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Risk Management with Suicidal Patients

Bongar B, Berman AL, Mavis RW, Silverman MM, Harris EA, Pakman WL, editors

New York: The Guilford Press; 1998.197 pp with index

ISBN 1-57230-302-6 (cloth)

This book was written in response to the fact that most psychiatrists lose a patient to suicide sometime during their professional life. Suicide cases are a leading reason for malpractice action against mental health professionals. Dr. Bongar begins by suggesting that this book is “a forum for the exploration of avoiding liability in working with the suicidal patient.” In his introduction, Bongar stresses that the book is not intended as a standard of care, but rather “a rich and wide-ranging set of opinions and guidelines.” However, the book is quite contradictory on this point — Chapters 1, 3 and 4 are dedicated to discussing standards of care and the suicidal patient. Since this book, authored by experts in suicidology, and based on work published in the American Association for Suicidology’s official journal, will have an important impact on the care of suicidal patients, its deficiencies must be addressed.

This book includes 3 chapters based on articles previously published in Suicide and Life-threatening Behavior, and 4 new chapters. The contributors include many of the most prominent American suicidologists, including Drs. Alan Berman, Bruce Bongar, Robert Litman, Ronald Maris, Morton Silverman and Andrew Slaby. Chapter 1 is dedicated to the outpatient management of suicidal patients. It discusses common failure scenarios from malpractice proceedings and goes on to outline an outpatient standard of care. Bongar and coauthors originally published this paper in Suicide and Life-threatening Behavior in 1992. In Chapter 2, Dr. Slaby presents the essential elements of outpatient care of the suicidal patient. However, given its all-encompassing goal, the chapter ends up being a cursory discussion of many important issues. For example, when discussing the management of patients with borderline personality disorder, Dr. Slaby simply concludes, “Clinicians are not gods and are not able to predict or prevent all deaths by suicide. This is most true when they are dealing with Axis II personality disorders.” (page 35). Fortunately, the American Psychiatric Association is developing practice guidelines for the care of patients with borderline personality disorder. This will provide a more comprehensive statement about what is known and not known about the care of these patients. Chapters 3 and 4 are based on articles that were published in 1993 and 1994, respectively, in Suicide and Life-Threatening Behavior. The editors have included a commentary of Chapters 3 and 4 from Dr. Robert Litman, who criticizes Dr. Silverman’s Chapter 4 for providing good clinical practice standards, but not the minimal standards that are often the reference point for court proceedings. Chapter 5 is a new contribution by Drs. Goldblatt, Silverman and Schatz-berg, dealing with the psychopharmacological treatment of suicidal inpatients. However, the chapter is disturbingly incomplete. For example, the value of lithium maintenance treatment in reducing the risk of suicide for bipolar disorder and clozapine treatment in reducing the risk of suicide in schizophrenia are inadequately addressed. These treatments may have important indications in the suicidal behaviour of individuals with these specific diagnoses. Also, the discussion of borderline personality disorder is badly outdated; for instance, their most recent reference is from 1986 and recent evidence for using selective serotonin reuptake inhibitors for individuals with impulsive aggressiveness is ignored. Chapter 6, a new contribution by Dr. Silverman, purports to be a model for psychopharmacological interventions for hospitalized patients. A psychiatrist will find this discussion broad and uninformative. I suspect that the target audience for this chapter is the psychologist, who may find discussion of the steps that are needed to determine appropriate psychopharmacotherapy informative. The last chapter on the risk management of suicidal patients, by Drs. Packman and Harris, contains very practical suggestions for minimizing liability. For example, the authors provide an approach for discussing, at the outset of therapy, breach of confidentiality when a highly suicidal patient is in crisis and there is a need to inform the patient’s family. This chapter is more current, as it discusses the issues of liability in the managed care environment. A document that includes in its title “standard of care” for suicidal patients has the potential to do more harm than good. This book is primarily based on data from malpractice claims to develop “standards of care” for suicidal inpatients and outpatients. As a result, most of the chapters are outdated with regard to recent scientific evidence. The 3 reprinted chapters appear to have been published without any attempt to update the references. The new contributions do not provide a clear statement of the nature of the supporting evidence used to develop their approach, and do not appear to include the evidence based on empirical research. Therefore, this book eschews the scientific evidence that has accumulated to guide clinical practice. Drs. Rudd and Joiner have recently published a paper on the assessment, management and treatment of suicidality based on existing literature, and provide an important alternative to the approach by Bongar and colleagues.

The book is under 200 pages, well produced and contains no production errors. Although this book will attain prominence in the fields of psychiatry and psychology, the reviewer cautions that it has employed a very limited methodology to determine standards of care for suicidal patients. This contribution must be seen as only one facet in the development of the appropriate care for suicidal patients.