Most psychiatric drug trials today—the majority of which are industry sponsored—exclude anyone expressing thoughts of suicide. This is for ethical as well as practical reasons: physicians consider it taboo to give people on the brink of suicide an experimental drug, let alone a placebo, if other options are available, and many additional safety precautions are required to run trials in this vulnerable population. To complicate matters, few mental health experts are trained in how to conduct suicide research, and those who do are often afraid of lawsuits.
As a result, institutional review boards aren’t always so amenable to this kind of high-risk research. “It takes forever to get anything approved to do suicide prevention research, and it’s incredibly frustrating,” says Marjan Holloway, a clinical psychologist who is running clinical trials with suicidal military personnel at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Kate Comtois, a psychologist at the University of Washington in Seattle who has run psychotherapy trials in people with borderline personality disorder (BPD), expresses a similar concern. “I hear many stories from other institutions where people have basically given up recruiting high-risk patients because their institutional review boards are so cautious that they throw up roadblocks,” she says.
Vaughan Bell explains additionally that ethical concerns can stymie research into risk assessment:
Normally, if I want to develop a way of predicting who will develop depression or not, I can assess a group of people and I can return later and see whether my predictions were right or not.
If I do the same with a suicide assessment and it suggests that several people are at high-risk of suicide, I have a moral duty to intervene and help them.
What complicates the issue is that this often applies regardless of the quality of my assessment. In other words, imagine that my suicide assessment is useless but I don’t know it – I will still intervene.
A few thoughts.
When clinicians are asked to conduct risk assessments with patients we don't know, quickly distinguishing level of risk using validated criteria would be a great help. Of course there are known demographic, historical, situational and personality factors that are associated with greater risk of suicide, but anything else we can learn about risk-assessment could be helpful in clinical situations where the possibility of suicide is of immediate concern, again, especially with patients we don't know.
In clinical practice, a significant number of patients mention suicidal thoughts at one time or another because suicidal thoughts are not all that unusual. Only a small percentage of those patients who report suicidal thoughts will ever attempt suicide. Nonetheless, clinicians can't be dismissive of these thoughts when they arise because a mistake in judgment would be tragic.
Many patients who bring up suicidal thoughts issue an immediate caveat, something like: don't worry, I'd never do it. I'm bringing it up because I know I'm supposed bring up anything I'm thinking. The statement with caveat might mean several things including but not limited to: (a) essentially what the statement says on it's face; or (b) I want to alarm you, but I feel guilty about alarming you; or (c) I want to alarm you, but I'm pretending I don't want to alarm you for other reasons or c) this is bad, but for God's sake don't hospitalize me. I really don't need it; or (d) this is bad, and I dread hospitalization, and I hope you'll make the right decision for me anyway.
Those are just a few possibilities.
Patients may also report thoughts of suicide without the accompanying reassurance and there are suicidal patients who don't mention suicidal thoughts.
How do I know what a suicidal thought means and how do I decide on my response? First, I listen to the patient. I ask questions if what I'm hearing doesn't get at something that I think I should know. I view the mention of suicidal thoughts within the context of possible triggers for those thoughts and further contextualize the triggers in terms of what I know about the patient's internal landscape of strenghts, conflicts and deficits. Of course, consideration of factors such as previous suicide attempts, access to firearms or pills and availability of social support also matter.