Major misunderstandings about clinical care related to suicidal risk tend to exasperate me a bit. Let me therefore address and clarify some common misunderstandings that can interfere with saving lives. The key constructs at hand are assessing suicidal risk, managing acute risk, and treating suicidal risk.
Assessing Suicide Risk
As I have previously blogged, there have been recent criticisms related to risk assessment because we cannot reliably predict future suicidal behaviors. But just because we cannot predict suicidal behaviors does not mean that there is no benefit to suicide risk assessment. It is also important to appreciate the differences between screening vs. assessment.
What is plain is that it is hard to save lives if we do not detect risk, so the goal of a good suicide screen is to tip off the prospect of suicidal risk using a short screener of questions. My favorite suicide screener is the ASQ developed by Dr. Lisa Horowitz at NIMH, which has been normed on youth and, more recently, on adult populations. Another potential screener that is widely used is the Columbia Suicide Severity Rating Scale (C-SSRS) developed by Dr. Kelly Posner at Columbia University. Both these screeners have solid psychometrics, and the C-SSRS has various versions for different populations and needs. Both screeners are non-proprietary and obtainable online. The PHQ-9 is another free online screener that is better than nothing, but it was developed as a depression assessment and is therefore an imperfect screener for suicide risk.
Suicide Risk Screening vs. Suicide Assessment
Nevertheless, screening for suicide risk is different than assessing suicide risk, which is more of an in-depth endeavor. For example, longer versions of the C-SSRS can be used for assessment along with literally dozens of other suicide-specific assessment tools that are not widely used (perhaps because they are typically proprietary). I know about all this because I have long studied this topic, and we know from our research that clinicians far preferred clinical interviewing and relying on their “gut” clinical judgments. The extensive research on clinical judgement shows that such assessments are never as good as actuarial assessment scales. But many providers do not care about such data because research shows that all too often, clinicians overly trust their gut judgements. Here are key takeaway points: screening is not assessment. Assessment is not treatment. Screening/assessment is only a start, and not an end unto itself.
Managing Acute Suicidal Crises
Interventions for helping to weather acute suicidal crises are not treatment. And like assessment, managing acute risk does not = treating suicidal risk. To clarify, Dr. Barbara Stanley and Dr. Greg Brown’s Safety Plan Intervention (SPI) is the most widely used tool for helping a person who is suicidal get through an acute suicidal crisis. We know that Safety Plan is superior to the “no-harm/no-suicide” contract—the data are clear. A “cousin” of the Safety Plan is the Crisis Response Plan (CRP), originally developed by Dr. David Rudd and further studied by Dr. Craig Bryan. There is some overlap between SPI and CRP, but they are slightly different. Craig did a superb randomized controlled trial with active-duty service members comparing the use of the CRP vs. no-harm contracts showing the significant impact of CRP for reducing suicidal ideation and suicide attempts. Moreover, a new European meta-analysis of six safety planning type studies showed that such interventions significantly reduce suicide attempts; but do not appear to reduce suicidal ideation. And once again, managing an acute crisis does not = treatment of suicide risk.
Treating Suicide Risk: DBT, CT-SP, BCBT, & CAMS
Finally, there are clinical treatments for suicidal risk including a handful of proven interventions that have been supported by randomized controlled trials (RCT’s), with replicated support, by independent investigators. A full description of all these considerations has been published elsewhere. It is interesting to note that effective suicide-focused treatments do not equally treat all aspects of suicidal risk. For example, Dialectical Behavior Therapy (DBT) clearly reduces suicide attempts and self-harm behaviors. Cognitive Therapy for Suicide Prevention (CT-SP) and Brief Cognitive Behavioral Therapy (BCBT) have both been shown to significantly reduce suicide attempts. Yet, these three effective behavioral interventions do not necessarily reduce suicidal thoughts. The intervention with the most support for treating suicidal thoughts is the Collaborative Assessment and Management of Suicidality (CAMS), with a total of five published RCTs, nine published non-randomized clinical trials, and a new independent meta-analysis of nine CAMS trials.
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In summary, some of my biggest professional frustrations around clinical misunderstandings related to suicide risk are implied above but permit me to spell them out plainly:
- Simply doing a suicide screening and/or an assessment is not an intervention.
- Having a patient complete a Safety Plan is not treatment.
- Many treatments used for suicidal risk have little to no empirical support (e.g., medications and inpatient hospitalizations).
- Not all suicide-focused treatments impact all aspects of suicidality (e.g., behaviors vs. ideation).
The CAMS Difference: Effective Suicide Risk Assessment, Management, and Treatment
As professionals in the field consider using CAMS, a common query we often hear is why do we need to use CAMS if we are already using the C-SSRS? Answer: The C-SSRS can be used as an excellent screener/assessment that can be used to trigger the use of CAMS (or perhaps some other proven suicide-focused intervention). The distinction here is that the C-SSRS is not treatment for suicidal risk. Moreover, the assessment aspects of CAMS are “baked” into an overall suicide-focused clinical intervention with extensive empirical support. From another meta-analysis, we also know that the assessment aspects of CAMS function as a “therapeutic assessment” experience. Beyond this valuable impact, CAMS also effectively manages and treats suicidal ideation better than any other clinical treatment in the field (with promising data on suicide attempts and self-harm as well). Needless to say, CAMS is not for every patient, every setting, and every scenario, but nevertheless it does an excellent job of assessing and managing suicidal risk and actually treating suicidal risk for the largest population in the field of suicide prevention: the 12 to 14 million Americans of all ages who experience serious thoughts of suicide. These varied aspects of CAMS are unique and set it apart as a proven suicide-focused interventions. Importantly, our clinical trial research shows that using CAMS meaningfully helps clinicians avoid common clinical misunderstandings that plague the field in the course of working to reduce the risk of suicide thereby ensuring better clinical care and potentially life-saving outcomes.