protective factors do not buffer when acute risk is present. To illustrate this model, consider the following case: The patient, a 52-year-old, divorced, White male attorney, is referred by his pastor. At intake, he complains of intense, work-related stress and consequent loss of sleep (early morning awakening), fatigue, low energy, tension, and dry mouth. He states that he feels like a failure in that he represented his church in an anticipated sale of a church-owned property that fell through and anticipates a lawsuit against the church as a result. He feels guilty and anticipates damage to his reputation. He describes himself as a workaholic and perfectionist, and his cognitions are noted to be distorted and overly personalized regarding this and other work-related issues. He admits to passive suicidal ideation (“I’m not sure I can go on living”), but states he has not seriously considered doing anything, and has a history of more active suicidal ideation (“driving my car into a bridge abutment”) a decade ago, when his marriage was dissolving. He drinks socially and denies illicit drug use. He has little time for friends, given the felt intensity of his work demands, and he has not dated much since his divorce. An active runner and tennis player, he has not had energy to engage in these hobbies for the past 2 months. His score on a Beck Depression Inventory is 15. History is uneventful, but for the divorce of his parents (when he was age 12) and the suicide of his maternal grandmother (when he was age 10). Table 2 describes this model of suicide risk formulation, wherein this patient’s risk for suicidal behavior is based on the preponderance of acute risk factors in the context of elevated chronic risk and research-informed understanding of suicide ideation, that is, current passive suicidal ideation is not minimized and historic suicidal

ideation (active suicidal ideation at the time of his divorce) suggests high risk. The RRSR model trains through repetition across multiple case scenarios, such as Table 2, to the point of demonstrated trainee competency in applying this process of deriving suicide risk formulations. As such, it mirrors the model proposed in 2004 by Ericsson that is based on deliberate practice of, and corrective feedback for, research-informed suicide risk assessments and suicide risk formulations [76]. Furthermore, the RRSR training incorporates Shea’s CASE Method as a best practice approach to eliciting variables of risk and, notably, to confront and elicit otherwise denied suicide ideation [100, 101].

Conclusion The core competencies for psychiatric residents have been determined and operationalized [102]. Frierson and Campbell [46] have integrated the principles of therapeutic risk management for suicidal patients [14] into each of the six core competencies of the Accreditation Council for Graduate Medical Education (ACGME). To aid in the process, Rudd et al. [103] have provided detailed guidelines for facilitating the adequate training of mental health trainees regarding competencies essential for the assessment and management of suicidal patients. These guidelines offer information for supervisors and instructors to ensure that trainees master the content and acquire the skills related to each domain. It is now necessary to require training programs to utilize these core competencies in their training of future mental health professionals. Ideally, these abilities would be demonstrated through supervised training with a competent supervisor and suicidal patients but, at a minimum, would require some measure of skills-based demonstration (e.g., supervised role plays). The Research Prioritization Task Force of the National Action Alliance for Suicide Prevention has proposed shortand long-term objectives relative to a number of key research questions [http://actionallianceforsuicideprevention.org/taskforce/research-prioritization]. Relative to addressing the question of what services are effective for treating the suicidal person, the “aspirational goal” is to “Ensure that health care providers…are well trained in how to find and treat those at risk,” and the short-term objective is to “Identify efficient ways

Table 2 Suicide risk formulation for case example Chronic risk factors

Acute risk factors

Level of risk formulation

Major depression, single episode Comorbidity: anxiety Parental divorce Divorce Family history of suicide Perfectionistic character

Insomnia Low Moderate High Acute Withdrawal In the context of considerable vulnerability to be suicidal (chronic Suicidal ideation (current and at worst point) risk), the presence of multiple, significant acute risk factors would Guilt suggest that this patient’s risk for suicide is high. Cognitive distortions Stress-induced anxiety

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to increase the number of providers who implement adequate suicide assessment and management skills that improve care.” To date, only the American Psychiatric Nurses Association has adopted a position statement regarding consumercentered, competency-based suicide assessment and prevention training for psychiatric mental health registered nurses (PMHRN) specifically practicing in the inpatient setting [104] [www.prweb.com/releases/2013/SuicidePrevention? prweb11062389.htm]. Moreover, because clinicians are potentially held accountable through tort actions when, and if, a patient in treatment dies by suicide, improving the clinical judgments involved in clinical decision making regarding the triage and treatment of these patients has significant implications for the clinician. Some have gone so far as to argue that risk formulations should not form the basis for clinical decision-making, preferring to focus attention simply on the treatment needs of each patient, regardless of risk for adverse events [105]. We agree that a patient’s treatment needs should be foremost in the mindset of the clinician, but in litigious societies, this argument (against conducting an SRF) has serious negative consequences for the clinician. The detection of suicide risk (SRA) and formulation of suicide risk (SRF), and the consequent triage and treatment decisions that are dependent on these procedures, are, perhaps, the most significant actions a clinician must make. The failure to reasonably accomplish these tasks has the potential for significant negative outcomes for both the patient (a possible preventable death by suicide) and the clinician (the premature death of a patient; a preventable tort action). It is time to move beyond the intuition and philosophy of the clinician and to develop and train to models for conducting an SRA and SRF.

Implications for Educators • Providing lectures and guidelines on suicide risk assessment and suicide risk formulation in order to develop competencies are not the equivalent of training, supervision, and practice with case applications. • Emphasis needs to be placed on the development and application of clinical judgment after the acquisition of data via a suicide risk assessment. • Developing competencies in conducting suicide risk assessments must incorporate strategies that do not rely on communicated suicide ideation as the sole gateway for conducting such assessments. • Suicide risk assessment and suicide risk formulation should be considered core competencies in medical school psychiatric clerkships and graduate psychiatric training. • Determinations of the levels of suicide risk must be linked to empirically based risk and protective factors, and correlated with proven interventions.

Disclosures The authors do not have any conflicts of interest to disclose, including financial or personal relationships with individuals or entities that may influence their work.

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Training for suicide risk assessment and suicide risk formulation.

Suicide and suicidal behaviors are highly associated with psychiatric disorders. Psychiatrists have significant opportunities to identify at-risk indi...
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