suicide/parasuicide risk assessment
Last reviewed 01/2018
suicide risk assessment
Suicidal risk assessment entails a clinical encounter where a patient is inquired about any suicidal thoughts or plans.
- this is usually carried out in emergency departments and specialty mental health settings, but many occur in primary care
- around 30% of American adults who committed suicide visited their primary
care provider in the month before suicide
- typically consists of collecting information regarding:
- previous suicidal behaviour
- current suicidal thoughts and plans
- hopelessness, stressors
- the presence of mental disorder symptoms
- themes of impulsivity and self control
- ready access to highly lethal methods (such as firearms)
- protective factors
Evidence shows that inquiring about suicidal thoughts from the patient does not increase suicidal ideation or attempts.
- a non systemic review of 13 studies (published between 2001 and 2013) found no evidence of an increase in suicidal ideation in patients who were asked about suicide
Several risk assessment tools or scales have been developed to predict suicide.
- most commonly used scales include the Beck hopelessness scale (BHS), the Beck depression inventory (BDI), the Beck scale for suicide ideation (BSS), the suicide intent scale (SIS), and the SAD PERSONS scale.
- newer suicide risk scales such as the Columbia-suicide severity rating scale (C-SSRS), the suicide trigger scale (STS), and the suicide probability scale (SPS)
- WHO recommends that non-specialist health care providers should ask individuals over 10 years of age suffering from mental disorders and other risk factors about thoughts or plans of self-harm in the last month or acts of self-harm in the last year at initial assessment and periodically as required (3).
- NICE guidelines does not recommend risk assessment tools to determine patient disposition and treatment
clinical assessment of patients with suicidal ideation
Clinicians should establish rapport and create a trusting relationship with the patient
- observe patient for verbal and non verbal features suggesting mental disorder or psychological problem
- e.g. - non-verbal signs of depression - facial expression, eye contact, signs of agitation or excessive slowing of speech and movement, mood, tone and volume of speech
- any indications of mental illness should prompt assessment for symptoms of depression, other mental disorders including delusions and hallucinations, and alcohol or drug misuse.
- open ended questions should be used to identify suicidal ideation e.g. - ‘do you ever feel like giving up?’, ‘do your symptoms/things ever become too much to cope with?’, ‘do you ever feel hopeless about your situation?’
- if the answer is “yes” or if there are other finding to suspect possible suicide risk e.g. - self harm, depression, any other mental illness, or unpredictable behaviour
- more closed questions can be used to identify presence, intensity, and persistence of suicidal ideas e.g. - ‘do you ever think about going to sleep and not waking up?’ or ‘are you currently thinking about or have you recently thought about death or harming yourself?’ (2,4,5)
Any admission of suicidal ideas should lead to direct questioning about suicidal plans. Questions which can be used include:
- have you thought about how you would harm yourself? What is your plan?
- how often have those thoughts occurred (including frequency, obsessional quality, controllability)?
- how likely do you think it is that you will act on them in the future?
- Wwhat do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)? (2,4,5)
Consider inquiring about other risk factors:
- have you or a family member ever attempted suicide in the past?
- are you currently using alcohol or drugs (illicit or prescription)?
- have there been any changes in your employment, social life, or family?
- do you have friends or family with whom you are close? Have you told them about these thoughts?
- do you tend to be impulsive with your decisions or behavior? (2)
For individuals who have attempted suicide or engaged in self-damaging action(s), parallel questions to above can address the prior attempt(s). Additional questions can be asked in general terms or can refer to the specific method used and may include:
- can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)?
- what did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)?
- did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)? (4)
Consider assessing the patient’s potential to harm others in addition to him- or herself:
- are there others who you think may be responsible for what you’re experiencing (e.g., persecutory ideas, passivity experiences)? Are you having any thoughts of harming them?
- are there other people you would want to die with you?
- are there others who you think would be unable to go on without you?(4)
- (1) Bolton JM, Gunnell D, Turecki G.Suicide risk assessment and intervention in people with mental illness. BMJ. 2015;351:h4978
- (2) Norris D, Clark MS. Evaluation and treatment of the suicidal patient. Am Fam Physician. 2012;85(6):602-5.
- (3) World Health Organization (WHO) 2012. Assessment for self harm/suicide in persons with priority mental, neurological and substance use disorders
- (4) Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(11 Suppl):1-60
- (5) Morriss R, Kapur N, Byng R. Assessing risk of suicide or self harm in adults. BMJ. 2013;347:f4572