Suicide Risk Assessment Often Inaccurate in Ambiguous Cases

Findings Suggest a Need for Better Risk Assessment Training

Jill Stein

March 16, 2011

March 16, 2011 (Vienna, Austria) — Faced with ambiguous cases, mental health professionals (MHPs) often inaccurately classify patients' suicide risk, new research shows.

Presented here at EPA 2011: 19th European Congress of Psychiatry, UK investigators found obviously high- or low-risk scenarios produced a predictable consensus of opinion among MHPs with respect to suicide risk. However, an ambiguous or incomplete scenario produced more variation in risk classification.

"The results mean that a group of MHPs may be misclassifying some of their patients, who are at high risk of suicide, as being at low or medium risk," Julian Beezhold, FRCPsych, consultant in emergency psychiatry at Hellesdon Hospital in Norwich, United Kingdom, told Medscape Medical News.

The data also identify the need for better risk assessment training, with a special focus on MHPs who assume the risk is low when presented with incomplete or ambiguous information, Dr. Beezhold added.

Lack of Guidance

According to investigators, suicide risk assessment accounts for a significant part of the MHPs' workload, and a large body of research has examined the efficacy of various methods of suicide risk assessment. Further, a significant amount of effort has been devoted to developing suicide risk assessment training to improve clinical outcomes.

To date, the various assessment methods available include the actuarial approach, which is based on algorithms and objective procedures; the clinical approach, which is more subjective, intuitive, and based on clinical experience; and a structured approach, which combines the actuarial and clinical approach, which is widely viewed as the preferred approach.

None of these methods, however, provide clinicians with guidance on how to respond to an ambiguous scenario.

Dr. Kate Manley (left) and Dr. Julian Beezhold (right)

The study examined suicide risk for various clinical scenarios with a particular focus on ambiguous cases.

A total of 720 MHPs from a broad range of disciplines were asked to assess suicide risk for 10 clinical scenarios developed to provide a mixture of high-, medium-, and low-risk cases. In some of the scenarios, the available information was incomplete or ambiguous.

The following is an example of an incomplete and ambiguous scenario that was included in the study:

"A 55-year-old man has been sent in by a community practitioner without a letter. He does not respond to your questions and avoids eye contact. You notice that he is short of breath."

About 20% of MHPs suggested that they didn't know how to classify a patient with ambiguous or incomplete information. About 40% of MHPs were more cautious and opted for a high-risk classification. The remaining 40% were less cautious and assumed that the patient was at low risk for suicide.

Best Response

"The best response in an uncertain scenario is to acknowledge that the lack of information and ambiguity may mask a higher-risk patient, and therefore clinicians should proceed more cautiously," Dr. Beezhold said.

"For example, they should take more time in order to complete a more thorough risk assessment. A lack of information in a given clinical scenario may prevent individuals from using a combined actuarial/clinical judgment-based method, such as a suicide rating scale, in their assessment of suicide risk. Without objective information, clinicians may have to rely on judgment alone," he said.

The MHPs in the study included junior and senior psychiatrists, mental health nursing staff, clinical psychologists, nursing assistances, and therapists working at the Norfolk & Waveney Mental Health Care NHS Foundation Trust, which provides a complete range of mental health care to roughly 1 million people.

Dr. Beezhold pointed out the study clearly identifies a need to target training more precisely according to individual response to ambiguity.

Finally, he noted that more studies are needed to better explain the discrepancy in responses to suicide risk scenarios among MHPs.

"The more information we have, the better we can predict suicidality," he said.

"Suicide is a major public health epidemic," Cathy Frank, MD, vice chair of clinical affairs in the Department of Psychiatry and Behavioral Sciences at Northwestern Feinberg School of Medicine in Chicago, Illinois, told Medscape Medical News.

"More than a million people die from suicide worldwide each year, and suicide is the 14th leading cause of death worldwide. Certainly suicide and suicide risk assessment are major issues not only for mental health professionals but for all physicians," she said.

Dr. Frank agrees with the study authors that that there is insufficient research and education regarding suicide risk assessment. "While clinicians usually do a reasonable job of evaluating suicide risk at the initial session, they often inadequately assess suicide risk at subsequent patient encounters," she said.

“What’s more," she added, "they tend to rely on patient's endorsement of suicidal ideation, which is not the only predictor of suicide risk or perhaps even the best predictor."

Dr. Frank noted that in her clinic it is assumed that anyone seeking mental healthcare has some suicide risk.

"There is no such thing as 'no risk' in a psychiatric population. A patient with major depression or bipolar disorder, even in full remission, has a greater risk of suicide than the general population.

"Acute risk factors include moderate to severe depression, mania, psychosis, current active substance abuse, severe anhedonia, global insomnia, severe anxiety, suicidal plan, or suicidal intent. Moderate risk factors for suicide may include a family history of suicide, history of suicide attempts, mild depression, hypomania, and moderate anxiety. Weapon availability, particularly firearms in the home, dramatically increases risk of suicide and must be explicitly asked of patients and families," she said.

Collateral information from family or significant others can help with the ambiguous cases described in the UK study, Dr. Frank said.

Dr. Beezhold and Dr. Frank have disclosed no relevant financial relationships.

EPA 2011: 19th European Congress of Psychiatry: Abstract P03-458. Presented March 15, 2011.

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