Editor’s Note: We began looking at how much people know about different topics and decided to engage readers with quizzes on important areas. For this first article we asked two of our Louisiana experts to help us with suicide prevention.
Dr. William Schmitz, Jr., is a psychologist and President of the American Association of Suicidology. His colleague is Dr. April Foreman, Kansas psychologist and expert in suicide prevention, media, and education. Together they agreed to design a short quiz on suicide prevention basics. Here are the 10 questions. Answers are on the next page.
TRUE OR FALSE?
1. If someone denies feeling suicidal, then they are not high
risk for suicide.
2. Simply documenting lack of report of suicidal ideation, or
denial of suicidal ideation is sufficient assessment and
documentation of risk of suicide.
3. If someone reports suicidal ideation, but does not go to the
hospital, then having your patient sign a “No Harm” contract
is the standard of care you should meet.
4. When assessing for risk of suicide you should ask about
and document which of the following: Suicidal Ideation;
Suicide Planning; Intent to act on suicidal thoughts/feelings;
Rehearsal for suicide and self-harm.
5. When assessing suicide risk you should do which of the
following: 1) Assign a level of risk “low-medium-high,” with a
corresponding treatment response, even if someone denies
current suicidal ideation; 2) Prioritize assessing for “distal”
risk factors, such as family history, which are more predictive
than “proximal” risk factors such as agitation and current
stressors; 3) Assign a lower level risk of suicide for patients
who feel they are a burden vs. a higher level of risk patients
who have a history of exposure to life-threatening situations.
6. You should generally only assess for risk of suicide when
someone self-reports suicidal ideation, or if you are made
aware of a history of suicide attempt.
7. No harm contracts are sufficient safety planning, as long
as someone is in outpatient care.
8. When doing a basic 6-step safety plan, you should address
restricting the means of suicide. For most patients this will
mean restriction of access to guns.
9. Means restriction has been proved to be ineffective at
preventing suicide. If you help a patient plan to make it
difficult to get access to one means for killing themselves,
they will just find another means. No harm contracts are
preferred for this reason.
10. Inpatient care is the best standard of care for people
assessed at high risk of suicide.
1. FALSE: Some studies indicate that the majority of people who die by suicide deny experiencing suicidal ideation at proximal mental health visits. It is more important to assess for overall risk factors, than to just ask about suicide, document it, and move on.
2. FALSE: If you are providing care under an independent license, then you are expected to know how to do a more thorough assessment of risk, and to document that clearly. If you are sued for malpractice, it is relatively easy for an attorney to demonstrate the standard of care for suicide risk assessment, intervention, and documentation, even though research shows that approximately 90% of Psychologists are not able to demonstrate knowledge of this standard.
3. FALSE: No Harm contracts are NOT the standard of care. An empirically based risk assessment and 6 step safety planning process is the accepted standard of care.
4. ALL OF THE ABOVE
5. NUMBER 1. Number 2 is false as both distal and proximal risk factors should be evaluated and addressed. Number 3 is false; as Perceived Burdensomeness, Thwarted Belonging, and Acquired Capability are all considered major risk factors for suicide.
6. FALSE: You should assess for risk of suicide at an initial intake, yearly, following all inpatient admissions, any time distress becomes more acute in the course of treatment, when a patient reports suicidal ideation, and regularly/frequently in the months after a suicide attempt.
7. FALSE: No harm contracts are not considered a standard of care, and have been empirical demonstrated not to significantly reduce risk of death by suicide. If you do a no-harm contract, and do not do the empirically validated 6-step safety plan, you have not met the understood standard of care, and may be in danger of malpractice. Inpatient or outpatient status is irrelevant. Many people in outpatient care remain at high risk for suicide.
8. TRUE: Self-inflicted gunshot wound is by far the most common way that someone dies by suicide–60-80% of cases. You should also ask about plans for suicide and restrict means used in those plan, as well as ask about means from prior attempts, and access to lethal types/quantities of medication.
9. FALSE: Research clearly shows that deaths by suicide significantly reduce after safety planning and means restriction. People who have their suicide plans interrupted by lack of access to lethal means to suicide often do not go on to attempt in other ways.
10. FALSE: When it comes to inpatient vs. outpatient treatment, providers should weigh the pros and cons of each approach and discuss that with high risk patients. Inpatient care is generally best to address acute issues such as immediate inability to keep one’s self alive or need to adjust medications under inpatient supervision. The majority of patients, however, can and should be treated on an outpatient basis using frequent contact with their mental health care team, safety planning, crisis contacts, and involvement of family/friends in safety and treatment planning. A 1-4 day stay in a hospital does not really have much long-term therapeutic benefit for most people with high risk of suicide.