“No Suicidal Ideation”: An Inadequate Managed Care Response

To the Editor: “Your patient is denying suicidal ideation, so he does not meet our criteria for continued acute hospital psychiatric care.” This is a refrain that I have frequently heard from managed care reviewers, particularly those authorizing only ultrashort hospital stays (1). However, individuals who are familiar with malpractice litigation of wrongful deaths know that asking only about suicidal ideation is considered prima facie evidence of an inadequate suicide risk assessment (2).

A recent article in the journal Focus proposed instead the evaluation of static, dynamic, and risk reduction factors as a comprehensive method of understanding a patient's risk of suicide (3). Static risks are defined as factors that do not change, such as age, sex, personal losses, history of suicide attempts, previous relationship ruptures, and family history of mental illness. Dynamic factors are changeable factors, such as mood, goals, impulsivity, hopefulness, and access to firearms. Risk reduction factors include being pregnant, being a caregiver for children, being employed, and having positive therapeutic and social support (3).

An inpatient's denial of suicidal thoughts to an interviewer provides no information about changes that may have occurred to modify the severity of static factors, alter dynamic ones, or promote risk reduction elements in a patient's intention to kill him- or herself. It is simply the answer to a question.

If reviewers for managed care companies and their physician advisors are committed to helping our patients effectively use financial health care resources, then their reviews of the treatment of suicidal patients must obtain information about what has changed in a patient's life during hospitalization that reduces the wish to die or increases the will to live. “No suicidal ideation” leaves this to the imagination of the beholder and is unworthy of our uncritical acceptance.