The Role of Case Managers

Bill called our call center at New Directions Behavioral Health Care stating that he had been sitting in his car thinking of gassing himself within the last hour. He had only stopped to make this call. After speaking with the clinician for a few minutes he stated that she had made him feel so much better that he was no longer suicidal. Unfortunately, the contact with this client did not end so productively and easily.

More than 30,000 people commit suicide in the United States every year. In 2005, suicide was the 11th leading cause of death. Suicide is most prevalent for males after the age of 65 and most common for females between the ages of 40-50. However, the risk of suicide is greatest when a person has certain psychiatric disorders, abuses multiple substances, or suffers from specific types of medical illnesses. For example, approximately 15 percent of all people suffering from major depression commit suicide.

It is not surprising that the Surgeon General of the United States (1999), the World Health Organization (WHO) (2005), and the Centers for Disease Control (CDC) (2001) are promoting efforts to reduce suicide. Accordingly, the Case Management Society of America’s Case Management Adherence Guidelines for Improving Patient Adherence to Depression Therapies from August 2008 states that “it is important to note that in order to complete a full social assessment for the individual with depression, a suicide assessment is paramount.”

Suicidal urges can be successfully treated, so becoming aware of a client’s suicidal ideation is of utmost importance. Accurate suicide assessment enables appropriate treatment and allows the individual to receive the necessary care for their problem. Obviously, not receiving treatment can end in death. This often has devastating effects on family and friends. Sometimes, case managers or other professionals are hesitant to ask the client about suicidal thoughts and feelings, erroneously believing that they are less responsible for the client’s well-being if they are unaware of the person’s suicidal urges. In addition, case managers sometimes believe the myth that asking about suicide will cause an individual to more seriously consider the option. Individuals thinking about suicide come up with the idea on their own. Not asking only decreases the opportunity for intervention and increases the danger of clients taking their own life.

When To Assess Risk

Case managers should always gather information about suicide risk during the initial meeting with the client. Three questions need to be asked:

• Have you ever attempted to kill yourself?
• Have you thought about dying in the past six months?
• Are you currently thinking about harming or killing yourself?

If the client answers yes to any of these, a more thorough risk assessment needs to occur. Bill answered yes to all three and the subsequent assessment revealed substance problems in addition to depression. This information warranted a more intensive assessment of suicide risk.

Circumstances other than an initial evaluation also require assessing suicide risk. One indication that a person may be suicidal is if he or she is presenting with abrupt behavioral change that is not easily understood. For example, a severely depressed person inexplicably acting less despondent may be due to the person making a decision to commit suicide and experiencing a sense of relief that their suffering may soon be over. Often, people who commit suicide do so around an experience of loss or an anniversary of a loss. This can be either a loss in the environment, such as a spouse, child or parent, or an internal loss such as a severe blow to the person’s self-esteem or ideals. Thus, when the person is experiencing, or anticipating, a loss, suicide risk assessment is warranted.

Another circumstance in which a client may become suicidal is when physical or mental health problems are not improving with treatment. The person may then feel increasingly despondent and hopeless about their situation. At this time, the risk of suicide needs to be evaluated. Another indication of the need for a risk assessment is when the person experiences a change in treatment settings such as inpatient to outpatient. Increases in suicide can also follow being discharged from treatment. Although it seems obvious, another occasion when risk assessment is warranted arises when a person either directly or indirectly says something indicating that he or she wants to cause self-harm. The majority of people who commit suicide express this desire to someone.