nity-based psychiatric care, with 11 percent making contact in the year before death and 4 percent within a day of contact (Pirkis and Burgess, 1998). About 5 percent of suicides occur during hospitalization (Crammer, 1984; Robins et al., 1959).

These figures imply the existence of lost opportunities and numerous barriers to effective treatment in the specialty setting. Barriers extend throughout the process—from the very beginning of diagnosis to after discharge. The problems are similar to those discussed in other clinical settings: the failure to assess suicidal risk and to treat patients who are suicidal or at risk for suicide.

There is an additional barrier to mental health treatment for individuals of racial, ethnic or cultural minorities. There is substantial under-representation of minorities among mental health providers, and cultural differences between provider and consumer can greatly interfere with both diagnosis and treatment (US DHHS, 2001).

Barriers to Detection of Suicidality

One overarching barrier to detection of suicidality is the lack of professional guidelines for both assessment and treatment of the suicidal patient in the specialty mental health care setting. The Surgeon General’s National Strategy (PHS, 2001) calls for the development and implementation of professional guidelines for suicide assessment—as well as individualized policies, procedures, and evaluation programs for treatment in a full range of specialty mental health and substance abuse treatment centers. The lack of professional guidelines partly accounts for clinicians’ reporting that they do not receive adequate training in suicide detection and treatment, as discussed above.

One early barrier to detection of suicidality, and thus treatment, comes in the form of exclusion of suicidal patients by certain types of providers. While research is sparse, one study found that 59 percent of training clinics affiliated with clinical and professional psychology doctoral programs had a policy of excluding patients with suicidal risk (Bernstein and Feldberg, 1991). There are likely many reasons governing the policy, but one salient reason is fear of malpractice. Though suicide-related malpractice claims are still relatively rare, they have increased in the last decades (Jobes and Berman, 1993). The payouts in settlement or verdict are disproportionately high relative to the percentage of claims. For example, among lawsuits for malpractice filed against psychiatrists, 21 percent involve a patient’s suicide, yet 42 percent of the dollars paid out are in connection to these cases (Bongar et al., 1992). Clinicians’ fear of being sued in the wake of a patient’s suicide is considered widespread, even though court deci-

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