Annotated Abstracts of Journal Articles
2015, 4th Quarter
Annotation by Kemuel Philbrick, MD, FAPM
Bolton JM, Gunnell D, Turecki G
BMJ 2015; 351:h4978
ANNOTATION (Kemuel Philbrick)
The Finding: Despite considerable effort in multiple, diverse clinical populations world-wide to refine instruments to facilitate suicide risk assessment that can provide meaningful positive (and negative) predictive value, psychiatrists cannot yet offer our colleagues, whether in outpatient primary care settings, or inpatient hospital units, a single reliable clinical sieve whereby to sift and separate those individuals who will go on to harm themselves. Nonetheless, this review does underscore elements of different tools that appear to demonstrate increased sensitivity to risk, although the predictive value of future suicidal activity is recurringly anemic. The review also briefly cites existing evidence regarding the role of pharmacotherapies, ECT, and psychotherapy in reducing future suicide risk.
Strengths and Weaknesses: In addition to detailing studies on multiple conventional risk assessment scales and a few empirically derived tools, the authors include an intriguing discussion of newer, novel attempts to ascertain risk, particularly when dealing with individuals who deny their suicidal intent or who may be unaware of their vulnerability. These include the implicit association test (IAT) and various neurocognitive tests. One can hope that these efforts will continue and perhaps strengthen our ability to serve such patients.
Relevance: This review is a useful resource for the consultation psychiatrist who is invited by our medical and surgical colleagues to provide a hoped-for definitive suicide risk assessment tool. No such tool exists and this review offers a practical summary of the relative strengths and weaknesses of the tools that have been studied thus far.
Suicide is the 15th most common cause of death worldwide. Although relatively uncommon in the general population, suicide rates are much higher in people with mental health problems. Clinicians often have to assess and manage suicide risk. Risk assessment is challenging for several reasons, not least because conventional approaches to risk assessment rely on patient self reporting and suicidal patients may wish to conceal their plans. Accurate methods of predicting suicide therefore remain elusive and are actively being studied. Novel approaches to risk assessment have shown promise, including empirically derived tools and implicit association tests. Service provision for suicidal patients is often substandard, particularly at times of highest need, such as after discharge from hospital or the emergency department. Although several drug based and psychotherapy based treatments exist, the best approaches to reducing the risk of suicide are still unclear. Some of the most compelling evidence supports long established treatments such as lithium and cognitive behavioral therapy. Emerging options include ketamine and internet based psychotherapies. This review summarizes the current science in suicide risk assessment and provides an overview of the interventions shown to reduce the risk of suicide, with a focus on the clinical management of people with mental disorders.