L’évaluation du risque suicidaire : enquête sur les pratiques des services d’urgences psychiatriques en Île-de-France

Background

Suicide remains a significant public health issue, with the World Health Organization (WHO) estimating that 700,000 deaths worldwide occur each year. This issue is particularly concerning in France, where the suicide rate is 13.2 per 100,000 people, accounting for approximately 200,000 suicide attempts annually. Suicide risk assessment in psychiatry, especially in emergency services, is crucial, but complex, varying between clinical approaches and standardized tools. The clinical approach has the advantage of adapting to the patient's discourse, but lacks objectivity and induces considerable inter-assessor variability. Standardized tools have been in development for many years. For example, in France, the Risque-Urgence-Dangerosité (RUD) have been developed to provide a structured framework and reduce the inter-evaluator variability. Although these tools’ aim is to improve risk prediction, they lack validation in the scientific literature, and their frequency of use is unknown. Furthermore, the integration of standardized SRA tools into daily clinical practice in French psychiatric emergency departments is unknown. This study aims to gain a better understanding of suicide risk assessment practices in psychiatric emergency services in the Île-de-France region, particularly the frequency of use and the extent to which standardized tools are employed compared to clinical approaches, and to know the perceptions of the psychiatrists about the different assessment methods.

Materials and methods

The study was conducted in two phases. The first phase involved a literature review to identify the most commonly used standardized suicide risk assessment tools, focusing on their advantages, limitations, and applicability in the French context. The second phase involved semi-structured telephone interviews with psychiatrists working in psychiatric emergency services in Île-de-France. A structured interview guide was developed to collect both qualitative and quantitative data on suicide risk assessment practices. The interviews aimed to gather information on the psychiatrists’ experience and training, the frequency of tool use, and their perceptions of different assessment methods. Interviews were conducted with 25 psychiatrists representing 25 out of the 43 identified services. Non-responding psychiatrists were contacted again at least once. The average length of the interviews was 21 minutes. Expert contributions, including insights from Professor Jollant, were integrated to provide additional perspectives on the challenges related to suicide risk assessment. Datas were collected by telephone between June 1st, 2024 and August 31st, 2024.

Results

Among the 25 psychiatrists interviewed, nearly half (48%) reported that they did not use standardized tools for suicide risk assessment, relying instead on clinical evaluations based on their personal experience and judgment. On the other hand, 52% of psychiatrists reported using the RUD in their clinical practice. One psychiatrist also mentioned using the SAD-PERSONS scale alongside the RUD. However, among those who used the RUD, 90% considered it more of a reminder tool than a structured assessment instrument. No psychiatrists reported using other standardized tools, although some expressed interest in supplementary tools as long as they could be easily incorporated into daily practice. In terms of psychiatrists’ perceptions of standardized tools, several advantages were noted: 64% of psychiatrists felt that these tools were particularly helpful for newcomers to suicide risk assessment; 52% believed that standardized tools allowed for a more comprehensive evaluation; 32% viewed them as a means to ensure a more uniform assessment, while 16% felt that these tools provided medico-legal protection. However, several disadvantages were highlighted: 36% of psychiatrists expressed concerns that the use of standardized tools could detract from the human aspect of the doctor-patient relationship; 28% were worried about medico-legal implications, especially in cases where there was a discrepancy between the clinical assessment and the standardized tool.

Discussion

The findings reveal that there is a significant gap in the use of standardized suicide risk assessment tools in psychiatric emergency services in Île-de-France. While the RUD is the most commonly used tool, its usage is often viewed as supplementary rather than central to the assessment process. This highlights the potential for further integration of these tools into clinical practice to improve consistency and accuracy in risk evaluation. The study also shows that the majority of psychiatrists still rely on clinical judgment, which can be highly variable. This suggests a need for greater standardization in practices, especially given the high stakes involved in suicide prevention. The study further identifies key barriers to the broader adoption of standardized tools, particularly concerns about their impact on the patient-provider relationship and medico-legal risks. These findings are consistent with other research, which suggests that while standardized tools can improve the thoroughness and reliability of suicide risk assessments, they are often seen as secondary to the clinical expertise of psychiatrists. Moreover, the lack of training and experience with these tools appears to be a limiting factor in their widespread use.

Conclusion

In conclusion, while the use of standardized tools like the RUD is common, their role in psychiatric emergency services in Île-de-France remains limited. There is a clear need for ongoing education, training, and support to help psychiatrists incorporate these tools more effectively into their clinical practices. Additionally, addressing concerns about the impact on the therapeutic relationship and medico-legal issues will be crucial in increasing the adoption of these tools.