Attitudes toward suicide prevention in front-line health staff

A questionnaire assessing attitudes toward suicide prevention was constructed and shown to have satisfactory reliability and internal consistency. The determinants and distribution of these attitudes were investigated in four groups of health professionals who are in contact with suicidal patients: general practitioners, accident and emergency nurses, psychiatrists in training, and community psychiatric nurses. Attitudes toward suicide prevention were shown to differ significantly between professional groups. More positive attitudes were associated with mental health professionals, working in the community, and previous training in suicide risk assessment. Negative attitudes should be assessed and targeted in training designed to improve the management of suicide risk.     

Legal issues of professional negligence in suicide cases

Suicide is the eleventh leading cause of death, accounting for almost 30,000 deaths each year in the United States. The loss of a patient to suicide is the most feared outcome among mental health professionals, while the fear of litigation and liability after such suicide may be a close second. This article will familiarize mental health professionals with the legal issues of professional negligence in suicide cases. We begin with an introduction to malpractice liability for suicidal patients, followed by an explanation of the essential elements of professional negligence and relevant legal terminology. We then discuss general theories of liability involving suicide, and provide illustrative legal case examples. We conclude with a discussion of risk management procedures that can substantially reduce one's exposure to malpractice liability.     

The assessment and management of suicide risk: state of workshop education

A systematic search of popular and scholarly databases identified workshops that addressed general clinical competence in the assessment or management of suicide risk, targeted mental health professionals, and had at least one peer-reviewed publication. We surveyed workshop developers and examined empirical articles associated with each workshop. The state of workshop education is characterized by presenting the learning objectives, educational formats, instructor factors, and evaluation studies. Workshops are efficacious for transferring knowledge and shifting attitudes; however, their role in improving clinical care and outcomes of suicidal patients has yet to be determined.     

Physician-assisted suicide: the role of mental health professionals

A review of the literature was conducted to better understand the (potential) role of mental health professionals in physician-assisted suicide. Numerous studies indicate that depression is one of the most commonly encountered psychiatric illnesses in primary care settings. Yet, depression consistently goes undetected and undiagnosed by nonpsychiatrically trained primary care physicians. Noting the well-studied link between depression and suicide, it is necessary to question giving sole responsibility of assisting patients in making end-of-life treatment decisions to these physicians. Unfortunately, the use of mental health consultation by these physicians is not a common occurrence. Greater involvement of mental health professionals in this emerging and debated area is advocated. Beyond describing mental health professionals' role in the assessment of patient competency or decision making capacity, other areas of potential involvement are described. A discussion of ethical principles relevant to this area follows, along with comments on the training necessary to adequately serve patient needs.     

Between Hippocrates and God: Ugandan mental health professional's views on suicide

A negative attitude towards suicide is generally assumed to be predominant in low-income countries. In order to understand the negative attitude in general it is necessary to look at how religion and morality influence the attitudes. Our aim in this qualitative interview study was to investigate what attitudes professional mental health workers in Uganda bear towards suicide and suicidal persons. The professionals argue for their attitude by employing religious, communal and medical ethics arguments, which draw both in a negative and positive direction. The professionals are in general unambiguously negative towards suicide and positive towards suicidal people who are mentally ill. In cases other than mental illness non-accepting attitudes surface. This is discussed against previous research showing that effective treatment of suicidal people is to be based on a trusting and accepting relationship.     

Suicide assessment and evaluation strategies: a primer for counselling psychologists

Suicide is a recognized national health risk in many countries. In order to effectively intervene in suicidal crises, it is important for mental health professionals to understand facts about suicidal behaviour, procedures for assessing an individual's risk of self-harm, and the evaluation of the lethality of a client's suicidal gestures. With updated knowledge and proper training, counselling psychologists can play a vital role in suicide prevention. This paper summarizes for counselling psychologists current statistics about suicide, general and specific risk factors for suicidality, and assessment tools used to evaluate suicidal risk.     

The Practice of Suicide Assessment and Management by Marriage and Family Therapists

Abstract

Over 90% of mental health providers encounter suicidal clients. However, the majority of marriage and family therapists (MFTs) are not exposed to suicide-specific trainings within their clinical coursework. Due to the lack of consistent training protocols for suicide assessment and management among MFTs, this qualitative study identified common MFT responses to suicidal clients, including assessment of risk severity and intervention modalities. Responses were then compared to best practices for suicidal clients. Participants inconsistently adhered to best practices identified in the larger field of mental health, revealing the need for increased MFT training on suicide to ensure appropriate and effective care.     

Suicide prevention in the genetic counseling context

Utilizing a case report, this paper explores psychosocial aspects of suicidal intent in a woman seeking prenatal diagnosis. Using knowledge and practice of appropriate assessment, referral, and intervention procedures, the therapy team of genetic counselor and psychotherapist facilitated successful identification and management of this potentially suicidal client. The main counseling goals for the genetic counselor are to assess the situation adequately, decrease the immediate danger, and, with supervision and/or consultation, stabilize the seriously suicidal person until that individual can be triaged to mental health or medical professionals for treatment. The prevalence of suicide issues in genetic counseling contexts is unknown and reports mentioning suicidal ideation unusual in the genetic counseling literature. Is this reported case a rarity among genetic counseling referrals? Systematically collected information on the prevalence and resolution of suicidal issues in genetic counseling contexts would be helpful for those setting curricula for genetic counseling training programs, standards for professional certification exams, and policy and procedures manuals for clinical units.     

Utah youth suicide study: psychological autopsy

We conducted a psychological autopsy study to further understand youth suicide in Utah. While traditional psychological autopsy studies primarily focus on the administration of psychometric measures to identify any underlying diagnosis of mental illness for the suicide decedent, we focused our interviews to identify which contacts in the decedent's life recognized risk factors for suicidal behavior, symptoms of mental illness, as well as barriers to mental health treatment for the decedent. Parents and friends recognized most symptoms universally, although friends better recognized symptoms of substance abuse than any other contact. The study results suggest that parents and friends are the most appropriate individuals for gatekeeper training and, in conjunction with other innovative screening programs, may be an effective strategy in reducing adolescent suicide.     

A comprehensive and concise assessment of suicide risk

Because suicide is one of the few fatal consequences of psychiatric illness and is a source of extraordinary stress for loved ones and the clinician, accurate assessment of suicidal risk is an essential aspect of the mental health profession. Innumerable individual differences, along with the low base rate of suicide, make assessment a challenging task in clinical practice that is both delicate and time consuming. In this article, the authors recommend examining and incorporating each patient's personal characteristics, dispositional factors, situational factors, and current presentation of symptoms into a unique individual picture of suicidal risk. This portrait of potential for suicidal behavior can, in turn, be used to evaluate risk and design a course of action. This thorough yet concise approach will likely reduce omissions in assessment, and hopefully lead to fewer false negatives and fewer deaths of suicidal patients.     

Assessing risk: confrontation or avoidance—what is taught on counsellor training courses

Recent mental health policy development has focused on the assessment and management of risk in vulnerable clients. Counsellors have a significant role to play in delivering mental health care in a range of settings, with clients sometimes presenting with suicidal ideation, self-injury and a risk of violence. The aim of this research was to explore the profile of risk assessment teaching within BACP accredited courses. A total of 49 BACP accredited courses were contacted and 24 responded. This response rate is discussed with particular reference to those courses that did not respond to the questionnaire. Risk assessment was viewed as an important consideration for counsellor training whilst suicide and self-harm seemed to have a higher profile than violence to others. Supervision was cited by the majority of respondents to have an important role in developing trainees' skills in assessing risk. The implications of the findings of this study for how counsellors are prepared by their training experiences to work with clients at risk are discussed and some recommendations made for future training developments.     

Behavioral Risk Assessment of the Guarded Suicidal Patient

Psychiatrists and other mental health professionals are trained to assess patients by direct observation and examination. Short inpatient length of stay, brief outpatient visits, emergency room evaluations, and other time‐limited clinical settings require rapid assessment of suicide risk. Recognition of behavioral suicide risk factors can assist in the early identification of the guarded suicidal patient, thus avoiding total reliance on the patient's reporting.     

Endocrinology and suicide

The data accumulated so far suggest several tentative conclusions. First, thyroid and adrenal gland disease unquestionably can produce severe mental disturbances. Most of these are "organic" in nature, but depressive symptoms are common as well. A connection between these diseases and suicide has not been established, however. Research cannot really address this possibility adequately, since these studies are difficult, if not impossible, to do in the postmortem state at this time. Ways should continue to be sought to overcome this problem. Clinically, it seems advisable to treat all depressed, suicidal persons with the same caution, whether they have diseases of these endocrine systems or not. The differences in responsiveness of the thyroid and adrenocortical systems among depressed and perhaps truly suicidal persons are of greater theoretical as well as practical clinical interest. The TRH-TSH test and the DST may not be as specific as once thought. Nonetheless, the abnormalities do occur with regularity in specific subgroups of depressed patients. It is far too early to stop research on the DST or the TRH-TSH test. Clinically, however, it is premature to make important management decisions about suicidal patients based on these test results. At this time, we really have no means of pinpointing the persons who will eventually suicide. The hope that they may someday provide valid data for assessing real suicide potential is there, and clinicians should stay informed in this arena. Until that day comes, though, we must continue to exercise caution regarding our clinical judgments and to live with their uncertainties.     

Rational suicide?

Abstract

Two competing paradigms of suicide imply different views of whether suicide can be rational. The first, the “received orthodoxy” of mental health professionals for more than a century, views all suicides as irrational and holds that suicidal persons should always be prevented from ending their own lives. The second grants that most suicides are irrational, but claims suicide may sometimes be a rational option. Lokhandwala and Westefeld's argument manifests the conflict between these two paradigms: After initially granting that suicide may be a rational option for some people, they in effect urge mental health professionals to presume in practice that any suicidal patient is irrational. Patients for whom suicide might indeed be rational will be ill-served by mental health professionals who follow Lokhandwala and Westefeld's advice.     

Presuicide attempt communications between parasuicides and consulted caregivers.

A high percentage of parasuicides visit professional caregivers prior to the attempted suicide. The content or outcome of these consultations is unknown. We interviewed hospitalized attempters and the professional caregivers they identified as having been consulted prior to their attempts. About half of these patients directly disclosed suicidal symptoms or intentions, especially to mental health professionals. These professionals more often inquired about suicidal ideations than did nonpsychiatric physicians. However, few caregivers noted suicidal thinking or probed suicidal symptoms. The data suggest that professional caregivers and especially nonpsychiatric physicians should be more sensitive and responsive to the signs and symptoms of suicidality.     

Suicide risk assessment: Clinicians’ confidence in their professional judgment

Suicide risk assessment is a critical component of mental health practice for which the stakes are high and the outcomes uncertain. This research examines the consistency with which clinicians make determinations of suicide risk and factors influencing clinical confidence. Seventy-one social workers interviewed two standardized patients performing in scenarios depicting suicidal ideation, judged whether the patient required hospitalization, and completed standardized suicide risk assessment measures. Self-ratings and qualitative interviews explored participants’ confidence in their judgment of risk. Participants had highly divergent views regarding whether or not the risk of suicide was sufficiently high to require hospitalization. However, regardless of the ultimate decision reached, participants were equally confident when recommending either clinical course of action. The variation in risk assessment appraisals in this study, despite at times high rates of confidence in risk appraisals, speaks to the need for ongoing training, consultation, and increased decision support strategies.     

Mental health professionals' determinations of adolescent suicide attempts

The degree of ambiguity in the term suicide attempt was examined among 14 expert suicidologists, and 59 general mental health clinicians who either did or did not receive a standard definition of the term. The participants judged whether each of ten vignettes of actual adolescent self-harm behaviors was a suicide attempt. Low levels of agreement were found within each group, although agreement was better for the most and least serious cases. Possible explanations were examined, including how professionals weight suicidal intent and medical lethality in their suicide attempt decisions, and the use of a "fuzzy," natural language conceptualization of suicide attempts was proposed.     

A School-Based Suicide Risk Assessment Protocol

Suicide remains the third leading cause of death among young people in the United States. Considering that youth who contemplate suicide generally exhibit warning signs before engaging in lethal self-harm, school-based mental health professionals can play a vital role in identifying students who are at risk for suicidal behavior. Nevertheless, the assessment of vulnerable children and adolescents is a challenging undertaking, with many variables considered relevant to the determination of a student's suicide risk level. This article introduces school-based mental health professionals to the Student Suicide Risk Assessment Protocol, an evaluation tool developed by the author to aid in the determination of student suicide potential, assist with the selection of appropriate interventions, and allow for documentation of school personnel's actions taken to mitigate a student's suicide risk.     

An integrated approach to estimating suicide risk

It is ironic that if we had a perfect predictive instrument we would not be able to recognize it because it could never be validated by its critical outcome criterion. Though some exceptions could occur, we would be obliged to take all available measures to prevent a suicidal outcome in cases where suicide was predicted. After the crisis we could have no way of knowing with certainty whether the person would have suicided or not. Even if we accepted the reality that people are not either 0% or 100% likely to suicide, and developed a perfect scale to estimate degree of risk, we would still be unable to validate it in individual cases. If it indicated "moderate" risk of 2.5-5.0%, for example, and no intervention were offered, we would have to observe one suicide in every 20-40 persons assessed at this level of risk to demonstrate its validity. The key to assessment is obtaining information, primarily regarding present or anticipated pain and the threshold of pain tolerance in the individual involved. Since different persons communicate in a variety of ways--verbal, nonverbal, symbolic, metaphoric, etc., eclecticism in approach is essential. For some clinicians communication will be facilitated most by one style; for others, a different method would be most effective. Thus, the "best" approach is the one that works best given the unique characteristics of the persons involved and under the conditions existing at the time. My own bias is that every assessment, whatever the approach, must include some form of direct inquiry regarding suicidal intent, and that the final decision in this regard must be a subjective and intuitive judgment. Contrary to possible assumptions in the legal world, accurate assessment does not necessarily mean safety. It can serve as a guide to the degree of risk that may be involved in a treatment program, but even low risk management measures may have an adverse outcome without implications of negligence or carelessness. There has been no mention here of biological markers of suicide, which are of much current interest but still in an investigational stage. Similarly, rational suicide has not been mentioned, though our aging population and the status of AIDS are making this issue progressively more important. The principles involved in assessment of risk are the same as with other forms of suicide, however. Finally, we can only presume that more precise assessment will operate to reduce suicidal deaths.(ABSTRACT TRUNCATED AT 400 WORDS)