Clinical risk assessment

The arguments outlined above and the failure of prediction to work at the individual level have led to a more or less consensual view that the emphasis should not be on prediction but on assessing risk (Maris et al., 1992). In other words, the task for the clinician is to gauge whether risk is elevated, not to forecast whether people will kill or harm themselves or not. The window of increased possibility of suicidal behaviour is what Litman (1990) has called the 'suicide zone'. People are in the suicide zone when they are in a state where killing themselves is a possibility, but, at the same time, perhaps only about one or two in every 100 who are in that zone of acutely high risk will kill themselves (Litman, 1990).

Clinical assessment differs from the predictive research in that it is concerned with immediate or short-term risk. It also differs from the predictive research in focusing more on individual factors than 'objective' factors. In fact, many of the factors that dominate the predictive models seem to be largely ignored by clinicians. Jobes et al. (1995) surveyed practising clinicians on their methods of assessing suicide risk. They found that their respondents rarely used any formal risk-assessment measures, relying much more on a clinical interview covering a broad range of questions. Interestingly, though not suprisingly, the three areas of questioning given the highest utility rating for arriving at an assessment were whether the person had a suicidal plan, suicidal thoughts, and a method of suicide available. Observations that were considered by clinicians to be most useful in making their assessments were difficulty in establishing an alliance with the patient, evidence of alcohol or drug use, and evidence of depressed affect.

In summary, hopelessness or, indeed, any known combination of variables is not a good predictor of suicidal behaviour. The cost of identifying those who will commit or attempt suicide is that many of those who will not are incorrectly labelled as being at risk. Reducing this high number of false positives results in missing those who are at risk. Predictive models perform poorly because suicidal behaviour is rare and because they cannot take account of individual variability. The focus has shifted from prediction to risk assessment, where the emphasis is on relative risk (is it possible?) rather than absolute risk (will it happen?). Clinical assessment of individuals can take account of individual factors, but the accuracy of such assessment is not known, and perhaps is not generally knowable, as it will depend on who is doing the assessing. The challenge is to integrate the empirical research base with an individually sensitive approach to clinical assessment.

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