It is 4 p.m. on Friday afternoon. “My wife is suicidal, Doctor. If you don’t admit her to the hospital, you’ll have blood on your hands on Monday...”
If the apparently suicidal patient is not hospitalized it could be a difficult weekend for the patient, of course, but also for the understandably worried spouse and even the psychiatrist. The psychiatrist would be aware that the guidelines for patients with suicidal behaviors recommend estimating the likelihood of suicide by combining clinical findings (such as suicidal thoughts and behaviors) with multiple risk factors to judge the seriousness of the suicide risk. The guidelines go on to suggest that if the patient does die by suicide that psychiatrists should contact their attorney. When the risk of suicide is high, it is not surprising that doctors often take what seems to be the safest option and arrange for hospital admission.
But how good are we at predicting the level of suicide risk? Not very good at all, it seems, according to two recent meta-analyses of the last forty years of suicide risk research. One group of authors even suggests that the process of suicide risk assessment itself might increase the likelihood of suicide.
In the first paper, Matthew Large and his group in Australia looked at the last 40 years of suicide risk assessment research. They found that 95 percent of high-risk patients will not die by suicide at all and that 50 percent of patient suicides came from the lower risk categories. They also found that predicting suicide by combining multiple risk factors was not much better than using a single risk factor. A disappointing, and perhaps the most telling, finding was that there has been no improvement in the accuracy of suicide risk assessment over the last 40 years. They found no statistical method to identify patients at a high-risk of suicide in a way that would improve treatment.
The second paper, published a few months later, was a meta-analysis of suicide risk factors and risk assessment scales in people who had already harmed themselves. In this analysis the four strongest risk factors (previous episodes of self-harm, suicidal intent, physical health problems and male gender) were so common that they are of no help in assessing suicide risk.There was no evidence to support the use of risk assessment scales either. The researchers believe that the widespread use of suicide risk assessment diverts clinicians from real engagement with patients. “We may well be putting our own professional anxieties above the needs of service users and,” the researchers conclude “paradoxically, increasing the risks of suicide following self-harm.”
In truth, the results of these two meta-analyses of all the available data on suicide risk assessment were not surprising. Although the American guidelines do recommend risk assessment, they simultaneously acknowledge how difficult this is. The UK guidelines resolve this conflict by stating that “assessment tools and scales designed to give a crude indication of the level of risk (for example, high or low) of suicide” should not be used.
So, how should the psychiatrist respond to the distraught husband and suicidal wife? The two studies above provide an unequivocal basis for a good response.
Most people who feel suicidal do not want to die they just want to end their emotional pain and suicide is the only way they can think of to do that. Your wife is experiencing unbearable emotional pain at the moment and as a result feels suicidal. Yes, her risk of suicide is relatively high, about 50-100 times greater than the general female population rate of 6 per 100,000 per year. You are bound to be very frightened by this. However, her absolute risk works out as a 99.9% likelihood that she will be alive on Monday no matter what we do. While hospitalization feels like the safe option, there is no evidence that it prevents suicide and it loses the opportunity to learn coping skills in the real world. The task is to identify the cause of your wife’s emotional pain and help her find a solution for it—a combination of medication, monitoring and learning skills such as problem solving and distress tolerance . If we can do that, the suicidal feelings will likely reduce. The experience will help her next time there is a crisis and reduce the likelihood of repeated hospital admissions. Although this might feel more risky in the short term, statistically it is not.
On Monday morning, and consistent with with the statistics and his 30 years of clinical experience, the psychiatrist does not have blood on his hands. The crisis was managed and the patient subsequently engaged in an outpatient therapy program. This does not mean that unpredictable tragic outcomes will not sometimes occur—they will. Suicide prevention however, is more a social than a medical issue. Society can help by restricting access to means of suicide (eg restricting guns, protecting iconic locations). The role of mental health services is to treat mental illness and alleviate the pain of patients and families, rather than expending energy and resources on futile efforts at risk assessment. If mental health clinicians and those they serve can absorb this reality they will be much better placed to understand and help those struggling with the urge to end it all.