New APA Practice Guideline on the Assessment and Treatment of Patients With Suicidal Behaviors
A new guideline designed to help clinicians assess and treat adult patients who exhibit suicidal behaviors and express suicidal thoughts has been approved by the board of trustees of the American Psychiatric Association (APA). The guideline cites studies indicating that the incidence of suicide in the U.S. population is about 10.7 suicides for every 100,000 persons, or .0107 percent. Suicide attempts occur in about .7 percent of the population. The guideline notes that the "statistical rarity of suicide, even in groups known to be at higher risk than the general population, contributes to the impossibility of predicting suicide," even when the clinician has made a comprehensive assessment of suicide risk.
Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors describes the psychiatric evaluation as "the essential element of the suicide assessment process." The extensive section on assessment makes recommendations for evaluating a patient's risk in several domains: current presentation of suicidality; psychiatric illnesses; medical and psychiatric history, including family history; psychosocial situation; and individual strengths and vulnerabilities. The section lists dozens of specific questions that may help the clinician inquire about suicidal thoughts, plans, and behaviors. Factors that have been shown to be associated with suicide, in such domains as demographic characteristics, psychiatric diagnoses, physical illnesses, and family and genetic history—as well as factors that offer protective effects—are each addressed in detail by means of extensive literature summaries.
The goal of the suicide risk assessment is to identify factors that may increase or decrease a patient's level of suicide risk, to estimate an overall level of suicide risk, and to develop a treatment plan that addresses patient safety and factors contributing to suicide risk that can be modified. The guideline describes the estimation of suicide risk as "the quintessential clinical judgment since no study has identified one specific risk factor or set of risk factors that is specifically predictive of suicide or other suicidal behavior."
The section on management of the suicidal patient provides guidance and makes recommendations in such areas as establishing and maintaining a therapeutic alliance with the patient, attending to the patient's safety, determining the level of care and treatment setting, developing a treatment plan, coordinating care and collaborating with other providers, promoting the patient's adherence to the treatment plan, and providing education to the patient and family.
Specific treatment modalities are addressed in a separate section and include a range of somatic therapies and psychotherapies. A section on risk management and documentation includes a discussion of the usefulness and limitations of suicide contracts.
The document is the result of a process that began early in 2002 with a comprehensive literature review in which more than 17,500 articles were screened to provide findings for the evidence tables. The initial draft was produced by a work group that included psychiatrists with clinical and research experience in suicide and suicidality. Multiple revised drafts followed, and six organizations and more than 60 individuals representing key mental health disciplines submitted significant comments. The practice guideline represents a synthesis of current scientific knowledge and "rational clinical practice." Each recommendation is keyed according to the level of confidence with which it is made. The introduction states that the guideline "strives to be as free as possible of bias toward any theoretical approach to treatment."
Part A of the guideline has been published as a supplement to the November issue of the American Journal of Psychiatry. It presents the general and specific recommendations for assessment, treatment, and documentation and ends with a list of 660 references keyed from A through G to indicate the type of study and nature of the supporting evidence in the reference. The entire practice guideline, which also includes Part B—"Background Information and Review of Available Evidence"—and Part C—"Future Research Needs"—is available on the APA Web site at www.psych.org and will be published next spring by American Psychiatric Publishing, Inc. as part of a compendium of APA guidelines
Nearly Half of Persons in Addiction Treatment Abuse Both Alcohol and Drugs, 2002 Survey Finds
Nearly half of the 1.1 million people receiving substance abuse treatment services were in treatment for both drug and alcohol disorders, according to the 2002 National Survey of Substance Abuse Treatment Services (N-SSATS) released in October by the Substance Abuse and Mental Health Services Administration.
The annual "snapshot" of treatment facilities and services showed that on a typical day in 2002, a total of 1,136,287 persons were receiving substance abuse treatment. Twenty-one percent were in treatment for an alcohol disorder alone, 31 percent were being treated for a drug use disorder alone, and 48 percent were being treated for both. About 8 percent of all treatment recipients, or 91,851 persons, were under the age of 18.
N-SSATS collects data on the location, characteristics, and use of alcohol and drug treatment facilities and services in the 50 states, the District of Columbia, and other U.S. jurisdictions. In 2002, a total of 13,720 facilities—96 percent of eligible facilities—participated in the survey, which was conducted on March 29, 2002. The current N-SSATS, formerly known as the Uniform Facility Data Set survey, is the 25th in a series of national efforts begun in the 1970s to gather data to help federal, state, and local governments assess the nature and extent of services provided to forecast treatment resource requirements. In 2002, facilities were given the option of responding to the survey on the Internet.
Nearly half of all facilities in the 2002 survey (49 percent) had special programs for persons with diagnoses of co-occurring substance use and mental disorders. More than a third (37 percent) offered programs to treat adolescents. Special programs or groups for persons arrested for driving under the influence of drugs or alcohol were offered by 35 percent of the facilities.
Outpatient treatment was the most widely available type of care, with 74 percent of the facilities offering this level of care. Most of the patients who were in treatment on the survey date (90 percent) were enrolled in some type of outpatient care. Of these, 54 percent were in regular outpatient treatment. More intensive outpatient care was offered by 44 percent of the facilities and was the mode of treatment for 12 percent of patients. Day treatment or partial hospitalization programs were offered by 15 percent of all facilities, and 3 percent of patients received these services.
Two percent of patients were being treated in outpatient detoxification programs, which were offered by 12 percent of facilities surveyed. Eight percent of the facilities offered opioid treatment, and 19 percent of the 1.1 million persons in treatment received outpatient methadone or LAAM maintenance at these facilities.
Residential detoxification was offered by 8 percent of the facilities in the survey, and hospital inpatient detoxification was offered by 7 percent. Each mode of care accounted for less than 1 percent of the treatment population. About 8 percent of patients were being treated in residential rehabilitation programs, and fewer than 1 percent were receiving inpatient rehabilitation in a hospital.
In 2002, private nonprofit facilities made up the bulk of the treatment system (61 percent), and private for-profit facilities accounted for another 25 percent. State or local governments owned 11 percent of the facilities, and the federal government owned 2 percent. Tribal governments owned 1 percent of the facilities surveyed.
Thirty-eight percent of the facilities offered programs or groups for women only, and 30 percent provided programs for men only. About 14 percent offered programs for seniors and older adults, and 13 percent had programs for gays and lesbians.
The N-SSATS report is available on the Web site of the Substance Abuse and Mental Health Services Administration at www.dasis.samhsa.gov. Survey data are also used to update the Substance Abuse Treatment Facility Locator (http://findtreatment. samhsa.gov), which provides the phone numbers and locations of the nearest state-approved treatment facilities.
News Briefs
IOM report on hidden costs of uninsured: A report by the Institute of Medicine (IOM) explores the economic and societal benefits that could be realized if everyone had health insurance, as people over the age of 65 currently do with Medicare. Hidden Costs, Value Lost estimates that the nation loses between $65 billion and $130 billion each year because of the poorer health and earlier death of uninsured citizens. These hidden costs are calculated on the basis of "health capital" and do not include the costs of medical services currently used by the uninsured population. According to the report, people who were uninsured for all or part of 2001 received services valued at about $99 billion, which includes out-of-pocket expenditures by uninsured persons, insurance payments for those insured for part of the year, workers' compensation payments for health care, and the cost of charity care. (Taxpayers pay about $30 billion each year to compensate hospitals and clinics for services provided free to uninsured patients—charity care.) Because uninsured persons use fewer services, providing them with coverage would result in their using an estimated $34 billion to $69 billion of additional services each year. However, the estimated potential societal and economic value—$65 billion to $130 billion—would likely exceed the costs for these additional services. The report can be downloaded from the IOM Web site at www.iom.edu.
AMA guidelines for Internet prescribing: The American Medical Association (AMA) has developed a set of guidelines to help physicians integrate online prescribing into their practices. The guidelines stress the need for appropriate safeguards to ensure that online communications do not replace the interpersonal aspects of patient-physician relationships. The guidelines state that physicians should obtain information on a patient's medical history and perform a physical examination before prescribing any medications online. They should transmit prescriptions over a secure network that includes features such as password requirements and prescription encryption. In addition, the guidelines emphasize that physicians who prescribe medications by using the Internet should either be licensed in the states where their patients live or meet the regulatory requirements of individual state medical boards. The guidelines can be downloaded from the AMA Web site at www.ama-assn.org/ama/pub/category/10292.html.
