Suicide risk assessment and intervention in people with mental illness

In the state-of-the-art paper written by Bolton et al. (2015),1 suicide risk assessment and intervention in people with mental illness were updated and thoroughly reviewed. It is informative that the authors listed various risk assessment tools including conventional, empirically-tested, or relatively newer suicide risk scales and discussed their usage and performance in predicting suicide. However, it should be noted that apart from suicide prediction by judging the performance of scale psychometrics, risk assessment tools also serve the functions of developing trusted relationship and identifying suicide risk levels for proper referral and management in different clinical settings. Through this letter the authors aim to discuss the multiple purposes such assessment tends to be neglected by clinicians and their implications for primary care providers in different cultural contexts.

For most first-line healthcare providers who encounter people with explicit suicide attempt, engaging these people by comprehensive psychosocial assessment through psychiatric referral must be an agreed decision considered as part of the treatment. However, if someone has self-harmed by taking 7 tablets of paracetamol for drug overdose but claims at the emergency department (ED) to have confused the dose because she was just too tired, would any ED clinicians consider psychosocial assessment in the first place over other medically severer cases? The technique of interview and sensitivity in identifying her suicide ideation most likely determine whether the clinician will take any management or actions further. At this point, a suicide risk scale is not being used mainly for prediction of future lethal act; rather, it helps the clinicians to identify suicide risk factors through facilitative communication led by the scale items rather than by “gut feeling”.2 Consequently, a scale should be regarded as a tool helping the clinicians to express patient-centered care in establishing mutual trust, to get informed consent in psychiatric referrals, and to better recognize potential risks for improved adherence in the following treatment. Having these purposes in mind, implicit suicide attempt such as the above example could ideally be identified due to proper attitudes and skills possessed by the clinicians who use a risk assessment scale.

Further, screening tools should never be seen as simply a checklist for healthcare providers in different settings. Given that only half of the patients received psychosocial assessment for self-harm acts at ED under policy regulation,3 still half high-risk patients were neglected of their potential risks and the treatment they need. This suggests that the majority of healthcare providers are not adequately trained to manage suicide risks with proper equipment. The essential problem lies in how these known gatekeepers value suicide prevention, whether explicit or implicit intent they are dealing with, and to what extent these clinicians would agree that follow the guidelines should ultimately prevent suicide. The paper by Bolton et al. pointed out that most guidelines are inconsistent in the ways they stratify suicide risk, recommend for outpatient management and means restriction, and provide guidance for training.4 It should also be highlighted that “Good communication between health and social care professionals and service users is essential…Treatment and care, and the information service users are given about it, should be culturally appropriate”.5

Thus, given these inconsistencies, the cultural meanings of using relevant tools in developing therapeutic relationship and humanistic caring to benefit treatment across the guidelines should be the key to identify suicide risks in different cultural contexts.

In summary, we maintain that suicide risk assessment tools should mainly be regarded as media for communication with high-risk clients rather than simply a predictor for suicidal behavior. It is the caring attitudes and interview skills that determine distress disclosure in certain cultures, not the assessment tool itself. In this respect, the training of first-line healthcare providers such as nurses should aim at promoting positive attitudes, awareness, and skills in facilitative communication under the guidance of an assessment scale.6,7 Regardless of the clients’ medical severity, healthcare providers are suggested to appropriately assess suicide risks by using concise scales to guide the process of management, referral, and evaluation. It is of prime significance to consider culturally-relevant and multi-purposeful risk assessment tools as part of the comprehensive preventive strategy in terms of early detection and timely engagement for the high-risk group in different cultures and clinical settings.

Reference
1. Bolton JM, Gunnell D, Turecki G. Suicide risk assessment and intervention in people with mental illness. BMJ 2015;351:h4978.
2. Ellis CLO. Is a clinician’s “gut feeling” enough to identify self-harm? BMJ 2012;344. doi: http://dx.doi.org/10.1136/bmj.e142
3. Hawton K, Bergen H, Cooper J, et al. Suicide following self-harm: findings from the multicentre study of self-harm in England, 2000-2012. J Affect Disord 2015;175:147-51.
4. Bernert RA, Hom MA, Roberts LW. A review of multidisciplinary clinical practice guidelines in suicide prevention: toward an emerging standard in suicide risk assessment and management, training and practice. Acad Psychiatry 2014;38:585-92.
5. National Institute for Health and Care Excellence. Self-harm: longer-term management. 2014. www.nice.org.uk/guidance/cg133/resources/newnice-guidance-for-the-longer....
6. Wu CY, Lin YY, Chang YM, Huang LH, Chen SJ, Liao SC, Lee MB. Effectiveness of interactive discussion group in suicide risk assessment among general nurses in Taiwan: A randomized controlled trial. Nurse Educ Today 2014; 34:1388-1394. Doi:10.1016/j.nedt.2014.03.015
7. Wu CY, Lin WH, Lee MB, Lin JY, Huang CW, Liao SC. Integrating Suicide Prevention Program into Clinical Nursing Education: A Focus Group Study. J Med Educ 2014;18:81-91. Doi:10.6145/jme201410