Can we usefully stratify patients according to suicide risk?
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4627 (Published 17 October 2017) Cite this as: BMJ 2017;359:j4627
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It would be very helpful to know if the same uncertainty surrounds similar attempts to stratify patients according to their risk of homicide or serious violence to other persons. Healthcare providers often include such tools in their risk management protocols or policies, while experienced clinicians doubt their clinical utility. Which side is more likely to be correct?
Competing interests: No competing interests
In their recent paper, Large, Ryan, Carter, and Kapur underline the deeply flawed nature of the clinical reflex of employing suicide risk assessment tools as guides for intervention. The authors identify that although suicide risk stratification provides some statistical prognostic information, it does not demonstrate predictive strength that warrants their prolific basis in intervention allocation.
The overt panic that risk assessment emanates in regards to a person’s ‘safety’ unsurprisingly nurtures a culture of distracted and dehumanising patient communication. This practice evidently fortifies the rampant barriers to mental health care by facilitating the neglect of those patients erroneously coined ‘low-risk’, and the subjection of those identified as ‘high-risk’ to grossly inappropriate treatment. This paper reveals risk assessment tools to be scripting a confronting theatre of people alternately ‘falling through the cracks’, or being brazenly prodded into a platitudinous and often inappropriate clinical pathway.
It would be misleading to therefore suppose that a collective refreshing of the risk assessment tools is in order. A paradigm shift towards individualised, person-centered care is palpably needed in erasure of the existing culture. Were there emergence of an accurate means of determining risk, patients ought still lead the translation of this evaluation into a care plan; the success of any clinical intervention is contingent on partnership.
Perhaps the most conspicuous strategy is due for consideration: that clinicians meet their patients in the space of their shared humanity.
Competing interests: No competing interests
Re: Can we usefully stratify patients according to suicide risk?
This is an important article as it is appeals for better clinical practice and advocates individualised assessments rather than over-reliance on instruments which have little evidence of effectiveness. However, what is often not acknowledged is that risk instruments also serve to protect individual clinicians and institutions. Hence in the NHS, following a suicide, there is usually a detailed investigation which usually concludes that trust/hospital policies were not followed and formal risk assessments were not carried out. There are often financial incentives as the trust insurance premiums are decreased if they can demonstrate that systematic risk assessments are being used by clinical staff. Commissioners too stipulate use of such instruments in their contracts and in our organisation, we are expected to complete a brief risk rating scale in each case. There is now consensus as illustrated by this article that these instruments add little to patient care and can act as a distraction with vital clinical cues being overlooked. However, we cannot underestimate the importance of form filling rituals in decreasing institutional anxiety. However, I would plead for more honesty about the process.
Competing interests: No competing interests