A refusal to grant your request to contact a loved one is also worrisome, and it may still be appropriate to contact others for collateral information or notification if the patient appears to be at considerable risk.20 In such cases, be aware of local laws, and document the rationale for gathering clinical information. Focus on obtaining information needed for risk assessment. Ethical guidelines state that when “the risk of danger is deemed to be significant,” confidential information may be revealed.21
CASE Dr. A is initially reluctant to allow you to call his wife, but consents after being told that this is a routine action and for his benefit. His wife confirms his history of depressive symptoms and recalls that he became more withdrawn than usual several months ago. She has been worried about him and is glad he is finally getting help. although she is not concerned about her husband’s safety, she agrees to remove the gun from their home— and to follow up with the FP to verify that she has done so. She accepts the FP’s explanation of this as routine and is not overly alarmed by the request.
Further questioning of Dr. A and his wife, along with the FP’s knowledge of the patient, makes it clear that he has previously demonstrated good coping skills. Dr. A cannot identify a recent stressor to explain his symptoms, but acknowledges that he has become more pessimistic about the future and intermittently feels hopeless.
Dr. A generally believes his depression will resolve, as it did in the past. he has no history of psychiatric hospitalizations or suicide attempts. Nor does he have a history of problem drinking, although he admits he has been drinking alcohol more frequently than usual in the past several weeks. He identifies his wife as his primary support, although he’s aware that he has been isolating more from her and his many other supports in the past month.
Estimate risk, decide on next steps
For experienced clinicians, a determinatiuon of whether an individual is at low, moderate, or high risk is often based on both an analytical assessment and an intuitive sense of risk. In some cases, it may be useful to distinguish between acute and chronic or baseline risk.3
Patients judged to be at the highest risk may warrant immediate transport to the emergency department.22 If a patient at this level of risk does not agree to go to the hospital, involuntary admission may be necessary, depending on the laws in your state. (For patients at moderate or moderate-to-high risk, especially if acutely elevated from baseline, hospitalization may still be offered or recommended— and the recommendation documented.)
Pay particular attention to risk factors that can be modified. Access to firearms can be restricted. Treatment of mental disorders, which can generally be considered modifiable risk factors, should be a primary focus. FPs may be able to successfully treat depression, for instance, with medication and close follow-up. Counseling or psychotherapy may also be helpful; provide a referral to an alcohol or drug treatment program, as needed.
Consider a psychiatric consultation or referral if you do not feel comfortable managing a patient who has expressed any suicidal ideation.23 Psychiatric referral should also be considered when the patient does not respond to treatment with close follow-up, when psychotic symptoms are present, when hospitalization may be warranted, or when the patient has a history of suicidal thoughts or an articulated suicide plan.
Avoid suicide prevention contracts.2,24 Asking a patient to sign a “no harm,” or suicide prevention, contract is not recommended. While such contracts may lower the anxiety of physicians, they have not been found to reduce patients’ risk and are not an adequate substitute for a suicide risk assessment.
Develop a crisis response plan. Collaboratively developed safety or crisis response plans may be written on a card. Such plans can provide steps for self-management (eg, a distracting activity) and steps for external intervention if needed, such as seeking the company of a loved one or accessing emergency services.
CASE Dr. A appears to be at moderate to high risk of suicide. Salient risk factors include his age, sex, occupation (health care providers and agriculture workers are at elevated risk12,13), depression, increased use of alcohol, and suicidal ideation. He denies any intent of acting on these thoughts, however, and has a number of protective factors, including the lack of a prior attempt, his expectation that the depression will resolve, demonstrated good coping skills, and a supportive marriage.