Suicide risk assessment and management in practice: the quintessential clinical activity

To the Editor: As Work Group chair (DJ) and medical editor (LF) for the American Psychiatric Association (APA) Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors [1], we read the recent review of multidisciplinary clinical practice guidelines in suicide prevention [2] with interest. The authors have done an excellent job of synthesizing available resource documents and guidelines related to suicide risk. Given the importance of this topic, we want to comment on several issues. In terms of clinical practice guideline content, professional organizations’ practice guidelines are now expected to use formal systematic review and ratings of strength of evidence in developing guideline recommendations [3]. Consequently, approaches besides practice guidelines may be needed to develop training recommendations and to educate clinicians about legal, ethical, and postvention issues. The authors also noted that relatively few guidelines discussed safety planning approaches. This is not surprising since formal development of safety plan procedures did not even begin until 2006 [4]. Although safety planning has intuitive appeal, a search of PubMed yields no citations comparing its use to treatment as usual, which would make incorporation into guidelines difficult. Such studies are in progress [4], but it may be premature to advocate for wholesale adoption of these interventions at present. Of greatest concern to us is the emphasis on screening inventories and standardized categorizations of risk. As noted in the review, the APA practice guideline did mention several rating scales, but the text made clear that we did not advocate routine clinical use. Specifically, the guideline states “Although a number of suicide assessment scales have been developed for use in research ..., their clinical utility is limited. Self-report rating scales may sometimes assist in opening communication with the patient about particular feelings or experiences. In addition, the content of suicide rating scales, ..., may be helpful to psychiatrists in developing a thorough line of questioning about suicide and suicidal behaviors. However, ..., such rating scales cannot substitute for thoughtful and clinically appropriate evaluation and are not recommended for clinical estimations of suicide risk.” [1] It may seem paradoxical that we would advise against use of standardized rating scales. After all, a clear-cut rating scale with a numerical estimate of suicide risk would seemingly improve identification of at risk individuals, simplify decisions about hospitalization, and allow proactive intervention to reduce suicide. Furthermore, rating scales have substantial utility in identifying and monitoring other psychiatric symptoms and syndromes. Unfortunately, we do not have good data on short-term rates of suicide or suicide attempts in individuals with specific risk factors or rating scale scores. For example, the Columbia-Suicide Severity Rating Scale (C-SSRS) purports to assess suicide risk and has gained widespread use in clinical research and other contexts. However, its only predictive finding in adults is that individuals with prior suicidal behavior or lifetime suicidal ideation with intent are more likely to report suicidal behavior during several months of follow-up [5]. Not only are these already well-documented risk factors, but research populations exclude individuals at highest suicide risk and no suicide deaths were mentioned, which makes the generalizability of their findings unclear. In addition, most clinicians do not understand concepts of preand post-test probabilities and fail to appreciate the impact of * Laura J. Fochtmann laura.fochtmann@stonybrook.edu