As a psychiatrist, assessing the risk of suicide is a constant part of professional life. Documenting these considerations in the medical record is an integral part of the job. When a patient later attempts suicide, the assessments and documentation are invariably scrutinized. Absence of documentation is often interpreted as a failure to assess.
There are several methods for assessing suicide risk. Traditionally, the “suicide ladder” is used, where the presence of desire for death, suicidal thoughts, and plans are noted. Recently, documenting protective and risk factors has become standard, and various structured risk assessment tools have been developed such as OxMIS. Many of us have probably wondered about the true impact of this. Does it make a difference?
The problem with listing risk and protective factors in an assessment is that it’s difficult to understand the cumulative effect of these factors. We can add them up, but we actually know that these factors interact with each other in ways that goes beyond mental arithmetic. There are algorithms available that calculates the statistical risk of death within a year based on entered values, which might be more relevant than grading suicide risk as ‘low, medium, or high.’ And, when we say ‘high’ risk, what are we comparing it to? Describing risk in relation to the general population is not as relevant for our patients; it would make more sense to compare it to other patients within the same unit.
Instead of focusing too much on trying to predict suicide risk - which is challenging to do with sufficient precision - we should focus more on measures that reduce suicide risk by addressing triggering factors. We shouldn’t fixate only on determining whether someone’s risk is high or low but also on what we can do to minimize that risk. Think of traffic safety prevention as an analogy. In the Nordic countries, we have significantly reduced traffic deaths. This was achieved not by predicting who would die in traffic but through various system - level measures - sometimes called “prevention by design” - like safer cars, reduced speeds, and road improvements.
In Sweden, we have a zero-suicide vision. Many people support it, and criticism of it can cause a stir, but I don’t believe it’s without problems. Psychiatrist Manne Sjöstrand and colleagues conducted interviews with Swedish psychiatrists, and there’s a lot of skepticism among them. Primarily, the zero-suicide vision is problematic because it’s not a realistic goal. We don’t have the means to get close to zero, so doesn’t this set us up for disappointment? A zero-suicide vision suggests that a world without suicide is possible, but how it would be achieved remains unknown. I also think the possibility of ending one’s life is something many people want to have, at least in extreme circumstances. Knowing that one has this option can be a source of comfort.
The zero-suicide vision also implies that something always went wrong if someone dies by suicide. Healthcare often tries to find an explanation, which can sometimes feel like a search for someone to blame. Doctors fear this, and I believe it contributes to the focus on risk assessment. Often, there is debate on whether self-harm risk was adequately considered. This is problematic. It would be better if we shifted focus from assessing suicide risk to assessing what we can do to minimize it.
One way to reduce suicidal actions is to develop more detailed crisis plans. What might trigger suicidality after discharge? Loneliness, alcohol, sleep disturbances, conflicts, or other stressors? What can the patient do to prevent or handle these situations? When should supportive people or healthcare come into play? Today, healthcare produces many crisis plans, but they’re often short and vague. It would be better to create comprehensive crisis plans for patients who truly need them. These are the kinds of crisis plans that have shown effectiveness in studies.
There is some evidence that certain interventions reduce suicide risk, such as dialectical behavior therapy during inpatient psychiatric care. ASSIP, a promising Swiss method, is a short intervention following a suicide attempt. However, these methods are relatively rare in clinical practice.
Suicide prevention isn’t solely a healthcare issue. It is now well-known that building barriers at places where violent suicides have occurred reduces the number of deaths. Suicidal individuals don’t necessarily go looking for another place if a bridge is fitted with protective railings. I think this reflects the fact that the average suicidal person doesn’t truly want to die - they just find it incredibly difficult to keep living.
We conclude our conversation by reflecting on suicide rates in Nordic countries. A recent report shows that Greenland has the world’s highest suicide rate, while Åland and the Faroe Islands have the lowest. What’s behind this? Rapidly changing cultural and political factors likely play a role, according to Christian Rück, as well as high levels of alcohol and drug use.
In many countries, suicide rates have remained stable over the past decade, but Finland has seen a dramatic reduction over the last 20 years. It would be interesting to understand the mechanisms behind this. Various suicide prevention programs have likely had a positive impact.
Sweden's suicide rate is average by international standards. Yet, there’s a belief that Sweden has an unusually high suicide rate. Rück suspects this dates to U.S. President Eisenhower’s 1960s warnings about the Swedes’ free lifestyle, amplified in films by Ingmar Bergman, where nudity and sex were shown openly. The American president spoke of "sin, sex, and suicide," suggesting that abandoning a traditional lifestyle would lead to mental collapse, and suicide. □