Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation Types

Summary

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Psychofarm Podcast – "Suicide Risk Assessment: Acute vs Chronic Risk, Formulation, and Suicidal Ideation Types"

Date: June 2, 2026
Hosts: Dr. Gregory Malsberg (A) & Dr. Drew (B)
Episode Theme: Understanding and applying suicide risk assessment in psychiatric practice—moving beyond checklists to nuanced clinical thinking, and discussing varieties of suicidality and key pitfalls for clinicians.

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Episode Overview

This episode takes a deep dive into suicide risk assessment, examining the complexities, limitations of rigid checklists, and the critical importance of narrative, diagnostic formulation, and personal clinical judgment. The hosts clarify the central confusion among both clinicians and trainees about what effective assessment really entails, dissect the different types of suicidal ideation, and offer pragmatic advice for clinicians seeking to balance care quality with professional/legal liability.

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Key Discussion Points & Insights

The Flaws of Bureaucratic, Checklist-Based Risk Assessments

• Mandatory Screening’s Impact

  • Rigid, mandatory suicide risk assessments (e.g., for every ER patient) often result in box-checking vs. true clinical thinking.
  • Dr. Malsberg: "Essentially, our suicide risk assessment... was just clicking every single box as quickly as possible and then typing, saying, the protective factors are that they're seeking care... The risk factors are that they're mentally ill..." (04:11)

• Origins of Universal Screening Mandates

  • These protocols are often due to organizational responses (e.g., The Joint Commission) to rare, high-profile adverse events, not robust evidence.
  • Dr. Drew: "Joint Commission... looked at the statistic that... majority of completed suicides are not from patients presenting reporting suicidality... simply asking them about it is not going to do very much." (05:56)

• Risk of Tools Replacing Clinical Reasoning

  • Box-checking forms may inadvertently replace nuanced thinking and discussion about the patient.
  • Dr. Malsberg: “Did you do the suicide risk assessment? They weren’t asking, did you truly think through the patient’s risks and benefits? They were asking, did you fill out that checkbox?” (09:32)
  • Dr. Drew: "You can do a clinical protocol, but if you do it blindly, you're doing cargo cult psychiatry... We can't simply do the ritual. We have to understand where the ritual comes from." (08:03)

How Suicidality is (or Should Be) Assessed in Practice

• Not Predicting the Future—Risk Stratification

  • Suicide assessment is NOT about predicting if a patient will act, but about identifying and grading risk, then planning accordingly.
  • Dr. Drew: "Your job is not to predict the future... What you are doing is grading the level of risk." (19:29)

• The Role of Narrative and Rapport

  • Rushed, rote questioning (“Any thoughts of hurting yourself?”) can make disclosure less likely and encourage patients to hide symptoms for pragmatic reasons (discharge incentives).
  • Dr. Malsberg: "Those questions are going to shut down the patient entirely... This is not gonna make them feel comfortable sharing... If I want to get discharged... I just have to answer these questions the way I know they expect to be answered." (13:06)
  • Dr. Drew: "Don’t be afraid, be professional... If you are overly fearful or anxious... you are going to... show this to the patient, and... make it that much harder... to be honest with you." (11:33)

• Teaching the Art, Not the Tool

  • Clinicians must learn to do a nuanced, individualized assessment; tools and forms are not a substitute for clinical supervision and experience.
  • Recommendations for learning:
    • Read the Columbia Suicide Severity Rating Scale for basic assessment structure.
    • "How to Write a Suicide Note: Practical Tips for Documenting the Evaluation of a Suicidal Patient" by Dr. Christos Ballis (Psychiatric Times, 2007). (17:28)

Varieties of Suicidal Ideation

[22:06] Five Main Types Discussed

1. True Rational Suicidality

   • Extremely rare in psychiatry; entails planning suicide for non-psychiatric, “rational” reasons, e.g., maximizing life insurance for family.
   • Dr. Drew: "You shouldn't assume that... they are that variety... the pretest probability is high that they are not purely rational." (25:07)

2. Dysregulated Response to a Stressor (Adjustment-Related SI)

   • Acute, situational response (e.g., breakup, job loss). Usually resolves with time or stressor resolution.
   • Most aligned with Adjustment Disorder in DSM.
   • Dr. Drew: "Some people... they don't get the ideation at all until they're under extreme level of stress." (25:23)
   • Treatment: Short-term safety (hospitalization as needed); long-term, not usually pharmacological.

3. SI as a Feature of Acute Intoxication

   • Substance-induced; SI appears only when the patient is simultaneously acutely stressed and intoxicated.
   • Dr. Drew: “Many people will only have serious suicidal ideation, intent and planning when they are both stressed and intoxicated.” (31:25)
   • Treatment: Support, sobriety—often risk decreases on detoxification.

4. Baseline/Recurrent Suicidal Ideation (“Trait SI”)

   • Chronic, persistent thoughts not tied closely to immediate stressors. Common in personality disorders (esp. borderline), but can be seen in dysthymia, autism, etc.
   • Manifestations and intent are highly variable; can be manipulative, existential, or just intrusive “background noise.”
   • Dr. Malsberg: “This is a very different... there's a huge... for each individual patient, the purpose that the suicidality is serving is very different.” (34:46)
   • Dr. Drew: “Sometimes this is something that becomes more of an acute danger... sometimes [referral] may be inappropriate... that's the job of the emergency room doctor, to determine is dangerousness elevated, if so, what's the treatment.” (35:37)

5. SI as a Symptom of Major Psychiatric Illness

   • Suicidality as an inherent symptom of severe psychiatric illnesses (major mood disorders, psychosis, severe PTSD, etc.).
   • Here, medication is indicated (lithium for bipolar, clozapine for schizophrenia), but SSRIs do not specifically treat suicidality per se.
   • Dr. Drew: "If it's bipolar, don't forget lithium. If they're appropriate for clozapine, don't forget clozapine... treat the underlying condition." (38:41)
   • SSRIs helpful for comorbid depression; do not treat SI as a standalone symptom.

6. Ego-Dystonic Obsessive Suicidal Thoughts ("OCD SI")

   • Intrusive, unwanted thoughts of suicide (e.g., OCD), triggering distress and compulsive checking/reassurance, distinct from genuine intent.
   • Dr. Drew: "People can have thoughts about suicide as part of a obsessive and compulsive disorder type process... If you have appropriately identified this as a feature of OCD, then the treatment is... talk therapy for OCD." (43:09)
   • Caution: Can be hard to distinguish from SI in comorbid personality disorders.

Notable Clinical Takeaway

• These categories are frameworks; every case is unique, and SI can mutate from one category to another within the same individual depending on context.

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The Importance of Narrative Formulation

• The clinician must identify the purpose and function of a patient’s SI—context, patterns, triggers, and meaning—rather than relying on static lists.
• Narrative allows for understanding patterns like:
  • “Cooling off” (hospitalization calms acute, adjustment-based SI)
  • Maladaptive coping (hospitalization may worsen chronic, manipulative SI)
• Dr. Malsberg: “The correct response to suicidality really depends on the patient... the big component about what you’re going to do is... related to the patient’s long term, best functionality outcome.” (29:44)

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Formulation’s Impact on Treatment Planning

• Global, Holistic Formulation
  • Consider acute risk factors (what’s dangerous right now), chronic risk factors (enduring vulnerabilities), and protective factors (durable and situational).
  • “Everyone’s dangerous,” meaning even no-history patients can behave unpredictably—focus should be on risk stratification, not binary prediction.
  • Dr. Drew: “Sum them all up. Align that to your understanding of the variety of suicidal ideation... and decide on a treatment plan.” (46:21)

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Gallonker's Acute Suicidal Crisis State

[49:46]–[52:51]

• Dr. Malsberg details Dr. Gallonker’s five-cluster syndrome predicting acute suicide risk (“Acute Suicidal Crisis State”):
  1. Entrapment – Sense of being trapped/hopeless (“that’s probably the most important thing…” 49:46)
  2. Affective Disturbance – Panic, rage, dread, intense emotionality
  3. Loss of Cognitive Control – “Tunnel vision,” rigid, repetitive, inflexible thinking
  4. Hyperarousal – Agitation, insomnia, increased energy/irritability
  5. Social Withdrawal – Pulling away from usual supports
• Clinician Gut-Feeling / Countertransference
  • The most important “variable”—how you (clinician) feel in the room (e.g., hopeless, anxious, compelled to rescue) is a powerful, if subjective, risk indicator.
  • Dr. Malsberg: "What [Gallonker] says is probably the most important variable is the clinician's emotional response to the patient." (51:17)
  • Over-involvement OR urge to detach are warning signs.

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Legal Pitfalls & Documentation

• Standard of Care = Process + Reasoning + Documentation
  • Not liable for outcomes, but for failure to follow assessment/treatment process and adequately document.
  • Include history, risk/protective factors, your clinical reasoning, and thought process leading to recommendations.
  • Dr. Drew: "You have to document, you have to do the thing and then you have to document it..." (56:28)
• Malpractice Suits
  • Most commonly stem from either not following standard of care, not documenting, or poor/no reasoning.

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Memorable Quotes & Moments

• On Bureaucratic Tools:
  "You can do a clinical protocol, but if you do it blindly, you're doing cargo cult psychiatry..." – Dr. Drew [08:03]
• On Checklist Assessments:
  "Did you do the suicide risk assessment?... they were asking, did you fill out that checkbox?" – Dr. Malsberg [09:32]
• On the Objective of Suicide Assessment:
  “Your job is not to predict the future... what you are doing is risk stratification.” – Dr. Drew [19:29]
• On Patient Gamesmanship:
  "Patients who want to be discharged learn the rules... say no to these questions and then eventually you can get out." – Dr. Malsberg [13:06]
• On Clinical Uncertainty:
  "Trainees think that this is waffling or inconsistent... it is unfortunately clinically subjective." – Dr. Drew [54:22]
• On Personal Reaction/Countertransference:
  "When I'm assessing risk, I'm paying attention to how I'm feeling... when I feel like a patient feels trapped... are the most concerning." – Dr. Malsberg [53:54]

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Timestamps for Important Segments

• [04:11] – Why bureaucratic suicide assessment tools are unhelpful in practice
• [05:56] – Flaws in universal screening mandates
• [11:33] – How to properly approach SI interviews (professionalism, narrative, non-judgment)
• [13:06] – How rote questioning fails patients and undermines honesty
• [17:28] – Recommended reading (Columbia scale & Ballis 2007 article)
• [19:29] – Suicidality: not about predicting, but stratifying risk and planning
• [22:06]–[43:09] – Varieties of Suicidal Ideation & Formulation
• [49:46] – Gallonker’s Acute Suicidal Crisis State: Five key symptom clusters
• [56:28] – The legal process: what’s defensible documentation and where clinicians get in trouble

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Final Takeaways

• Suicide risk assessment is a complex, individualized process requiring nuanced clinical reasoning, not just checklists or mandatory forms.
• Understanding the patient’s narrative, differentiating types of suicidal ideation, and being attuned to your own emotional responses are all crucial.
• Documentation must detail both the process and the reasoning behind your conclusions; it protects you legally and guides quality care.
• The field is still evolving—be humble about the limitations of prediction, err on the side of prudence, but don’t let fear strip you of clinical judgment.

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Transcript

[A]

Welcome to the Psychopharm Podcast. This podcast is for education and entertainment. It certainly is not medical or psychiatric advice, diagnosis or treatment. Listening does not create a doctor patient relationship with me or Dr. Drew. Your patients certainly don't change your treatment plan because of something you hear on the show. If you're a clinician, do not use this podcast as a reference or substitute for your own training, judgment, thinking and up to date sources. Opinions are our own and don't necessarily reflect any employer or affiliated organization and may even be detached from reality.

[B]

Good morning, Dr. Malsberg.

[A]

Good morning. How you doing?

[B]

Well, not bad. Back on the sugarless Red Bulls.

[A]

As you can see, once upon a time we. I thought you said bread bowl, but it's. You're drinking your Red Bull.

[B]

I do love a bread bowl. It's so pointless, but it's distinctly American. And you know, you got to have some San Francisco sourdough with that clam chowder.

[A]

Yeah, I haven't had one at Panera. The half. What was it? It was like half a soup, half a salad.

[B]

No, I've never been to a Panera bread. Isn't that weird?

[A]

Oh, wow.

[B]

I think that makes me completely aberrant.

[A]

What do you mean by aberrant?

[B]

Well, I'm abnormal. I think it's normal to go to a Panera Bread.

[A]

Yeah, it's very normal. It's very odd. I feel like you're revealing something about your character.

[B]

Yeah, I don't think this was our planned opener. Didn't you have something. You had some kind of opener?

[A]

Oh. Oh. So. So partially related to our topic during residency. The residency I actually went to, I had an interview with Dr. Gallagher, who's known for the suicide. He's famous in suicide research. I don't know. Famous is the word. He's a suicide researcher. And outside the door. So I was told to go to a random door. So I walked to the door and the door says, in big things, do not knock.

[B]

This sounds like a game show. Go on.

[A]

So I forget what time it was. It was scheduled for like 11:30. And so I sit down at like 11:25. And I'm not going to knock on a door that says do not knock. And then time keeps going and it goes to like 11:45. So I'm 15 minutes late and I'm like having an internal crisis of like, okay, I'm 15 minutes late. Does he think I'm not here, but I'm not going to knock on this door that says don't knock. And eventually he came out and he's like, why didn't you knock? I was like, it says it on the door.

[B]

Well, what did he say?

[A]

So the interview started 15 minutes late, and then it ended 10 minutes early. The only question he asked was like, have you read Freud? I said, yes. And he's like, what do you think? And I was like, This was for

[B]

a residency interview or this was for a residency interview.

[A]

Oh, man.

[B]

Okay, but how do you respond to the indication that you had not knocked because you saw the sign?

[A]

He was just like, you should have knocked. Oh, God. I was. Yeah, yeah, yeah.

[B]

Talk about double bind.

[A]

Yeah. It felt like a psychological test.

[B]

I would have yelled out, that's the way I do it. You follow the rules, but you're a little aberrant. Anyway. Okay, so today's topic, therefore, is suicide risk assessment. And I think at the outset, we should say that you cannot learn suicide assessment from one person, and you cannot learn it from one podcast, especially one episode. So we're not here to teach you psychiatry or the assessment of suicide risk so much as we're going to point you, I suppose, to a starting point and kind of globally discuss some issues. And the reason why we're doing this is because of a lovely email from psychiatrist Eric. Not me. Different person who says, would love an episode about a practical guide to suicidality, particularly when it presents in the Edge. I think so many educators tend to hedge on this topic, which leads to learners receiving mixed messages. Let's see if we can clear things up a little bit today.

[A]

Absolutely. And just to start, maybe I'll talk about some of my grievances with the suicide risk assessment. In residency, every single patient needed the suicide risk assessment. It was so burdensome to complete. And it essentially got to the point where. I mean, basically how hospital systems work is they hand down these tools, and then the tools are extremely burdensome to use, and you have to ask questions so that you can't do your own interview. And then you mindlessly fill out the tool and don't even think about what the tool even represents. That was my experience with a lot of these things. So our suicide risk assessment, which was required for every single patient, was just clicking every single box as quickly as possible and then typing, saying, the protective factors are that they're seeking care, that they're blah, blah, blah, blah, blah. The risk factors are that they're mentally ill, given all these risk factors. And then you would just say what you wanted to do. It was so burdensome. I hated it. It didn't help at all. And I Can maybe by the end I can explain why that suicide risk assessment was particularly unhelpful.

[B]

Well, I am curious, was that for every patient, every visit, Was that for every new patient? What was that?

[A]

So in the emergency room it was every patient, every visit because it was on admission and then on discharge and then if they were admitted you'd have to do another one. So essentially it was every patient. But so in the emergency room when a lot of patients are there for 24 hours. Yeah, you had to do it very quickly.

[B]

Do you happen to know the backstory of why that is, why they had that mandate?

[A]

I'm sure it has to do with a patient who was discharged and then committed suicide shortly after the discharge.

[B]

Actually, my understanding, I could be wrong here. I didn't exactly look into it like even a, you know, amateur historian, but my understanding is that that happened within the last. How many years is it now? Within the last 10 years? Because joint Commission in all of their wisdom basically looked at the statistic that I was going to mention a little later on and it's that the majority of completed suicides are not from patients presenting reporting suicidality. Okay. Majority of people who complete suicide are actually people who've never even seen a psychiatrist and usually have never mentioned suicidality at all. So, you know, Joint Commission being a very good group of people who knows a lot about clinical care and really makes great decisions in policy. I'm being sarcastic right now if you can, I can't tell thought that universal suicide screening in all settings would be a great way to do this without thinking for a second that this group of people probably never reports suicidality because they know how to hide it. And therefore simply asking them about it is not going to do very much. Now I don't know if they did any follow up studies to see if this universal screening actually changed anything, but I'll tell you this, I bet it changed the amount of documentation burden that people had to do in the United States.

[A]

And you bring up the thing that was the grand irony of the suicide risk assessment that we were doing in that it was asking in terms of risk factors for suicide, we were asking questions of previous attempts at suicide, the seriousness of their suicidal thoughts, any male, female. And the irony, the way they were presenting changes what the risk factors mean. Because in the emergency room if a patient has 15 suicide attempts, it sounds like that they're super high risk, but it doesn't actually indicate anything about risk for the patient in front of you. So it was all these different variables that didn't actually explain how I was thinking about the risk or help me to think through that risk.

[B]

I think I'll probably have to disagree with that. I think what you described sounded like the right suicide risk assessment based on research and practice. But I think the problem is applying it in a way that doesn't make sense or requiring checkboxes, so to speak. But I guess we're going to get into that. You know, you can do a clinical protocol, but if you do it blindly, you're doing cargo. Cult psychiatry, as I've in the early episodes had the tendency to refer to. We can't simply do the ritual. We have to understand where the ritual comes from and why it's done. And only then can we integrate that into our clinical thinking. So, yeah, I agree that poorly thought out mandates and policy, it's not going to help. That being said, especially after that particular requirement was, you know, put into the United States, you can't not do this anymore. You do have to do this for every new patient. And I think that you should do it explicitly on paper anytime there is an event that happens that would arguably change the suicide risk assessment, because now it's standard of care. Thanks, everybody. Even if it doesn't help care, if you create something that every reasonable clinician does, then that means that if you don't do it, someone can potentially have a cause of action against you in a court of law. So that's just kind of the system that we work in.

[A]

Yeah. And maybe I didn't word how I wanted to put it correctly, but I think the big problem was that we were doing this bureaucratic tool in replacement of actually thinking through the person's suicide risk. And when someone would ask, did you do the suicide risk assessment? They weren't asking, did you truly think through the patient's risks and benefits? They were asking, did you fill out that checkbox? And listen, if I had a great mentor who said, this checkbox is so that you don't get sued, and then we need to figure out how to really think through the problem, that would be awesome. But the issue is, I personally didn't have that teaching. This was done in replacement of the thinking and I didn't learn the proper way to think through the problem. Yeah.

[B]

And that is another problem. When we think about designing policy and systems and it's that if you create a box that forces people to do something that properly is a complex thinking task, then it replaces the complex thinking task because it becomes a symbol in place of the actual process. And then people can feel or think that they've actually done their job when really they've done the form. Right. I think you really see this when it comes to mental status exam documentation. In EMR is where it's checkbox instead of free text. I'm very much against that because you should have the flexibility to document in semi narrative form what you are actually seeing in front of you. It is not reasonable that every patient will neatly fit in their mental status exam into checkboxes. I feel like we're definitely getting into too much opinion now and not the actual episode topic, so maybe we should move on.

[A]

All right. Yeah. And I have more opinions to give, but let's, let's, let's get to the meat.

[B]

We'll save it for the end if we can remember to.

[A]

All right. Okay. You start us off.

[B]

All right. So I think when it comes to being any kind of clinician, whether you're a physician, emergency room doctor, psychiatrist, primary care doctor, social worker, if you have a job where you have to do suicide risk assessment, the first rule is basically a variation of what you have to do when you work in emergency settings. Don't be afraid, be professional. Or the old saying goes, in the emergency room, first take your own pulse. Right? If you are afraid, if you are overly fearful or anxious about talking about this topic and thinking about this topic and assessing this topic, you are going to consciously or unconsciously show this to the patient, the person you're talking to. And I think it's going to make it that much harder for somebody to be honest with you and to be clear and really get into the details of what's been going on with them. Because we don't want to get in there and ask for specific information so much as we need to build narrative. We need to understand, where's this person now, how did they get here and where are they going in a more global, real sense. Again, not checking off boxes as we were just talking about. That being said, you still have to get a good history.

[A]

Yeah, that reminds me, and I bring this up a bunch of times on the podcast, having a lot of times, what I would see in the emergency room is the resident would go up to a patient, they would do a super fast interview. Any thoughts? Hurting yourself, any thoughts are hurting other people? Are you hearing any voices? Are you seeing things other people can't see? And then it'd be like they'd turn to me in the room, be like, they're not suicidal. And the truth is those questions are going to shut down the patient entirely. You're not going to get access to their internal world, which, when you're asking what's clearly just a checklist of questions, this is gonna shut down patients. This is not gonna make them feel comfortable sharing. And what I do see is patients who wanna be discharged learn the rules. And the rules are say no to these questions, and then eventually you can get out. So it's actually really doing a lot of danger because it teaches patients that, like, if I wanna get discharged in the hospital, I just have to answer these questions the way I know they expect to be answered, and then I'm done.

[B]

Yeah, yeah. And a related point is, I think when we talk about this, it's very common and normal for the layperson listener, a certain type, to say, I hate inpatient hospitals. They don't help you. Inpatient hospitals don't help with suicidality. Why should I ever be honest about this? And, well, no one can force you to be honest. But in life across time, being honest with a healthcare provider of any kind is key for you to actually get better. So, you know, we're not gonna get into the philosophy of suicidal ideation acts across society. But my plea anyway is to stay honest regardless of what the system is. If you are full and honest and you work together with a physician clinical team, things will go better over time than the opposite.

[A]

And that's very challenging for patients because a lot of patients lose trust in their providers by being admitted for maybe just a comment or two about how they're feeling inside. So I think while you say that, I do want to give credence to the fact that this doesn't come from, you know, this comes from people learning the. From experience of being. I've seen patients who get admitted because they screened. Yes. For suicide and, you know, they didn't actually have intention or, you know, it was more of a feeling. But because the system didn't appropriately do the assessment, they get admitted for making, you know, a quick statement about how they're feeling.

[B]

Yeah, it's a big problem when clinicians are not adequately trained to do these assessments, but are nonetheless given the power to act. I remember one of the worst consults I ever got back when I still did that. I hate doing consults, but, you know, back in the day, you would do the things that you have to do. I was consulted by a surgeon to assess for suicidality in somebody who just went through some kind of a painful waking procedure and afterwards said something along the lines of, boy, if I have to go through that again, I'm Going to kill myself. Okay. And when I received this consult, I said, well, did you ask any follow up questions? They did not. Apparently, as far as I could tell, they just kind of quietly left the room instead of asking more questions, as if the assessment could only be performed by a psychiatrist. Okay. And of course, upon assessment, the patient was. No, it was just kind of a figure of speech. That was just a really awful procedure. You know, I don't want to kill myself. So, yeah, bad training leads to bad outcomes.

[A]

So one more quick one for the hospital. I worked at the detox. To get into detox, they had to not have any suicidality. Had one patient who came to the, they got transferred from detox because they screened for suicide. On, on the conversation, talking to them, they said like, yeah, if I don't get into detox, I'm gonna. I'm thinking about killing myself. No other suicidality aside from the fact that they didn't get into detox, they were thinking about suicide. So we got them into detox and they did fine. Okay.

[B]

A classic conditional suicidal remark. Okay. So, you know, we don't have the time, nor is this appropriate setting to talk about how you actually take a suicide history or document it. And for that I would lead you to your clinical supervision. If you're a learner or if you're, let's say, at around the medical student or intern level for this and you want to learn some basics, I would definitely just at least read the Columbia Suicide Severity Rating Scale. That's a pretty good scale, kind of a gold standard scale these days. It really does collect the history that you need. And remember, history is not the same as assessment. History is the first step towards assessment. And then there's also a great article, a classic one that I recommend to most people called how to Write a Suicide Practical Tips for Documenting the Evaluation of a Suicidal Patient. This is from Dr. Christos Ballis, published in the Psychiatric Times in 2007. Great article. I would read them both if you're on the beginner end of things.

[A]

Yeah, I read that pretty early and it definitely massively informed how I approach suicidality.

[B]

And then I think beyond the history and assessment, and we're still going to get into some details about that. The main thing that most people who are more new at this want to know is what's the criteria? What's the criteria for saying someone is suicidal or not?

[A]

Just a small plug to leave a review if you can. Leaving a review will help other clinicians find our show and will let us keep making it if you're on Apple podcasts, open the show page, scroll to ratings and review. If you like us, tap five stars. If you're not sure what to put for the review, just say, hi, Dr. Fu. And if you're on Reddit or YouTube, leave a comment. Dr. Fu reads absolutely every single one. Let's get back to the show.

[B]

I think it's because. And you see that. Because the question is not a binary. It is not a question of are they suicidal or not. Your job is not to predict the future. You cannot predict the future. And you should not make yourself out to anybody, patients, family, or the courts, the system at large, to be a predictor of actual outcomes. Okay? Unfortunately, a lot of people seem to think that we are able to do that, including other professionals who consult us. Right? That is not what you are doing when you're doing a suicide risk assessment. What you are doing is that you are grading the level of risk, okay? It's a complex process, and based on that and your understanding of where that risk comes from, recommending a treatment plan. This is going back to the fundamental job of a physician and every psychiatrist. Diagnosis formulation and treatment planning. Treatment recommendations, diagnosis formulation first leading you to treatment recommendations. That is suicide risk assessment.

[A]

Yeah. And that's totally different than, I feel like, how it's always been portrayed of like, are they going to do it or are they not going to do it?

[B]

Yeah, yeah, exactly. There's a classic teaching that I don't know I have permission to repeat for my forensic training. So I'm trying to think of a difference, a different analogy that will still paint the same picture. Okay, I have one. When you do this, you are again, not predicting the future. What you are doing is that you're almost actuarially, like as an actuary, you are almost rating the level of dangerousness. Okay? You're saying, is there dangerousness or not compared to the general population? Is there dangerous or dangerousness or not compared to this person's normal baseline? Those are the questions that you're actually answering. Imagine that you run a car insurance company, okay? Your job is not to say, is this person going to have a car accident or not in the next five years? It's a ridiculous thing. You're not going to be able to do that. What you're doing is you're saying, how dangerous is this driver, generally speaking, compared to the other person? And should we therefore insure them or raise their premium or not insure them? Right. Diagnosis and formulation. That then leads you to treatment planning.

[A]

So what you're saying is you're not saying whether or not they're going to do it. What you're doing is assessing their chronic risk. Then, based on their. On top of their chronic risk, their acute risk, is there anything going on that they're more likely or less likely to cause harm to themselves or others? And then if you feel like there is increased risk, what are you going to do about it?

[B]

Yeah. Yeah. And the key there then is to really have a deep understanding of psychopathology, human nature, statistics, normal and abnormal, clinical interviewing and assessment, and tease out, what variety of suicidal ideation am I seeing in front of me? And we'll talk now about some varieties of suicidal ideation. It's not an exhaustive list. It's impossible to come to a single list that will cover every single situation that you ever see clinically. Right. This is just to give you some ideas of a framework. But your job in interviewing is to get the narrative to understand why is this person doing or thinking what they're doing? That's the job. So here are some rough categories of the varieties of suicidal ideation. The first one is something we've just talked about, kind of. At least we presume this is what it is. It's true. Rational suicidality. Okay. I think that's very rare to see as a clinician, unless of course, you're a palliative care doctor. And I don't think we really consider that suicide these days. But when there is a intent or plan to end one's life and it's based on rational things, and it is not the product of any identifiable mental disorder that can be treated medically, that's one category. What's an example of this? Somebody who plans to end their life and they have no depression or psychosis or any mental health disorder because they want to cash in a large life insurance policy for the family, you can argue about the morality of that. You can even say that must be mental illness. But I would say that it's likely that there are varieties of suicidal intent that are not from a mental illness. Let me put it a different way. We are assessing the rationality, but we're not only assessing the rationality.

[A]

Correct.

[B]

You cannot stop at the rationality. Right. Because the varieties can coexist. There can be multiple factors that are causing the suicidal ideation. And our job is to find and medically address anything that can respond to some kind of treatment.

[A]

What's our next variety?

[B]

Yeah, so that first variety I'm pointing out because it's kind of something we don't know very much about. As psychiatrists, we don't see that variety actually. Okay, so you shouldn't assume that when there's someone in front of you, they are that variety. That's probably the better point to be made here.

[A]

Right?

[B]

That even if there seems to be something rational, the fact that someone is in front of you as a psychiatrist means that the pretest probability is high that they are not of the variety where it's purely rational. Okay, so second type of suicidality is suicidal ideation. That is a dysregulated response to a stressor. What do I mean by that? I mean that there are some people where when they're sufficiently stressed out or feeling badly, they will go to suicidal ideation. You can call that a coping skill. You can call that a desire to escape stress or suffering. You can call it a way to use aggression where they don't know where to turn it. Whatever the theory is, you can see that some people don't really get the ideation at all until they're under extreme level of stress. You know, think someone who just went through a really, really awful breakup and they're just feeling really desperate. That's an example.

[A]

So for this patient, you're not. This isn't the type of patient that is. You know, I'm thinking of the borderline personality disorder where suicide thoughts are part of their entire experience. This is someone who. It's not a day to day thing or a common thing is what you're saying.

[B]

Yeah. We should understand when someone has this as a chronic problem versus when it's essentially a stress based contextual problem. And of course, the diagnosis that matches this particular presentation the most in the DSM system is adjustment disorder.

[A]

Right.

[B]

In this particular kind of patient, we anticipate that with enough time or with resolution of the stressor, the suicidal ideation will go away. It's not a baseline feature for them. Why do I mention this? Well, it's because actually one's tendency to think about, plan or attempt suicide doesn't seem to be just about what the person is going through. Either from a diagnosable mental disorder like depression or, or bipolar disorder or from stressors. It seems very individual about whether or not people will do it. You can see people living the most awful life possible that you can imagine who will say, I will never think about even suicide or commit it and they never do. And then you'll see people with relatively mild experiences, but it still stresses them out and they'll immediately think about killing themselves.

[A]

Right.

[B]

So it's a mistake to think that suicidal ideation is inherently tied into a particular mental condition, even if some mental conditions obviously lend more towards suicidal ideation.

[A]

Yeah, I'm thinking of. I feel like Bill Burr has a bit that, like, if something awful is going in his life and you know, he has a big breakup and all these things, he never once thinks of suicide. But if he goes to Starbucks and there's a long line, the first thing that pops in his head is I should just kill myself. And he says it jokingly, but I think he's being serious in that. I just think that captures a different patient than yeah, yeah.

[B]

Now the point of basically identifying this adjustment scenario, and we're presuming that it's been correctly identified, is that the long term treatment is different and sometimes the short term treatment is different than other varieties. This is a variety where the short term involuntary detention model, which you see in most of the United States, all the United States, I believe, is warranted. If you give a supportive environment, a safe environment, which unfortunately many inpatient units are not today, and they should be, then people can take the time to calm down, talk through their situation and get the social support that they need to at least turn the volume down on how much they're suffering based on what's happening and get whatever changes they need in their lives to stop thinking about as seriously or planning or intending to hurt or kill themselves.

[A]

And you'll probably get into this a little bit more. But this is why the formulation backing the suicide risk assessment is the most important thing. Because the correct response to suicidality really depends on the patient. So here, as you're saying, is the best treatment for a patient that has what you're describing, which is an adjustment disorder, is hospitalization, because it does actually help and benefit their long term mental health. We'll talk in a second, I'm sure, about patients who use suicidality as a coping skill or as a way of getting other people to feel things, in which case hospitalization can be very harmful. So I like that we're kind of getting talking about narrative, talking about formulation, and that the big component about what you're going to do is in the end related to the patient's long term, best functionality outcome.

[B]

That's right. And very much related to the adjustment disorder type suicidality in my mind, is the suicidal ideation as a feature of acute intoxication. Because they often go hand in hand.

[A]

Right.

[B]

A lot of people, when they undergo some kind of a major stress in their lives, may turn to intoxicants of, you know, drugs, alcohol, whatever it may be. And many of these can dysregulate people.

[A]

Right.

[B]

So you can think of two factors that can lend towards suicidality in the acute phase. Right. You have things that lower your ability to cope. Intoxicants, drugs, alcohol. And you have things that raise your level of distress. Stressors, major life conflicts and issues.

[A]

Right.

[B]

When you combine those two in particular, that's when the involuntary detainment is extremely applicable.

[A]

Right.

[B]

Many people will only have serious suicidal ideation, intent and planning when they are both stressed and intoxicated. And then even if they're still stressed after the two days that they sober up, they may no longer be genuinely suicidal. Right. And so again, that's the other related category where simply you need time and support rather than any particular specialized short term or long term treatment.

[A]

Absolutely. All right, what's our next category of suicidality?

[B]

I think the next category that's important to talk about is when suicidal ideation is a baseline.

[A]

Okay.

[B]

Again, you can call it a coping skill, you can call it a repetitive thought, you can call it maladaptive tendencies, you can call it whatever you want. But for some people, they do simply have at their baseline, even without a particular stress in their life, just thoughts about not wanting to be alive, wanting to hurt or kill themselves most of the time. Now the classical diagnosis associated with this is of course dsm, Borderline personality disorder. But that's not the only personality condition where people can have this. Right. You might see this in a dysthymic disorder. That's possible. And you can see it in many other conditions. I've seen it though. When I see it in this setting, I consider that there's borderline traits. I've seen it. Intellectual disability, you could see it in a cluster C personality. Even if they have less aggression and self harming tendencies, they may have the fun thought quite a lot. Right. You can see it as sort of a manifestation in autism spectrum disorders of a certain type. But again, I think there are some mixed personality traits in those situations. But what I'm getting at is that there is a group of people where they think about suicide all the time. You know, can be a daily basis, can be a weekly basis or even just a monthly basis or less. But it's essentially a feature of their day to day life.

[A]

Yeah, I'm glad you mentioned that. It's part and parcel of borderline personality disorder. But the group that you're describing is a very heterogeneous group. And the purpose or what the suicidality is serving is different for every person in this group because I've had on one hand I've seen patients who use their suicidality in a manipulative way to get the things that they want. They're. I've seen parents not being willing to give their inheritance or not. You know, they have a trust fund and the person wants money now and then they raise their level of suicidality. I've also seen patients who I've had as patients for a really long time and only after, you know, two years of them being my patient, they open up and say like, hey, this is something that I really haven't told anyone because I'm a little scared of what people will think. But I pretty much think about suicidality pretty much every day. I don't tell anyone in my life. It's just this little background thing that, you know, I'm not never going to do it, but it's just this background monologue that kind of occurs in my head. So this is a very different. There's a huge. We don't. For each individual patient, the purpose that the suicidality is serving is very different.

[B]

Yeah, it's very important. I'm glad you emphasized how various this group is because as a result this group can be referred for emergency evaluation and detainment and treatment both appropriately and inappropriately. And it can be a little hard to tell because sometimes this is something that becomes more of an acute danger because again of intoxicants and acute stressors. Right. Even if they have a baseline of thinking these things, they can become dangerous and impulsive under enough stress. Anyone can.

[A]

Right.

[B]

That's human. On the other hand, sometimes people who have a baseline suicidal ideation recurrent type will be inappropriately referred because somebody who maybe doesn't have enough training in their assessment might refer or it can even be a well meaning family member who gets very scared when they learn about it for the first time. Right. Some people think suicidal ideation go to the emergency room, which is not necessarily the case. And we don't expect laypeople to be able to tease this out. But that's the job of the emergency room doctor, right? To be able to determine is dangerousness elevated, if so, what's the treatment. And so for this group of patients, depending on what's going on, again, the cooling off period of emergency detainment, supportive environment and ensuring safety can be be the indicated treatment. But sometimes the indicated treatment may not be hospital admission. Sometimes hospital admission can potentially slow down the overall progress towards getting better, which would be Getting an understanding of these thoughts, where they come from, if they come from anything, what makes them better or worse, and what to do with them. And that's a talk therapy issue. Right. In the classical borderline personality disorder type of the DSM variety, you would do something like a DBT, for example, for that. But of course, every patient is different and deserves an individual formulation.

[A]

So far, we have the true rational suicidality. We have the dysregulated response to a stressor what we said most.

[B]

Or intoxicant.

[A]

Or intoxicant. We have the baseline recurrent suicidal ideation as a coping skill or just a repetitive thought as a result of personality. Keep going. Yeah.

[B]

Then we finally get to one that feels a little bit more medical because medications will finally be indicated. Okay. Keep that in mind. By the way, so far, with the varieties of suicidal ideation we've talked about so far, none of these respond to an ssri. Okay. None of these respond to an antidepressant primarily. So do not just think someone is suicidal or depressed. Give an ssri. Right. You need to have a formulation, diagnosis and treatment plan before you prescribe things. But suicidal ideation is dangerous.

[A]

What's that? That doesn't mean that the person shouldn't get me ssri. So one thing I've learned in terms of all these, a lot of these patients, this applies to a lot of different diagnoses. Patients who have suicidality likely have a comorbidity that will respond to an SSRI and potentially decrease suicidality. So it doesn't mean that they shouldn't get a SSRI or get medication. It just means that the symptom by itself does not warrant medication.

[B]

Yes. I can't disagree with that, but I do disagree with the emphasis and the reason why I emphasized it the way I did.

[A]

You're de emphasizing?

[B]

I think so, yes. Because I think that the common practice today is to simply assume that the presence of suicidality or reported depression means that you should give an ssri. If we were in the era where we may be going to in another decade where people are under prescribing, then we may rephrase what we say. But yes, balance is key. Again, you need to look at the whole picture and see what is likely to or not likely to respond to what kind of treatment. So the next category is suicidal ideation. That is a inherent feature of some. Moderate to severe, usually can be mild mood or primary mental disorder, schizophrenias, major depressive disorders, bipolar disorders, anything. It could even be. It could even be enough distress from ptsd that that they want to kill themselves. It could be anything. It could be suicidal ideation secondary to pain from a medical condition. The point is it's secondary to something treatable. But since we're psychiatrists, let's focus on the psychiatric things. If it's bipolar, don't forget lithium. If they're appropriate for clozapine, don't forget clozapine in schizophrenias. But you don't have to necessarily go to the big guns. What you have to do is that you do have to treat the underlying condition. And while that underlying condition is being treated, that may in some cases require involuntary detainment because many of these medications take minimum two weeks to really start kicking in. Right. And this is again why there is any culture in practice at all of inpatient psychiatry, because often these situations do medically warrant inpatient stays.

[A]

Yeah. And just to you mentioned those two medications not at random, those are the two medications that have shown to have evidence in reducing suicidality. Lithium for bipolar and clozapine for schizophrenic patients has shown to actually reduce suicidality.

[B]

Suicidality and SSRIs have not been shown to specifically reduce suicidality, though of course they have far less side effects and are much safer than older antidepressants. So they still came with a decrease in suicide risk across the board as a public health concern when they were invented. So they're not bad medications, but you have to know when they're indicated. There's a final category and again, there are going to be more categories, but there's a final category I want to mention because of its oddness in a way many clinicians aren't familiar with this. Patients themselves may not necessarily understand it until you give the appropriate psychoeducation. People can have thoughts about suicide as part of a obsessive and compulsive disorder type process. Properly it will be called a ego dystonic obsession with matching compulsions. In rare instances, the person with OCD who has thoughts about self harming or suicide may also want it too if they have another axis one condition or axis two personality condition that makes them suicidal or they're stressed out. But people can simply have it as a recurrent obsessional thought. And how do you tell the difference? Well, you need to examine the compulsions, both the mental and physical acts that come along with the suicidal ideation. One I could think about was that one of my previous patients would frequently have intrusive thoughts about. Actually this is multiple patients would often have intrusive thoughts about jumping in front of A vehicle or a train. This uniformly made them frightened. Okay. And the compulsions that were associated with this would be first repetitive thoughts, checking within themselves. Do I actually want to hurt or kill myself? Am I depressed? Okay. And also checking in with other people, please make sure I keep myself safe, don't let me do anything crazy. Right. Because they assume that the fact that they were having these thoughts meant that they actually wanted to do it, even if they were afraid of it. Right. If you have appropriately identified this as a feature of ocd, then the treatment is of course a talk therapy for ocd.

[A]

Right.

[B]

And this can get very, very, very difficult to tell when it's in the setting of a co occurring psychosis or depression, which can happen. Right. So this gets very advanced. And I would leave this to the psychiatrists personally.

[A]

You know, it's funny, this is one of those things that's going to be severely under diagnosed and we're about to see it in my. This is just a prediction. We're about to see it over diagnosed. Just in terms of what I see now with tms, one of the indications is ocd and I've heard of a lot of patients whose borderline personality disorder is formulated through OCD because it's one of. It's a more preferred diagnosis. I think we should do an episode on preferred diagnoses one day. But. And their symptoms of suicidality, which are better formulated through borderline, are being inappropriately formulated through the OCD ego dystonic obsession lens. So I think we're about to see it increase the misdiagnosis.

[B]

Well, that's a very tricky area and we can consider this a little bonus discussion. That's a very tricky area for me because I think in my experience there's definitely a subtype of borderline personality disorder, DSM diagnosable, that comes with obsessions and compulsions. And on initial and even later interview it may seem like obsessive compulsive disorder. It's very, very easy for them to look the same. You know, there's certain things in medicine that just mimic other things and can mimic like a billion other things. Right. Pheochromocytoma is a famous example of that. As one condition that can look like a bunch of different other stuff. I'm sure there are some others from medical school that I'm forgetting, but in my opinion borderline personality disorder is actually one of them. It can look like a lot of different things. It can look like a depressive disorder, it can look like a addiction disorder, it can look like A trauma disorder. And in some people it can also look like obsessive compulsive disorder. But what I find is that like obsessive compulsive disorder, their apparent obsessions and compulsions wax and wane with stress. That's normal. But unlike obsessive compulsive disorder, they do not respond well to ERP and SSRI treatment. Why? Because I think what's happening in this subset of patients is that the underlying problem is the self and other relating the personality functioning problem. And that needs to be addressed first because they have many different manifestations of that stress and distress related to their self interpersonal functioning. Whereas in a classical OCD, their self and interpersonal functioning is pretty much normative. And the main problem is the repetitive thoughts, intrusive thoughts and the compulsions.

[A]

All right, so just to wrap up very quickly, we talked about the different varieties of si. True rational suicidality. SI is a dysregulated response to a stressor baseline recurrent ideation as a coping skill versus repetitive thoughts secondary to personality. SI is a feature of SMI and SI as an ego dystonic obsession.

[B]

So then I guess we can try our best now because I think we covered most of. I wanted most of what I wanted to talk about. We can try our best now to say still, where's the bar? Where's the bar? Well, it's not that simple, as I've said. But this is basically what you do. You globally consider the patient, you globally consider their history. And now you look at what are the things that are actively raising their suicide risk right now and what are the things that raise their suicide risk that will never go away? And what are the things that are protecting them right now? And what are the things that are protective that are never going to go away? Right. You're looking at short term and long term for risk factors and protective factors. Sum them all up. Align that to your understanding of the variety of suicidal ideation or varieties that this patient has and the treatment options. Then decide on a treatment plan. Okay? So don't worry about answering, is this person dangerous or not just yet. Everyone's dangerous. Okay. Even if someone has no history of ideation, intent, planning or acts around hurting themselves or others, it's always theoretically possible that some situation might emerge where they would do it. Right. For example, with dangerousness to others, self defense. Right. It's possible. We're not predicting the future, we're just risk stratifying. So once you've determined the appropriate treatment plan, then you'll know, does this person need to be kept in the hospital for a couple days? Do they need to be kept for a couple weeks while you adjust medications? Do they not need to be in the hospital? But we need to create a safety and treatment plan at home in conjunction with family. Do they need a therapist in the long run? And this is what they're going to to be encouraged to be engaged with. Do they need rehab? Do they need detox? Do they need to engage in support groups? Once you have that treatment plan, then you're going to know what to do.

[A]

Ian, I'm glad you're bringing this up in terms of a holistic evaluation, because what I would see all the time in residency was patients or providers would be like, oh, they're just borderline discharge. This is all just borderline. And that's so dangerous because. Or they'll say like, oh, it's all cluster B stuff. It's cluster B, just discharge. And we have to keep in mind that the global holistic formulation is the more important thing, because patients with borderline personality disorder are at an elevated risk compared to patients without borderline personality disorder of completing suicide. So it's not just. We're not trying to identify one or two variables that tell us what the information is. We're doing a full assessment based on lots of variables and lots of different things. And I do want to spend a little bit of time talking about Gallonker's formulation of the acute suicidal crisis state. Have you heard about that?

[B]

Probably not specifically attributed to him, but let's go over it first, and I'll tell how familiar I am with it.

[A]

Yeah. So he points out to the two important things. So first he describes a syndrome that he calls the acute suicidal crisis state. And that's a cluster of symptoms that he considers the most worrisome with regards to elevated risk of suicidality. And these are acute symptoms that you see. So those five things are entrapment. So if a patient feels trapped or hopeless or that they're stuck in a situation, that to me is actually probably the most important thing that you can see in a patient that would warrant. That would increase my risk. The second thing is affective disturbance. So any sort of intense emotionality, panic, rage, dread, essentially feeling of emotional distress. The third is loss of cognitive control. So for patients with elevated suicidality, what you're seeing is very rigid thoughts. When you're talking to them and you're trying to maybe talk about solutions or talk about different ways of thinking about them, you'll experience a lot of rigidity. You'll experience an inability. Like maybe you'll start talking something and it'll keep circling back to what they're kind of talking about or their problems.

[B]

Yeah, in my training that was called tunnel vision. But yes, a very important topic.

[A]

Yes, tunnel vision.

[B]

Go on.

[A]

The fourth is hyperarousal. So we're thinking of not the depressed slow, the patient who's withdrawn, talking about, like, agitation, insomnia, feeling irritable, being really activated.

[B]

That's why bipolar and agitated depressions are the most dangerous in terms of treatable medical conditions towards suicidality.

[A]

And then the fifth thing, that cluster of symptoms is social withdrawal. So you'll see that they're not in touch with their friends and family that they're normally in touch with. They're pulling away from others. Now, how the way to think about the two most. The two biggest things, those are the cluster of symptoms that you see in the patient. That's worrisome. And what he says is probably the most important variable is the clinician's emotional response to the patient. So he thinks of the countertransference you experience with the patient. That gut feeling that you get when you're sitting with that patient is probably the most important information for predicting whether or not a patient's gonna commit suicide. So everyone's countertransference is gonna be different in regards to what it is that warrants for that increases risk of suicide. The one that stuck with me is the feeling of hopelessness, of feeling trapped. So those two things when I'm with a patient and feel hopeless and trapped are the most concerning. The things that he said that the things that he warns about is any patient who evokes a strong pull to either rescue or over involve yourself or on the flip side, to detach and just like, give up on a patient. So just those are the two things that he warns about. The over involvement versus the like wanting to push away.

[B]

Yeah, those are interesting. I think they're important. You obviously wouldn't be able to raise that in a court of law for involuntary detainment purposes, which is more relevant in some states than others. Because you can get challenged seven times in a court of law for involuntary detainment in some states versus within the first two weeks compared to some other states where it takes 50 days. I think it's definitely clinically relevant. I think that the countertransference issue is really pointing to the presence of borderline personality organization, or DSM defined alternative model, low level of personality functioning. If you have intense countertransferential feelings of Any type, that's a sign of self and interpersonal functioning and that can, especially under distress, be quite dangerous. Even if they have a recurrent baseline suicidal ideation and self injury, under distress, they may be more impulsive and lethal than under other times. So that does warrant observation and containment.

[A]

Yeah. And my big takeaway is that when I'm assessing risk, I'm paying attention one to how I'm feeling. And the things that really concern me is when I feel like a patient feels trapped and when I feel like a patient is, as I mentioned, hyperarousal and the feeling of hopelessness in the room are the things that really raise my, my risk for suicidality.

[B]

Personally, I say if a patient is not at their normal level of risk, based on your assessment, that is a sign to consider changing the treatment plan. Okay. And how you change the treatment plan, then deter is determined on is the patient's level of risk of acting on this real and different than normal? Right. And that's that clinical judgment call. That is why trainees think that this is waffling or inconsistent. It's because it is unfortunately clinically subjective. It is based on the clinician's own experiences in treating people and assessing people. And it's going to be contextual and it's going to be subjective. We don't have another choice.

[A]

Right.

[B]

There is no biomarker for suicide dangerousness. Right. You can know all the studies and all the data and the research up and down, but that's not going to tell you a prediction of the patient in front of you. And ultimately the majority of states will punish the doctor. Okay? Punish the doctor for being more lax rather than being more strict in terms of you will not go wrong for involuntary detainment and allowing a judge or a judicial officer to release the patient. But if you release the patient and they go on to do anything dangerous, your license and your money is going to be on the line. If you don't like that, you're going to have to change social policy. People out there, laypeople. But that's not something that the physicians have decided. Okay. That's something that policymakers and politicians and legislators and everybody in society have decided for us. We have to follow the rules.

[A]

This brings me to my big question, because I know you have a good familiarity with the legal system and as it connects to this, what are the things that practitioners do that gets them in trouble and what are the things they can do to protect themselves?

[B]

Well, ultimately you're less liable. Okay, let me put it this way. What you're ultimately liable for isn't an outcome, it's a process. So what you need to be doing is that you need to be actually doing your assessment process within the standard of care and also documenting it. Yes, unfortunately, documentation burden is a normal and just inextricable part of our practice today. You have to document, you have to do the thing and then you have to document it. Don't spend more time on documentation than you need to, though. You need to put enough detail in there that an average reasonable person would conclude that, yes, you did your job, but in the end it's about aligning yourself to the process and then picking the right treatment plan based on your conclusion. You don't need to be 100% accurate, but you need to have fidelity to the standard of care.

[A]

So what are the things? I mean, you mentioned documentation, documenting what

[B]

is protective, documenting what your exam findings were, the history that you got, and the thinking process that led you to your conclusion. That's what you need to document. And unfortunately, if your training or own reasoning is inadequate, then you're still going to get in trouble, right? But if your training is good and your reasoning is good and you document it, no matter the outcome, if you have done your job, technically you're not supposed to be liable. Now, there are still outrageous court cases out there, but there are few in number and hopefully you won't be one of them. And for that, make sure your malpractice insurance is up to date.

[A]

And what are the things that you see people get in trouble for? Like what are things commonly that occur that you've seen people had bad, bad get, get legally in trouble?

[B]

I mean, I wouldn't say I'm an expert on that particular area. I haven't done some kind of survey of all the successful malpractice cases, but I'm going to just say globally, what you get in trouble for is not doing the standard of care, your full assessment and treatment planning, or not documenting in a way so that people had enough doubt that you actually did the job you're supposed to do. If you want to get a familiarity with this beyond my global summary of that, subscribe to your local medical board's newsletter of discipline or go onto any of the many excellent popular blogs now newsletters that kind of post and discuss civil cases for malpractice and you'll be able to search for things that pertain to suicide risk assessment and see what's going on.

[A]

We're getting close to time, but I'm curious. I guess we haven't touched on. What are the things with regards to suicidality that really worry you? What are your red flags? What are your, what are the things that kind of set raise your alarm bells?

[B]

I don't worry, as I said, you know, don't worry, don't be afraid. Just be professional. But what makes me refer out or escalate the level of care, again is more clinical change of this patient's baseline. Because we presume that every patient remains alive as far as we have seen them up until the nearest visit. Right. We're not pathologists. So if you see a change from the patient's clinical baseline or if you don't know the patient's clinical baseline and their risk assessment is showing things like they won't contract for safety, they have been planning and preparing things, then those are indicators that you need to more seriously consider change in the level of care or a change in the treatment plan. But beyond that, it's so case to case that I don't think I can comment more.

[A]

Okay, I see we're running close to time. Any other topics you want to touch on for this?

[B]

Not really. I feel like we should say, and maybe even put at the beginning of the podcast, my apologies that we did not do another tier list. I think the people on Reddit hated it. Maybe they didn't even listen. But it seemed that it was quite popular with the people. But Dr. Malsberg wanted to do another one as was requested, and it was my fault for saying let's do something of a little bit more inside baseball substance for the clinicians before we do another tier list. But I think the next one will be a tier list and you can put that up at the front if you want.

[A]

All right, well, we'll leave it for the back. Now, there's one other thing I want to talk about. I think pretty soon we're going to be starting. I think we're thinking about starting a Patreon, and I really want to build somewhat of a community. And I'm curious listeners who are deep into this podcast. I genuinely want your feedback in terms of what you would do you think, would you subscribe to a Patreon? Is there something else that you would subscribe to? Is that something you think is a good idea? What would you want to see as a part of the Patreon? Yeah, I would just like to hear people's thoughts in terms of potentially monetizing our little podcast.

[B]

And on my end, I'd like to wonder about whether, well, I think that we should do a non professional podcast on the side here, me and Dr. Malsberg. I think I have confidence in our thinking and our interests that we can talk about just random things on the Internet or things on the news or societal topics and that people might be interested to hear that, even people who've never heard this podcast before. But of course, I could be overestimating our potential popularity, but I'd be curious for any commentators to say if that's something they'd want to hear more of.

[A]

I definitely think so. But the problem is we don't have a lot of time. And the time that we do have, we got to get the psychiatric learning out there. So while I don't disagree, I think

[B]

we've had a lot of good backlog. You know, there's only a finite amount of things we can really talk about. I always feel like we've exhausted that. But I know we have always meant

[A]

to find there's so much more,

[B]

but all right, okay. Until next time,

[A]

thanks for listening. If you want to support the show, check out my very friendly antidepressant course. If you want to check that out, go to Psycho Arm Farm. If you prefer to read, you can go to Amazon.com you can just search my name Gregory G R E O R Y Mallsford M A L D B E R G and the book is Psychopharm's Guide to Treating Depression. Nice, easy, readable practical guide to depression Medications for Depression.