References: Suicide Risk; Volume 3 Issue 8

1. TITLE	APA statement on dangerousness.
SOURCE	American Psychiatric Association, 1983.

2. AUTHOR	McNiel-D-E, Binder-R-L.
INSTITUTION	Department of Psychiatry, School of Medicine, University of California, San Francisco, USA.
TITLE	Correlates of accuracy in the assessment of psychiatric inpatients' risk of violence (see comments).
SOURCE	Am-J-Psychiatry 1995 Jun, VOL: 152 (6), P: 901-6, ISSN: 0002-953X.
CM	Comment in: Am-J-Psychiatry 1996 Jun; 153(6):845-6.
ABSTRACT	OBJECTIVE: The authors evaluated characteristics of patients whom clinicians accurately assessed as being at high or low risk for violence and patients for whom clinicians overestimated or underestimated the risk. METHOD: At admission, physicians estimated the probability that each of 226 psychiatric inpatients would physically attack someone during the first week of hospitalization. Nurses rated assaultive behavior in the hospital with the Overt Aggression Scale. Acute symptoms were rated with the Brief Psychiatric Rating Scale. RESULTS: For the group as a whole, assessed levels of risk were substantially related to later physical aggression (sensitivity = 67%, specificity = 69%). Multinomial logit analysis showed that patients with psychotic disorders such as schizophrenia, organic psychotic conditions, and mania were more likely to be accurately assessed by clinicians as being at high risk (true positives) than to be true negatives or false positives. A recent history of violence was associated with higher estimated risk but did not distinguish true positives from false positives. An admission mental status characterized by low levels of hostility, uncooperativeness, and suspiciousness and high levels of depression, guilt, and anxiety differentiated true negative patients from others, but symptom profiles did not differ among true positives, false positives, and false negatives. Clinical judgments emphasizing gender and race/ethnicity were associated with predictive errors: nonwhite and male patients tended to be false positives. CONCLUSIONS: While clinicians can accurately classify the potential for violence in the majority of patients at admission, systematic errors characterize inaccurate assessments of the risk. Awareness of these patterns may help improve assessment of the risk of violence in clinical practice. Author.

3. AUTHOR	Hughes-D-H.
INSTITUTION	Psychiatric Emergency Service, Cambridge Hospital, MA 02139, USA.
TITLE	Suicide and violence assessment in psychiatry.
SOURCE	Gen-Hosp-Psychiatry 1996 Nov, VOL: 18 (6), P: 416-21, ISSN: 0163-8343 37 Refs.
ABSTRACT	Psychiatrists are increasingly expected to predict and prevent the suicidal and violent/homicidal impulses of their clients. This article reviews the current literature and research in these areas. While the debate continues on whether the clinician can successfully predict either violence or suicidal behavior in their patients, the preponderance of studies weighs in that predicting suicide and violence in the individual may not be possible currently given present knowledge. To compensate for forecasting limitations, conservative clinicians deliberately overpredict suicide or violence to help insure the safety of their patients and the greater communities in which they reside. In addition, clinicians need to perform thorough assessments and make logical clinical decisions that are in line with the perceived risks. Preventive measures for violence remain complex, but clinicians can maximize treatment effects by following specific intervention guidelines. Minimally, documentation concerning violence needs to focus on the rationale for why treatment interventions were or were not implemented. The chart does not require lengthy notations but should include a reasonable assessment of risk and the delineation of a prudent course of action. Author.

4. AUTHOR	Thienhaus-O-J, Piasecki-M.
INSTITUTION	Department of Psychiatry, University of Nevada School of Medicine, Reno 89557, USA.
TITLE	Assessment of suicide risk.
SOURCE	Psychiatr-Serv 1997 Mar, VOL: 48 (3), P: 293-4, ISSN: 1075-2730.

5. AUTHOR	Bongar-B, Maris-R-W, Berman-A-L, Litman-R-E.
INSTITUTION	Clinical Psychology Program, Pacific Graduate School of Psychology, Palo Alto, CA 94303.
TITLE	Outpatient standards of care and the suicidal patient.
SOURCE	Suicide-Life-Threat-Behav 1992 Winter, VOL: 22 (4), P: 453-78, ISSN: 0363-0234.
ABSTRACT	This article is a review of the legal and clinical literature on standards of care for nonhospitalized adult suicidal patients. The authors discuss effective assessment, management and treatment procedures that balance the need for high-quality care by a reasonable and prudent practitioner with the requirements of court- determined and statutory standards. Through a review of malpractice claims data and through an examination of the clinical literature we detail the essential guidelines for sound assessment, intervention, and management procedures. The authors specifically discuss common failure situations in outpatient care (e.g., problems in pharmacotherapy, the decision to hospitalize, inappropriate and dual relationships, the assessment of imminence and lethality, and so on). Details regarding practical considerations in developing an outpatient standard of care are provided, as are suggestions that such a standard of care must include an ongoing assessment of the therapeutic alliance. Author.

6. AUTHOR	Goldberg-R-J.
INSTITUTION	Department of Psychiatry, Rhode Island Hospital, Providence.
TITLE	The assessment of suicide risk in the general hospital.
SOURCE	Gen-Hosp-Psychiatry 1987 Nov, VOL: 9 (6), P: 446-52, ISSN: 0163-8343.
ABSTRACT	The assessment of suicide risk is a central activity of the general hospital psychiatrist for patients admitted following a suicide attempt and others who are identified after admission as being potentially suicidal. While biologic and psychosocial measures have some long-term predictive value, there is no valid measure to predict acute suicide risk. The lack of a valid measure does not, however, relieve the clinician of the obligation to perform an appropriate assessment. Pertinent appellate case law decisions not that the evaluation and record keeping must be "adequate, " though no definition for adequate standards is provided. This paper presents issues that are considered so fundamental for suicide assessment that failure to obtain and record such information would potentially constitute inadequate practice. These areas include: the patient's statement regarding current suicidal ideation and planning, the presence or absence of delirium, psychosis and depression, what the patient says it makes sense to do, confirmation by a third party, and global formulation. The guidelines in this paper are presented with the intention of establishing the basis for optimal clinical care and for minimizing legal vulnerability in the evaluation of the potentially suicidal patient in the general hospital. Author.