This article is more than 5 years old. Information may no longer be current.

Expert calls for change in suicide assessment, formulation models

SAN DIEGO ─ Suicide assessment and formulation should focus on preventing suicide, rather than predicting it, according to research presented at the U.S. Psychiatric and Mental Health Congress.

“We need to reconceptualize risk factors into enduring risk factors and dynamic risk factors. We need to reconceptualize risk status from a prediction model to a prevention model, and our argument is [that] we are not interested in predicting something, we are interested most in preventing someone from engaging in self-harm. I believe it is our duty and responsibility, not only to prevent it, but to come up with a treatment plan or approach that is in the patient’s best interest and will result in their not engaging in suicidal behavior,” Morton M. Silverman, MD, assistant clinical professor of psychiatry, University of Colorado School of Medicine, Denver, said during a presentation. 

The standard practice of suicidal risk assessment and formulation begins with asking the patient about whether or not suicidal ideation is present. Depending on the patient’s response to the question, the risk assessment either continues or ends, which is below the standard of care, Silverman said. He noted that the assessment, frequently asked as ‘have you ever thought about killing yourself,’ often lacks a timeline, which is an important part of assessing the patient’s frame of mind.

While suicide risk assessment and suicide risk formulation may be related to one another, each requires a different sets of skills, experience, knowledge and perspectives, Silverman said. Traditional models of assessment and detection are based on an intuitive understanding of patients most at-risk for suicide, not a research-based understanding, he said. 

During his presentation, Silverman cited data that demonstrated among patients who died by suicide, the majority denied having suicidal thoughts the last time they were asked, or communicated their risk with more behavioral messaging, compared with verbal messaging. This is what makes the standard practice of ending assessment if the patient has not expressed suicidal ideation potentially harmful, according to Silverman.

Patients may deny having suicidal ideation for a number of reasons, including not having suicidal ideation at the moment; being unclear of the question; having “fleeting” suicidal thoughts; fear of losing autonomy, relationships or employment; fear of being judged or stigmatized; feeling as though they are not capable of being helped; or feeling that suicide is a sign of weakness, Silverman said. 

While clinicians may be less inclined to worry about patients who express passive suicidal thoughts compared with active suicidal thoughts, Silverman said there is no evidence to support the notion that patients with active suicidal ideation are at greater risk for suicide, and that risk for suicide is similar among both groups.

Silverman suggests providers try to gauge a patient’s suicidal ideation at the “worst point” in their life when inquiring about suicidal ideation. This is often a better predictor of death by suicide, rather than their current suicidal ideation or expressed hopelessness, he said. Directly asking, ‘have you ever attempted to kill yourself’ is, in his opinion, the best approach to suicide assessment. 

Currently, there are no empirical data on the best approaches to suicide risk formulation, including risk levels, or definition and components of risk levels, according to Silverman. The models that do exist are based on intuitive understandings of those most at-risk, rather than on research.

A formulation that considers risk status, risk state, available resources and foreseeable changes is needed, Silverman said, rather than the current formulation based on the categorization of low, medium or high formulation of risk. The model he proposed would help providers determine the best suicide prevention safety plan. 

“We have to recognize that people die by suicide, even when they don’t express suicidal ideation. What are really missing in our field are good studies that look at the 30-day span of lifetime before someone kills themselves; [we need] to identify those risk factors that play an important part in making them vulnerable and leading them to engage in actual suicidal behaviors,” Silverman concluded. – by Casey Hower

For More Information:

Silverman MM. Suicide Risk Assessment and Suicide Risk Formulation: Past, Present and Future. Presented at: U.S. Psychiatric and Mental Health Congress; Sept. 10-13, 2015; San Diego.

Discloures: Silverman reports no relevant financial disclosures.