Risk assessment
The Directorate of Health refers in an information letter dated June 2017 to statements that "too much emphasis should not be placed on the actual risk assessment at the expense of other thematic areas in the national guidelines" (8). We do not agree with this, and in our view great emphasis should be attached to the risk assessment, but it should be limited to a short-term perspective. Nor can we see any contradiction between assessing suicide risk and focussing on other topics. On the contrary, it is probable that allowing the patient to talk about her pain, her feelings of hopelessness and her suicidal impulses – key factors in assessing suicide risk – will make it easier for us to identify topics that can help the patient avert the suicide and to regain hope and zest for life.
It is not an objective per se to predict who is likely to take their life in the long term, just as a cardiologist will not aim to predict who is likely to die of heart disease some years after a heart attack. The main purpose of assessing suicide risk is to gain a basis for determining how to save the patient's life and to decide what measures need to be taken to ensure optimal follow-up.
The national guidelines have contributed to drawing greater attention to the suicide prevention work. At the same time, it has become more common to report suicide and attempted suicide to the health supervisory authorities. We have seen examples of the criticisms made by the health supervisory authorities being based at best on questionable reasoning. It is both easy to be wise after the event and to imagine that all suicides among patients undergoing psychiatric treatment can be prevented. Fear of criticism has probably led to a number of repeated and simplistic assessments of suicide risk. The aim may perhaps be more to protect the therapist from criticism than the patient from self-destructive behaviour. It is quite a different experience for the patient to be assessed for suicide risk than to talk to the therapist about her problems.
There are many statistical risk factors for suicide, but they are of limited value in an acute suicide crisis (10). In that situation, it is more important to identify whether the patient has suicidal thoughts and plans for suicide, how concrete those plans are, whether they are present all the time or intermittently, whether the patient is hearing voices telling her what to do, and whether the patient is agitated, has access to means such as weapons or medication, and has no plans for the future (11).
One question of interest here is whether questionnaires are of use for assessing suicide risk. Used alone, they are insufficiently precise because of a low degree of sensitivity and specificity. The United Kingdom's National Institute for Health and Care Excellence (NICE) has recommended that questionnaires should not be used to predict suicide or repetition of self-harming, nor to determine who should be offered treatment or who should be discharged, although they can be of help in structuring a risk assessment (12). Instruments of this kind can indeed be a useful supplement to the clinical assessment, not least if the findings are discussed with the patient. A complete suicide risk assessment must include many elements, one of which can be the use of questionnaires. This is similar to the way in which cardiologists assess the risk of heart attack. Naturally, they will not content themselves with measuring only a single risk factor; ECG measurements, blood pressure, cholesterol level, many other variables and, not least, the patient's own subjective and objective symptoms, will all form part of the assessment.
An issue has been made out of the fact that, if one were to distinguish between individuals with high and low suicide risk, most suicides would be among those in the low-risk group (3, 6). There is nothing surprising about this. The ‛prevention paradox' dictates that when there are few people in a high-risk group, most of those who have a negative outcome will not come from that group. For example, most alcohol-related injuries affect people with medium to low alcohol consumption, and not those with the highest levels of consumption, even if the risk at individual level is greatest among heavy drinkers. In the same way, most individuals who take their own lives will not come from the group with the highest suicide risk.
It is particularly difficult to predict rare events, such as suicide, but that does not mean that we should not try. An example from another area of society may serve to illustrate that point. There are far fewer people who will carry out acts of terrorism than will take their own lives, thus making these events much more difficult to predict (9). Nevertheless, the security services in many countries carry out risk assessments, and there is every indication that they have managed to prevent a number of terrorist acts.