Journal Article Annotations
2016, 4th Quarter
Annotations by Kemuel Philbrick, MD, FAPM
This citation departs from the usual quarterly assessment of a research paper to mention a review article that addresses the debate over the pros and cons of constant observation (CO) of patients at high risk of suicide.
In the article, the absence of compelling evidence of the efficacy of CO is acknowledged but also further scrutinized by exploring the methodological weaknesses inherent in assessing an outcome (suicide) in the face of the necessary absence of randomized controlled trials, varied assessments of the degree of suicide risk (thereby shaping the population receiving this intervention), and different definitions of constant observation, not to mention the subsequent human variability in actual, moment-by-moment implementation. The author argues that the recurring call for more research on the effectiveness of CO to prevent suicide is misdirected effort and that patients will be better served by focusing instead on research exploring how best to implement CO, minimize known areas of operational shortcomings, and shape practice in ways that optimize patient and staff acceptance of this tool. The author provides a proposed protocol and reviews vulnerabilities that have been reported in previous studies.
Relevance: Although this article draws on studies examining the use of CO in both inpatient psychiatric units and the general hospital, the emphasis on the manner in which CO is implemented is even more important for consultation psychiatrists because the general hospital environment typically presents greater risk for the acutely suicidal patient given the absence of structural modifications that mitigate risk, the greater opportunity for flight, and support personnel who may have less experience in managing such patients. The proposed protocol and accompanying recitation of errors observed in past reviews of patients who successfully committed suicide while on inpatient status provide a framework for the consultation psychiatrist to review relevant practices in our respective institutions and look for opportunities to improve our care of vulnerable patients.