VA telemental health: suicide assessment

The Department of Veterans Affairs (VA) encompasses one of the largest telemental health networks in the world, with over 45,000 videoconferencing and over 5,000 home telemental health encounters annually. Recently, the VA designated suicide prevention as a major priority, with telehealth modalities providing opportunities for remote interventions. Suicide risk assessments, using videoconferencing, are now documented in the literature, as are current studies that find telemental health to be equivalent to face-to-face treatment. Remote assessment of suicidality, however, involves complex legal issues: licensing requirements for remote delivery of care, legal procedures for involuntary detainment and commitment of potentially harmful patients, and liability questions related to the remote nature of the mental health service. VA best practices for remote suicide risk assessment include paradigms for establishing procedures in the context of legal challenges (licensing and involuntary detainment/commitment), for utilizing clinical assessment and triage decision protocols, and for contingency planning to optimize patient care and reduce liability.     

Using the Linehan Risk Assessment and Management Protocol With a Chronically Suicidal Patient: A Case Report

The Linehan Risk Assessment and Management Protocol (LRAMP) is an empirically supported, comprehensive framework used to assess suicide risk and protective factors, and provide a guide for the therapist to consider reasonable options for intervening on suicidal behavior. This protocol includes a structured checklist for assessing, managing, and documenting suicide risk. It also structures the documentation to clearly describe the presentation, assessment, in-session interventions, decision-making process, and follow-up to other members of the treatment team. This paper describes a case in which the LRAMP was used to guide the assessment, intervention, and documentation of the suicidal behavior of a patient, “Ann,” being treated with outpatient Dialectical Behavioral Therapy in a community mental health clinic. Each section of the LRAMP is discussed as it was used with this complex patient, who had history of high utilization of acute psychiatric services. Application of the LRAMP included the assessment of risk and protective factors, and the use of an individualized crisis plan that engaged the patient, her family, the therapist, and the clinical team, to decrease acute risk, continue outpatient treatment, and avoid inpatient hospitalization. The considerations for documenting clinical decision-making with chronically suicidal patients are discussed.     

Gun safety management with patients at risk for suicide

Guns in the home are associated with a five-fold increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety management requires a collaborative team approach including the clinician, patient, and designated person responsible for removing guns from the home. A call-back to the clinician from the designated person is required confirming that guns have been removed and secured according to plan. The principle of gun safety management applies to outpatients, inpatients, and emergency patients, although its implementation varies according to the clinical setting.     

Empirically informed approaches to topics in suicide risk assessment

The purpose of this article is to approach topics in suicide risk assessment from a scientifically informed standpoint. We summarize and elaborate a general framework for an empirically supported best practice recommendation in evaluating suicide potential and minimizing risk. This risk assessment framework provides a concise heuristic for assessment of suicidal symptoms, points the way to relatively routinized clinical decision-making and activity, and is compatible with best practices relevant to the legalities of suicide risk assessment. Having established a general and scientifically based framework for risk assessment, we go on to address the other questions noted above, with reference to the framework and to our ongoing scientific work. We conclude by summarizing all the work and providing clear and concise clinical recommendations based thereon.     

The standard of care in suicide risk assessment: An elusive concept

Suicide risk assessment is now a core competency requirement in the residency training of psychiatrists. The purpose of suicide risk assessment is to identify modifiable or treatable acute, high-risk suicide factors, and available protective factors that inform patient treatment and safety management. The standard of care varies according to state statutory definitions. Heretofore, most states adopted an average physician or "ordinarily employed standard." Currently, more states are adopting a "reasonable, prudent physician" standard. No single source or authority defines the standard of care for suicide risk assessment. Evidence-based psychiatry can inform clinicians' suicide risk assessments. Carefully documented risk assessments will assist the courts in evaluating clinicians' decision-making process.     

MMPI ratings of suicide risk.

Among past attempts to use MMPI data to predict suicidal behavior, there has been a lack of research on the ability of clinicians to identify MMPI profiles of suicidal persons. In this study, the MMPI profiles of 20 male psychiatric patients who committed suicide and the MMPI profiles of 20 male patients who did not attempt or commit suicide were presented to six clinical psychologists with expertise in MMPI interpretation. The clinicians were asked to classify each MMPI profile as coming from a patient who did or did not later commit suicide, and to rate eight variables thought to be relevant to the assessment of suicide risk. Data analysis revealed that the clinicians could not identify suicide and nonsuicide patients from their MMPI profiles. Furthermore, the ratings of the eight suicide variable did not differentiate suicide and nonsuicide patients.     

Environmental risk factors in hospital suicide

Suicide of hospitalized patients is the most common sentinel event reviewed by The Joint Commission on Accreditation of Healthcare Organizations. Shorter lengths of stay, sicker patients, and higher patient to staff ratios challenge the ability of the hospital to maintain safety. Risk factors associated with the physical environment of the inpatient psychiatric unit, cited as the most common root cause of inpatient suicide, may be neglected because evaluation of these factors is generally not included in medical education and training. Minimization of fixtures that can facilitate strangulation and other high risk aspects within the hospital environment is an important element in the prevention of suicide on psychiatric units.     

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)     

Assessing and Managing Risk With Suicidal Individuals

The University of Washington Risk Assessment Protocol (UWRAP) and Risk Assessment and Management Protocol (UWRAMP) have been used in numerous clinical trials treating high-risk suicidal individuals over several years. These protocols structure assessors and treatment providers to provide a thorough suicide risk assessment, review standards of care recommendations for action, and allow for subsequent documentation of information gathered and actions taken. As such, it is a resource for providers treating high-risk populations across multiple contexts (e.g., primary care, outpatient psychotherapy, emergency department). This article describes both the UWRAP and UWRAMP. Taken together, these assessment and risk management tools include (a) assessment questions for gathering information to determine the level of risk, (b) action steps that can be taken to ensure safety, and (c) a companion therapist note where providers document their assessment and actions.     

The role of objective personality inventories in suicide risk assessment: an evaluation and proposal.

Objective personality assessment instruments offer a comparatively underutilized source of clinical data in attempts to evaluate and predict risk for suicide. In contrast to focal suicide risk measures, global personality inventories may be useful in identification of long-standing styles that predispose persons to eventual suicidal behavior. This article reviews the empirical literature regarding the efficacy of established personality inventories in predicting suicidality. The authors offer several recommendations for future research with these measures and conclude that such objective personality instruments offer only marginal utility as sources of clinical information in comprehensive suicide risk evaluations. Personality inventories may offer greatest utility in long-term assessment 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.     

Clinical training and the duty to protect.

Given that the duty to protect is now a well established clinical and legal expectation, training in professional psychology should assist students in developing conceptual models for violence risk assessment and management. This report presents a training model incorporating recent advancements in risk assessment (such as the assessment of psychopathy), the need for basic legal understanding, and knowledge of specific risk management strategies. Additionally, academic and internship training programs in Michigan were surveyed by telephone about current training patterns. Preliminary results indicated program strengths in general awareness and training in risk factors. However, the data also suggested a need to formalize a faculty role in risk education, improve the training of students in relevant legal information, and establish coherent conceptual models of dealing with potential patient violence. It is argued that improving training of future professionals in this way will improve clinical practice, reduce legal liability, and improve public safety.     

Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder

A childhood history of sexual or physical abuse is highly prevalent in borderline personality disorder (BPD) and is associated with self-destructive behavior in clinical and nonclinical samples. Viewing BPD as a "high risk" disorder, we asked if childhood abuse was a risk factor for adult suicidal behavior or if it was related to other known risk factors for suicide in BPD. A semistructured Abuse History was obtained in 61 criteria-defined BPD patients, who were characterized by structured interviews and self-reports for Axis I disorders, Suicide History, BPD severity, hopelessness, impulsivity, impulsive-aggression, and antisocial traits. Occurrence and severity of childhood sexual abuse, but not physical abuse, predicted adult suicidal behavior independent of other known risk factors. The odds of a sexually abused patient attempting suicide in adulthood was over 10 times that of a patient who was never sexually abused. Given a history of childhood sexual abuse, the risk of adult suicidal behavior in BPD was increased by antisocial traits, severity of BPD, hopelessness, or comorbid major depressive episode (MDE).     

African American and Caucasian attempters compared for suicide risk factors: a preliminary study

The aim of the study was to compare African American and Caucasian substance dependent suicide attempters for risk factors for suicidal behavior. One hundred and fifty-eight African American and 95 Caucasian substance dependent patients who had attempted suicide were interviewed and their family history of suicidal behavior recorded. Patients completed the Childhood Trauma Questionnaire, the Eysenck Personality Questionnaire, and the Foulds Hostility and Direction of Hostility Questionnaire. The results revealed that there were no significant differences between the African American and Caucasian suicide attempters for marital status, age, childhood abuse, or for personality scores for neuroticism, extraversion, psychoticism, or hostility. However, the African American attempters had significantly lower childhood emotional neglect scores. Also, significantly more of the Caucasian attempters had a family history of suicide and current legal problems. Further studies seem warranted examining for differences between African Americans and Caucasians for risk factors for suicidal behavior.     

Legal Risk in Selection: An Analysis of Processes and Tools

Purpose

This paper reviews a decade of employment litigation to illuminate the most legally dangerous selection devices and employment practices.

Design/Methodology/Approach

A sample (n = 312) of court cases drawn from 10 years of Bloomberg BNA case briefs was analyzed to determine which selection tools (e.g., biographical information blank, interview, cognitive ability test, and psychomotor test) and which selection processes (e.g., violations of the four-fifths rule, administrative inconsistencies, lack of documentation, failure to provide accommodations) are most at risk for litigation for unfair employment practices.

Findings

Results demonstrate that while some selection tools do attract legal scrutiny, dangerous hiring practices such as favoritism against protected classes and improper human resource documentation put employers at far greater risk of suit. When considering cases settled outside of court and those that continued to trial, the data reveal that employers lose employment discrimination cases at a rate nearing 90 % and suffer an average payout of over $1.5 million per case.

Implications

Just as legal challenges once drove the search for selection tools free of adverse impact, the current legal landscape demonstrates the necessity of fair and consistent selection processes. This paper provides evidence of common mistakes in implementing selection systems—mistakes that lead to costly legal battles.

Originality/Value

This paper reduces cumbersome legal records into useful evidence of trends in recent employment law cases. Selection system designers and organizations who implement them will benefit from avoiding the risky hiring practices presented in this paper.     

Firearm Storage Practices and Risk Perceptions Among a Nationally Representative Sample of U.S. Veterans With and Without Self‐Harm Risk Factors

Despite the disproportionate use of firearms in Veteran suicides and the well‐established link between firearm access and suicide, little is known about how Veterans store their firearms or what they think about the relationship between firearm access and suicide risk. Using data from 2015 nationally representative online survey (response rate 60.9%), we compare characteristics of Veteran firearm owners with and without self‐harm risk factors with respect to how they store their firearms and their beliefs about suicide risk related to firearms. Overall, one in three U.S. Veteran firearm owners store household firearms loaded and unlocked, one in twenty believe that a firearm increases household suicide risk, and one in four consider their loaded and unlocked firearm to be inaccessible to suicidal household members. Storage practices and risk perceptions are similar among those with and without self‐reported suicide risk factors. Affecting risk perceptions may be a critical aspect of interventions addressing lethal means safety among U.S. Veterans.     

Post-Admission Cognitive Therapy: A Brief Intervention for Psychiatric Inpatients Admitted After a Suicide Attempt

To date, no empirically based inpatient intervention for individuals who have attempted suicide exists. We present an overview of a novel psychotherapeutic approach, Post-Admission Cognitive Therapy (PACT), currently under development and empirical testing for inpatients who have been admitted for a recent suicide attempt. PACT is adapted from an efficacious and brief outpatient cognitive therapy protocol (Brown, Henriques, Ratto, & Beck, 2002; Brown et al., 2005) for inpatient delivery to individuals with recent suicide attempts. Within a cognitive framework, attempting suicide is conceptualized as a maladaptive coping strategy that deserves immediate targeted clinical attention regardless of the patient's diagnosis. The primary aims of PACT are to reduce the likelihood of suicide attempt recurrence as well as decrease the severity of established psychological risk factors for suicide. The three phases of PACT involve (1) building a therapeutic alliance and developing a cognitive conceptualization based on the recent suicide attempt; (2) instilling hope, practicing effective coping strategies, and addressing problem-solving deficits; and (3) preventing relapse, constructing a safety plan, and promoting timely linkage with outpatient aftercare services. The efficacy of PACT as a targeted inpatient treatment package remains to be established. The cognitive behavioral components of PACT, as described here, are based on evidence-informed practices aimed at improving the quality of care provided to inpatients following a suicide attempt.     

Youth suicide risk and sexual orientation

Using a broad suicide risk assessment (suicidal ideation, hopelessness, hostility) with 100 youth ages 17 to 19, this study examined the relationship between sexual orientation and youth suicide risk. Participants were compared across sexual orientation, as well as level of perceived external support, which may be a mitigating variable in suicide risk. The suicide risk demonstrated by sexual minorities in this study was no greater than that of their heterosexual peers. Youth who reported more external support demonstrated lower overall suicide risk and, specifically, lower levels of hostility, hopelessness, and suicidal ideation. The results indicated that suicide risk is not determined by demographic criteria alone, and may be influenced by psychosocial variables, such as support.     

Adolescent suicide, gender, and culture: A rate and risk factor analysis

The current paper provides a comprehensive research review of gender differences in rates of and risk factors for adolescent suicidal behavior in four main U.S cultural subgroups: African Americans, Native Americans, Asian Americans, and Latino Americans. The paper highlights substantial findings from the most recent literature and provides direction for future research and clinical work. The data presented suggest that clinicians and interventionists relying on nonfatal expressions of suicide will continue to fail to identify adolescent males at risk for suicide, as females are more likely to report suicide ideation and attempts across all cultural groups reviewed. We conclude that researchers and clinicians should utilize indirect, broad measures of suicide proneness, as opposed to the traditional direct self-report tools. Although past research has examined cultural and gender differences in risk factors for suicidal behavior, these investigations have been primarily isolated from each other. Therefore, we sought to examine adolescent suicidal behavior and how it operates as a function of both gender and culture.     

Assessing Legal Strains and Risk of Suicide Using Archived Court Data

Relatively little is known about legal entanglements and suicide risk. This matched case–control study estimated the risk of suicide associated with legal strains using online court archives, a novel source of exposure data. Court records linked to suicide deaths (N = 315), controls (N = 630), and unintentional injury and poisoning deaths (N = 630) for an urban county from 2000 to 2005 revealed that nearly a third of suicide victims had recent court involvement, twice the proportion among controls. Misdemeanors, car accidents, and foreclosures were each associated with a threefold risk of suicide. Implications for suicide prevention and research are discussed.