How do healthcare professionals interview patients to assess suicide risk?

Abstract

BackgroundThere is little evidence on how professionals communicate to assess suicide risk. This study analysed how professionals interview patients about suicidal ideation in clinical practice.MethodsThree hundred nineteen video-recorded outpatient visits in U.K. secondary mental health care were screened. 83 exchanges about suicidal ideation were identified in 77 visits. A convenience sample of 6 cases in 46 primary care visits was also analysed. Depressive symptoms were assessed. Questions and responses were qualitatively analysed using conversation analysis. χ 2 tested whether questions were influenced by severity of depression or influenced patients’ responses.ResultsA gateway closed question was always asked inviting a yes/no response. 75% of questions were negatively phrased, communicating an expectation of no suicidal ideation, e.g., “No thoughts of harming yourself?”. 25% were positively phrased, communicating an expectation of suicidal ideation, e.g., “Do you feel life is not worth living?”. Comparing these two question types, patients were significantly more likely to say they were not suicidal when the question was negatively phrased but were not more likely to say they were suicidal when positively phrased (χ 2 = 7.2, df = 1, p = 0.016). 25% patients responded with a narrative rather than a yes/no, conveying ambivalence. Here, psychiatrists tended to pursue a yes/no response. When the patient responded no to the gateway question, the psychiatrist moved on to the next topic. A similar pattern was identified in primary care.ConclusionsPsychiatrists tend to ask patients to confirm they are not suicidal using negative questions. Negatively phrased questions bias patients’ responses towards reporting no suicidal ideation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-017-1212-7) contains supplementary material, which is available to authorized users.

Associations between clinicians' emotional responses, therapeutic alliance, and patient suicidal ideation

“…Accordingly, The National Action Alliance for Suicide Prevention's “Research Prioritization Task Force” has identified “exploring the roles of patterns of care that are associated with increased risk, such as […] patient‐care provider “ruptures in trust,” or other therapeutic relationship changes” as a priority (National Action Alliance for Suicide Prevention, ). Nevertheless, there is currently a lack of training for clinicians in awareness and management of their emotions when working with patients at high risk for suicide (McCabe, Sterno, Priebe, Barnes, & Byng, ; Schmitz et al, ). Dialectic behavioral therapy (Chapman & Rosenthal, ), the Collaborative Assessment and Management of Suicidality (Jobes, ) and recognition, acceptance, investigation, and nonidentification (Ellis et al, ) are some of the interventions designed for improving therapeutic relationship and outcomes with suicidal patients and should be more broadly implemented.…”

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“…It should also be emphasized that these difficulties are mostly related to distinguishing between non-suicidal self-injury, not aimed at death, and suicidal behavior, where there is intent to die. In any case, the increasing trend towards the practice of defensive medicine would render decision-making based on patients’ wellbeing as the main target more difficult [ 68 , 69 ]. On the other hand, evidence shows that one out of every three mental health professionals does not regularly ask patients about ideas or thoughts related to suicide [ 39 ].…”

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