Date Published: December 14, 2015
Publisher: Springer International Publishing
Author(s): Anthony R. Pisani, Daniel C. Murrie, Morton M. Silverman.
Psychiatrists-in-training typically learn that assessments of suicide risk should culminate in a probability judgment expressed as “low,” “moderate,” or “high.” This way of formulating risk has predominated in psychiatric education and practice, despite little evidence for its validity, reliability, or utility. We present a model for teaching and communicating suicide risk assessments without categorical predictions. Instead, we propose risk formulations which synthesize data into four distinct judgments to directly inform intervention plans: (1) risk status (the patient’s risk relative to a specified subpopulation), (2) risk state (the patient’s risk compared to baseline or other specified time points), (3) available resources from which the patient can draw in crisis, and (4) foreseeable changes that may exacerbate risk. An example case illustrates the conceptual shift from a predictive to a preventive formulation, and we outline steps taken to implement the model in an academic psychiatry setting. Our goal is to inform educational leaders, as well as individual educators, who can together cast a prevention-oriented vision in their academic programs.
Dr. Lang, a first-year resident, interviewed Mr. Colban and his wife in the psychiatric emergency department (ED). Mr. Colban, 54, was referred by his primary care physician, and arrived reluctantly, after endorsing “Nearly every day” on the routine depression-screening item, “Thoughts that you would be better off dead.” When his doctor asked about it, he quipped, “You never know what can happen when a guy is cleaning his gun, Doc.”Dr. Lang determined that Mr. Colban probably had mood instability much of his life, but more erratic behavior began six months ago when he discovered his wife and his best friend in bed together. After confronting them, Mr. Colban sped off in his car and struck a concrete wall, fracturing a hip and femur. These injuries continue to cause pain.Mrs. Colban stated emphatically that she has ended the extramarital relationship, although her husband remains suspicious, angry, and moody. He drinks with friends after work almost daily. In the heat of a recent argument, Mr. Colban said, “Maybe I should just shoot myself so you can screw Tom without guilt.” He owns a gun.During the interview, Mr. Colban denied suicide ideation. “I say that when I’m mad, but I wouldn’t do it.” Questioned about troubling statements he made to his physician and wife, he asked, “Don’t you people have anything better to do?” Asked if he would keep himself safe he said, “Yes…I already said I would never do it.” He agreed to let a family member keep his gun temporarily.
We define risk formulation as a concise synthesis of empirically based suicide risk information regarding a patient’s immediate distress and resources at a specific time and place. The goal of this synthesis is not to predict behavior but to promote communication and collaboration among professionals, patients, and families to reduce risk in the short and long term.
Educational leadership often requires casting and executing a vision for new clinical paradigms in our training programs. The model articulated in this article has gained traction nationally through its adoption by existing training programs. The model has been used to train psychiatrists, psychologists, and social workers in a range of facilities, in a government-sponsored national webinar, and it has been recently adopted by two curricula disseminated nationally [23, 24]. We have adopted this model in our academic psychiatry programs at the University of Rochester, integrating it into clinical workflows, case discussions, change-of-shift reports, patient education, and documentation used in the Comprehensive Psychiatric Emergency Department for training psychiatric residents and fellows. Adopting this model required a paradigm shift for many of our faculty and staff, since most were accustomed to prediction-oriented risk categories and labels.
National attention has focused on “suicide safer” care in behavioral health. Academic psychiatry is in the best position to lead the way toward clinical paradigms of suicide risk that change the focus from prediction to prevention. In the model we propose, the risk formulation process comprises four components flowing logically from one to the next: risk status, risk state, available resources, and foreseeable changes. This model synthesizes advances made over the past decade in suicide risk assessment [7, 10, 11, 17] with innovations in forensic assessment of violence risk . In this model, assessment and description of risk are explicitly anchored in the clinical context and patient population, in the patient’s own history, and in the patient-specific opportunities for prevention. The model is straightforward, easy to remember, and suitable for teaching and supervision, communication among professionals and with patients, and documentation. The visual representation or “map” helps reinforce the relationship between constructs—a strategy consistent with research in health sciences education and best practices for cognitive schema formation and key concept retention .