Speaker: Devise risk assessment plan for treating suicidal patients

Working with suicidal individuals is inevitable for clinicians, thus making it essential to understand suicide and create a plan for its risk assessment, according to a presenter at the Psych Congress 2020 Virtual Experience conference.

“If you haven't worked with suicidal clients, chances are that regardless of the area of your clinical expertise, you will,” Doreen S. Marshall, PhD, vice president of programs at the American Foundation for Suicide Prevention, said. “We know that in 2018, the last year for which we have complete data, 48,334 people died by suicide. That's roughly 14.2 persons per hundred thousand, and it's the 10th leading cause of death age-adjusted across age groups.”

The effects of suicide are felt far beyond the clinical sphere, as over half the population of the United States have lost at least one person to suicide during their lifetime, according to Marshall. Further, those who have lost someone to suicide are themselves are at subsequent higher risk for suicide.

The psychiatric connection in suicide prevention appears particularly relevant, as Marshall noted 90% of people who die by suicide have a diagnosable mental health condition at the time of their death.

“It's important to note that there are differences between thinking about suicide, attempting suicide and dying by suicide,” Marshall said. “Just because someone is thinking about suicide doesn't mean they're necessarily at risk for death, but it does tell us that we need to do a risk assessment. We should be mindful that suicide is complex and that there's never one single cause of suicide.”

Marshall provided an overview of a suicide risk model that accounts for interactions between various risk factors. Certain stressors, such as job loss, economic difficulties, divorce or any substantial relational loss, are common among most individuals. However, people at risk for suicide often experience other factors that intersect with current and common life stressors. These include biological, psychological and social and environmental factors, she said.

Examples of these factors, according to Marshall, include the following:

• biological: genetics, physiological factors, stress response, lower threshold for impulse control;

• psychological: tendency to interpret life events through a more negative lens, diminished sense of locus of control; and

• social and environmental: exposure to suicide or suicide attempt, past trauma, history of childhood abuse.

According to the model, those at risk for suicide experience one or more significant stressors and have access to lethal means.

“When someone has the urge toward suicide and they have an attempt method in mind, if they can’t access that method, they are not cognitively flexible enough in those crisis moments to switch to a different method,” Marshall said.

Steps like securing firearms and limiting access to medication can help reduce access to lethal means and thus mitigate suicide risk, according to Marshall.

A six-pronged approach can be implemented to evaluate suicide risk, beginning with assessment of past and current suicidal ideation and behavior upon patient intake. Clinicians should then assess regularly for suicidal behavior, particularly during times of change and/or stress, Marshall said.

Other steps include determining a patient’s contributing and protective factors, as well as their access to resources and their willingness/ability to use them.

Lastly, Marshall suggested devising a safety plan with patients that is actionable, feasible, collaborative, documented and accessible.

“I want to encourage [clinicians] to learn more about interventions that are effective in reducing suicidal behavior, such as cognitive behavioral strategies, dialectic behavior strategies and cognitive processing therapy,” Marshall said. “These are therapies that have been shown to have an impact on suicidal behavior.

“It is also important to engage in self-care,” Marshall said. “We know this work is hard, but we will be better at assessment the better we take care of ourselves and can really tune in to what's going on for our clients.”