Developing a New Suicide Risk Assessment for Virtual Encounters with Non-Clinicians

INTRODUCTION: The COVID-19 pandemic has necessitated that many research encounters be conducted virtually. Non clinician staff (e.g. research assistants (RAs), study coordinators, or research trainees) with varying levels of clinical training and experience are typically the primary point of contact for research participants. Consequently, they are often the first to encounter suicidality. This highlights the need for robust virtual suicide risk assessment procedures that are at an appropriate level for research staff and optimized for remote clinical research visits. The current procedures for in-person visits conducted by the Geriatric Psychiatry Program at McLean Hospital require non-clinician staff to complete the full Columbia Suicide Severity Rating Scale (CSSRS) in situations of active suicidal ideation (SI) before requiring clinician notification and intervention. However, staff and clinicians both reported that the virtual visit format limited the quality of the assessment and the ability to respond rapidly in situations of passive suicidal ideation, especially when this ideation did not meet the threshold for clinician notification specified in the in-person protocol. Thus, we established the need for a specific virtual suicide risk assessment protocol. Here we present our process for needs assessment and its findings, which in turn have shaped our revised protocol. METHODS: We surveyed clinicians and social workers affiliated with the Geriatric Psychiatry Research Program at McLean Hospital. The first goal of this survey was to collect information on how clinicians respond to situations of suicidality during telehealth assessments, and how clinicians recommend that staff navigate these situations in a virtual research setting. The second goal was to gather qualitative data that would guide preparatory safety planning (PSP) that non-clinician staff could complete prior to research visits. Because there are no standardized instruments for the information we wanted to collect, we developed a survey based on consensus among research staff. RESULTS: Of the 19 clinicians surveyed, 11 completed the brief survey. Nine (81.8%) of the eleven clinicians that responded had needed to deal with a patient at imminent risk of suicide in any setting. Only three (27.27%) clinicians were fully comfortable using the in-person SI protocol for virtual encounters. All 11 (100%) of responding clinicians conveyed that PSP should include information on (a) the exact location of the patient's home, (b) contact information for friends and family, and (c) an assessment of firearm access. The PSP should be completed as early as feasible in the research process, prior to formal enrollment, even if there was no reason to suspect SI at the time. Additional qualitative feedback included recommendations for lowering the threshold for enacting the SOP from subjects expressing active SI to passive SI to facilitate earlier intervention. Clinicians also recommended training staff on formal assessment measures such as the combined SAFE-T (Suicide Assessment Five-step Evaluation and Triage) and CSSRS protocol in a structured interview so that they could conduct a more systematic assessment if passive SI was reported. CONCLUSIONS: As more research encounters are conducted virtually, protocols designed for in-person assessment of suicide risk must be adapted. We found that the most useful addition to a virtual SI protocol may be to lower the threshold for action from active to passive SI and inclusion of PSP. Our findings also indicate that staff should be trained in standardized suicide assessment and that there should be a low threshold for conducting these assessments (i.e. passive ideation) and notifying clinicians. Our findings may be broadly generalizable to all mental health research settings that involve virtual assessment by non-clinician staff. THIS RESEARCH WAS FUNDED BY: This work was supported in part by an unrestricted philanthropic gift from Eric Warren Goldman to the Technology and Aging Lab at McLean Hospital