September 11, 2013 Blog Suicide Risk Assessment in the VHA

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Eric G. Smith, MD, MPH, and Jan E. Kemp, RN, PhD

Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts (Dr Smith), and VHA National Mental Health Program, Canandaigua, New York (Dr Kemp)


The recent article in The Journal of Clinical Psychiatry“Suicide Risk Assessment Received Prior to Suicide Death by Veterans Health Administration Patients with a History of Depression” revealed several important findings. Among Veterans Health Administration (VHA) patients with a history of depression from 1999 to 2004, 74% of patients who died by suicide had received an assessment of suicidal ideation in the year prior to suicide,1 and this rate was achieved prior to the major initiatives that VHA has put in place over the last 7 years emphasizing suicide risk assessment and prevention. However, only 30% of patients with depression or a history of depression received such an assessment at a time that it might have been especially important—the last health care visit. Furthermore, of those assessed, 85% denied suicidal ideation when asked, and a similar proportion (>70%) denied suicidal ideation even when asked within 7 days of their impending suicide death.

These findings, which demonstrate the challenge of suicide risk assessment, are not unique to VHA.2–5 What was new in this study is that these trends of low rates of assessment and high rates of denial of suicidal ideation continued even in higher-risk patient groups and even when patients were assessed just 7 days or less prior to suicide death. Additionally, we ascertained that mental health providers appeared to assess for suicidal ideation at a much higher rate than other providers, but apparently through routinely assessing patients with depression or a history of depression more frequently rather than through having more skill in ascertaining which patients were in particular need of an assessment. We found no strong evidence that providers, mental health or otherwise, were able to sense when patients might be particularly in need of a suicide risk evaluation, although our design did not allow us to rigorously establish this conclusion.

One interesting aspect of our study was that its findings closely support the approach that VHA has been taking toward suicide risk assessment since 2007. Since 2007, VHA has implemented an extensive suite of initiatives to reduce suicide. These include establishing the now well-known 24-hour/7-days-a-week Veterans Crisis Line (1-800-273-8255); posting high-risk flags on the electronic charts of patients deemed at particular risk for suicide or suicidal behavior (to enable all VHA providers to incorporate these concerns into their care); increasing requirements for monitoring and mental health care access when the flag is in place; and creating a personalized safety plan with each high-risk veteran concretely listing his or her own internal, social, and health care resources that can be used in times of crisis. The personalized safety plan is part of an intervention shown to reduce suicide attempts,6 and the Crisis Line number is now frequently given to many veterans receiving both mental health and nonmental health care. VHA is also working on a smart phone application (“app”) to enable veterans to reach out for help using that technology.

These initiatives help with the crucial aim we highlighted in the study of making suicide prevention efforts less time- and visit-dependent. This is important because suicidal crises can often occur quickly and in little relation to scheduled health care visits.

Financial disclosure:Drs Smith and Kemp had no relevant personal financial relationships to report.


1. Smith EG, Kim HM, Ganoczy D, et al. Suicide risk assessment received prior to suicide death by Veterans Health Administration patients with a history of depression. J Clin Psychiatry. 2013;74(3):226–232. Full Text

2. Isometsä ET, Heikkinen ME, Marttunen MJ, et al. The last appointment before suicide: is suicide intent communicated? Am J Psychiatry. 1995;152(6):919–922. PubMed

3. Busch KA, Fawcett J, Jacobs DG. Clinical correlates of inpatient suicide. J Clin Psychiatry. 2003;64(1):14–19. Abstract

4. Draper B, Snowdon J, Wyder M. A pilot study of the suicide victim’s last contact with a health professional. Crisis. 2008;29(2):96–101. PubMed

5. Vannoy SD, Robins LS. Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis. BMJ Open. 2011;1(2):e000198. PubMed

6. Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563–570. PubMed

Category: Depression , Veteran
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9 thoughts on “ Blog Suicide Risk Assessment in the VHA

  1. It is not sufficient just to ask a patient if she or he is suicidal. That is not an assessment of suicidal thinking. There are a number of screens (free) which can be used to learn more about depressed patients. The MADRS,BDI,Zung self rating for depression,QUIDS-SR and others which ask about suicidal ideations. Of course the copyrighted gold standard is the CSSRS in which there needs to be training in it’s use. Using these tools to help keep our veterans alive is worth all of this effort in the world. Those men and women deserve first rate treatment and it appears they are not getting it.
  2. Wondering if there were post-attempt interviews with survivors; those who denied suicidal ideation 7 days before. Did they say that they simply denied/lied what they were thinking or that they were honest and became suicidal in the time after that contact?
  3. Assessment should be done by team of staff from different discipline and followed either thru phone or face to face contact,daily/weekly for those pt considered high risk,but no admitted.Family needs be part treatment planning.
  4. If I ask if a patient is suicidal, I will virtually always get a negative answer. So I ask, “Do you ever feel that your family (or community) would be better off if you were not there?” or “do you ever feel that it just isn’t worth trying anymore.” or “do you ever wish that you didn’t have to wake up in the morning?” These questions sometimes elicit suicidal thoughts and give me a better understanding of the depth of the despair the patient is feeling.
  5. My most recent experience with a suided patient involved a 33 Y.O. man whom I had never met before. He was brought to the MHMR clinic by a relative who knew he was suicidal because he had told her so. However, in the relatively rushed clinic where 20-something patients were being screened, he entered my office ; not with the relative (whom I did not know was seated in the lobby); but he entered with a crisis worker who pre-exam informed me that the patient had never spoken to a psychiatrist before and was very frightened that he was going to get involuntarily committed. He denied suicidality to me and I thought that I had set his troubled mind at ease that he as going to get treatment in a non-frightening manner. I Rx’d him an anti-depressant and a follow-up appt. A few days later he cheerfully kissed his spouse good-bye; got in his motor vehicle and drove off somewhere other than to his job; parked and shot himself in the head/died. I was sued and I lost the suit and the survivors in the deceased’s family were awarded a sum. That was 16 years ago. Since then I have learned the tragically hard way, that a more systematically and psychosocially knowledgeable way of assessing and treatment- planning for the crisis patient is warranted. Not at all proud of this revelation; just underlining the importance of a more thoroughly systematic way of insuring that the patient’s family is involved in the risk-assessment and treatment-planning.
  6. It is with sorrow that i express these thoughts thinking of some of my missed calls. It may be self evident, but we are asked to see more patients in less time at the expense of thoroughness.It is almost impossible to discern the suicidality without a good rapport and it takes time to achieve one. I use scales and sometimes I can find it useful. they by no means guarantee any success, but could help in a busy practice. the best predictor for me remains previous and family attempts or completed suicides. Also the critical 2-3 weeks following inpatient Rx or a sudden(+) response within 2 weeks.
  7. I am not sure how useful all these assessments, rating scales etc. I don’t think any one can accurately predict when a person will commit suicide. There are of course some signs which may predict potential for suicide. But, these are assessed by a very careful observation and history taking and not by the rating scales. If anyone says these scales can predict suicide in one year, may God bless you and your patient. Keep in mind, a person who really wants to kill himself will not come to you and announce that he is suicidal knowing fully well that he will be hospitalized and kept under suicide supervision.
  8. Shawn CHristopher Shea, MD, has a really good book on how to proprerly assess a person for suicidality – what to ask and why to ask it – along with a cogent explanation about what is going on in the mind of a suicidal person. A bonus is his explanation of how to protect oneself from lawsuits if intervention fails. The book is The Practical Art of Suicide Assessment. Both editions are the same.

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