Collaborative Care, Not Robotic Risk Assessment, Reduces Suicidal Ideation

A new randomized controlled trial led by Monika Lohani and colleagues finds that suicidal patients experience a greater reduction in suicidal ideation when clinicians engage with them collaboratively rather than using a standard, interview-like approach. This finding underscores the importance of a personalized, humanizing treatment process in effectively addressing suicidality.

The researchers emphasize just how sterile the process can be when a suicidal patient is receiving treatment and forming a safety plan:

“Although safety planning-type interventions are intended to be created by a suicidal patient in close collaboration with a trained clinician, in many settings, the level of patient-clinician collaboration can be very low or even absent. Self-guided versions of the SPI [(safety-planning intervention)], wherein suicidal individuals are directed to use a ‘fill-in-the-blank’ safety plan form with minimal interaction between clinician and patient, are common in many healthcare settings,” they write.

“The effectiveness of self-guided safety planning-type interventions for reducing suicidal behavior has garnered some support, although reported effect sizes are smaller than those observed in studies using a collaborative approach wherein the patient and clinician work together to identify the patient’s personal warning signs for an emotional crisis, self-management coping skills, and sources of social support. Thus, collaboratively developed safety planning-type interventions require more clinician time, but they may also be more effective.”

The study, which included 82 participants, divided them into four groups based on the level of collaboration in their treatment. The findings were clear: patients who experienced high levels of clinician engagement through Narrative Assessment saw the most significant reduction in suicidal thoughts. The research advocates for a shift from the rigid, standardized methods often used in healthcare settings to a more collaborative, narrative-based approach, highlighting the profound impact of personal connection in the treatment of suicidality.

While healthcare settings have focused on evidence-based methods to prevent suicide, the care and approach can differ significantly based on the clinicians and patients involved. Some interventions are only offered to patients deemed to be at the highest risk of suicide, and the methods used by clinicians to assess this risk have been found to be inconsistent.

Monika Lohani and her colleagues propose that rather than imposing strict and standardized healthcare protocols for suicidal patients, clinicians should actively engage with their patients’ personal stories to assess the risk and work together to develop safety plans. In their study, 82 participants underwent multiple eligibility assessments and were randomly assigned to four groups. Each group received one of the four combinations involving different interview types and response plans.

1. The clinician gives a structured interview (low collaboration) & a safety plan intervention (low collaboration) is looked over.
2. The clinician gives a structured interview (low collaboration) & a crisis response plan (high collaboration) is formed.
3. The clinician engages with the patient via Narrative Assessment (high collaboration), and a safety plan intervention (low collaboration) is reviewed.
4. The clinician engages with the patient via Narrative Assessment (high collaboration) & a crisis response plan (high collaboration) is formed.

Safety plan interventions are primarily self-directed by the patient. A clinician gives their patient the Stanley-Brown safety plan form and asks them to read it over, asking questions where necessary. The form is a bulleted list of hobbies and loved ones that could distract oneself from suicidal thoughts, with phone numbers next to the names of family, friends, and doctors. There is little to no collaboration between the clinician and the patient in forming this plan.

On the other hand, crisis response plans (CRPs) focus on five instrumental components: “personal warning signs of an emerging suicidal crisis, self-management strategies to distract from the situation or reduce emotional distress, reasons for living, sources of social support, and professional and crisis services.”

The authors explain that these plans, which are typically handwritten on an index card, can be effective in reducing suicide attempts and suicidal ideation for adults who participated in randomized controlled trials both over six months and in the immediate hour following the creation of the CRP.

Because the clinician engages with their patient’s story—the reasons they feel the way they feel, the steps that brought them to feeling suicidal, and the thoughts and behaviors that yield hopelessness—the crisis response plan has greater feasibility and accuracy. It is more insightful in its capacity to reasonably and realistically handle a potentially life-threatening internal crisis.

The authors found that participants assigned to any of the four groups saw a decrease in suicidal ideation but that the Narrative Assessment step (groups 3 and 4) saw a significantly greater reduction in suicidal thoughts than the groups that received structured interviews (groups 1 and 2). The group of participants that saw the most significant reduction in suicidal ideation was group 4—the double-high collaboration group.

The authors find that the narrative engagement step may be the most critical stage of all because even if the safety plan intervention is lacking in depth compared to the crisis response plan, it is still created with a feeling of collaboration between the clinician and patient after having taken part in the Narrative Assessment.

Unfortunately, this study was limited in its follow-up time, as participants were only checked upon once after two weeks had passed. This is not a negligible amount of time, especially as suicide risk can sometimes increase immediately following intense treatment—but the authors highlight how it would still be ideal to gain more information about the impacts of collaboration over a more extended period of time.

Suicides in the United States have increased by 35% from 1999 to 2018, and in 2021, the CDC estimated a total of 1.7 million people attempted suicide in America. The process by which people are treated for suicidal thoughts remains unnecessarily sterile. Bringing both patients and clinicians into a more personalized process is critical to reducing suicidal ideation.

 

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Lohani, M., Bryan, C. J., Elsey, J. S., Dutton, S., Findley, S. P., Langenecker, S. A., West, K., & Baker, J. C. (2024). Collaboration matters: A randomized controlled trial of patient-clinician collaboration in suicide risk assessment and intervention. Journal of Affective Disorders, 360, 387–393. https://doi.org/10.1016/j.jad.2024.06.004 (Link)

 

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