sions usually do not hold clinicians liable if they have practiced according to a loosely defined standard of care (Bongar et al., 1992; Bongar et al., 1998).

Clinicians who accept suicidal patients are legally and ethically obligated to assess suicidal risk through a clinical interview, mental status examination, direct and indirect questioning about suicide, and history taking (see Chapter 7). From a legal perspective, the assessment of suicide risk does not mean prediction of risk, because the latter is not yet possible. Rather, it means that the clinician used reasonable prudence that other professionals would exercise in similar circumstances (Maris et al., 2000). In one of the few surveys, researchers asked practicing psychologists, psychiatrists, and clinical social workers about their methods of suicide assessment. Respondents reported infrequent use of assessment instruments (e.g., Hopelessness Scale and Suicide Intent Scale) and reported that they did not find them to be very useful. Psychologists frequently use various psychological tests (e.g., MMPI, Rorschach Ink Blot). The overwhelming majority (>80 percent of clinicians) use clinical observations about patient affect and appearance, as well as direct interview questions about suicide plans, suicide thoughts, method availability, history of drug/alcohol use, and previous attempt, among others (Jobes and Eyman, 1995). Although these findings are not nationally representative and are limited by low response rate, they indicate the need for better assessment instruments.

Another barrier related to the assessment of suicide concerns appropriate diagnosis of the associated mental disorder. If a mental disorder is not properly diagnosed in specialty care, then patients receive either no treatment or inappropriate treatment, placing them at risk for suicide. One misdiagnosis that enhances suicide risk relates to bipolar disorder. Patient surveys (N=600) indicate that 69 percent are misdiagnosed, and they frequently consult four physicians before a correct diagnosis is made (Lewis, 2001). Through review of patient charts at first clinical contact, bipolar disorder is misdiagnosed as unipolar depression in more than one-third of patients with affective disorder (Ghaemi et al., 2000). When treated with antidepressants, but not with mood stabilizers, these patients are risk for rapid cycling (Ghaemi et al., 2000; Kilzieh and Akiskal, 1999), which carries a poorer prognosis and higher risk of suicide (Goodwin, 1999; Schweizer et al., 1988). Bipolar depression carries markedly higher rates of suicidality than do other phases of bipolar disorder (Dilsaver et al., 1997; Isometsa et al., 1994c). Many patients also do not receive adequate treatment even when bipolar disorder is accurately diagnosed, as discussed in later sections.

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