Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management

I did not hesitate to accept the opportunity to review Robert Simon’s latest book on suicide. I have come to expect great things from him over the years. This book is not a disappointment. It is an easy and enjoyable read, informative, filled with relevant and interesting clinical cases, and built around an inescapable reality. The fact is that the most frequent reason for a malpractice lawsuit against a psychiatrist is the suicide of a family member who was the patient. In the foreword, Thomas G. Gutheil explains how the shifts in legal theory from blaming the victim to blaming the treating physician occurred. The management of the risk of suicide has become one of the major hazards of contemporary psychiatric practice.

I read this concise book on a long automobile trip. From time to time I would read passages out loud to my nonphysician wife, who was the driver. She was also fascinated by aspects of the book, which should be of great interest to the layman as well. All physicians and attorneys, for that matter, could benefit from reading this work.

I loved the scholarship and the erudition. The quotes at the beginning of the eight chapters are worth reading on their own. Perhaps my favorite is from Sir William Osler’s Aequanimitas: “Errors in judgment must occur in the practice of an art which consists largely of balancing probabilities.” A close second is from Voltaire in a letter to Emperor Frederick the Great: “Doubt is not a very pleasant condition, but certainty is absurd.” It is in this setting that Dr. Simon casts his net. No standard of care exists for the prediction of suicide. It is a rare event. Most patients with depression do not kill themselves. Yet, when it occurs, the family often blames the treating doctor for the failure to predict, protect, and cure.

This book does two things well. It provides friendly, optimistic practical advice on developing suicide risk assessment documents and suicide prevention contracts, discussing at length the pros and cons of such documents. Dr. Simon uses different settings to describe the complexities of outpatient, inpatient, emergency, and collaborative treatment. Second, he deals with coping with the aftermath of the patient’s suicide, including the care of the survivors, the documentation that is required, and the need for confidentiality.

A personal problem I have with the approach of “defensive medicine” was stimulated in a small way by the need to develop a legal defense if sued. For more than 40 years I have practiced psychiatry without basing my treatment on how it will appear in court, and I refuse to practice with the specter of an attorney looking over my shoulder. I fear I am hopelessly out of date, but I suspect that using the fear of a lawsuit to grab the attention of a young resident in psychiatry to do the right thing is, as T.S. Eliot wrote, “the greatest treason: To do the right deed for the wrong reason.” Robert Simon goes to great lengths to avoid that temptation, but it is still there.

I agree with the assessment of this book by Robert L. Sadoff, another legal psychiatrist for whom I have enormous respect. “Bob Simon’s books always make sense and are extremely helpful to the practicing psychiatrist. This one is no exception.”