Collecting accurate suicide assessment information
In this section:
- Assessing suicide risk
- Investigating suicidal intent
- Documenting the assessment of suicide risk
- Suicide Assessment Five-Step Evaluation & Triage (SAFE-T)
- Cultural Health Assessment Tool (CHAT)
- Other suicide risk assessment tools
Clinical assessment is the gold standard for determining suicide risk in patients demonstrating warning signs. It is better than suicide screening instruments and scales because they have unacceptably high rates of false positives and false negatives, poor generalizability and limited usefulness. They function primarily as aides memoires for the clinician (Craven et al., 2011).
There are many ways to ask about suicide-related behaviour. Stovall and Domino (2003) have developed the following questions for assessing suicidality:
- Other people with similar problems sometimes lose hope; have you?
- This must be a hard time for you; what do you think about when you´re feeling down?
- Do you ever consider running away from your problems?
- With this much stress, have you thought of hurting yourself?
- Have you ever thought of killing yourself?
- How would you do it?
- What would happen to your family or significant others if you did that?
- What has kept you from acting on these thoughts?
The cascading question strategy is another technique for assessing suicidality (U.S. Department of Veterans Affairs, 2006). It follows this progression:
- Are you feeling hopeless about the present or future?
- If yes, ask: Have you had thoughts about taking your life?
- If yes, ask: When did you have these thoughts and do you have a plan to take your life?
- Have you ever had a suicide attempt?
If the patient indicates suicidal thoughts, the clinician's next task is to investigate suicidal intent by assessing the type and frequency of suicidal ideation, severity of suicidal thinking, plans and access to means, and intent to act. The following set of questions assess suicidal intent (Cravens et al., 2011):
Ask about the type and frequency of suicidal thinking:
- What kinds of thoughts have you been having? (This is a high-yield question, so be sure to let the patient talk.)
- How long have you been having these thoughts? When did they first start?
- How often are they happening? Daily? Weekly? All the time?
Ask the patient to rate the severity of the suicidal thinking:
- On a scale of 1 to 10, with 1 being very low intensity and 10 being extremely intense or severe, how severe would you consider your suicidal thoughts?
Ask about a plan and access to means:
- Do you have a plan for how you would kill yourself?
- Have you thought about any other methods? (Patients may not reveal the most lethal method at first-ask.)
- Do you have any firearms or other weapons at home? Where are they?
- If the preferred method is overdose or hanging, ask:
- Have you bought or saved pills? Do you have a rope?
- Have you "rehearsed" or "gone through the motions" of killing yourself?
Assess intent to act:
- In the next 24 to 48 hours, how likely is it that you will act on your suicide plan? (Ask the patient to rate the likelihood on a scale of 1 to 10, with 1 = very unlikely and 10 = certainly.)
- Consider whether the patient has a history of impulsivity (high-risk behaviours, overspending, fights, poorly thought-out decisions). If you don´t know the patient well, ask:
- Would you consider yourself an impulsive person?
- Have you recently felt out of control at times?
Proper and consistent documentation promotes a higher quality of care and is a clinician's best defence against a potential lawsuit (Simpson & Stacy, 2004). It is recommended to assess and document a suicide risk assessment at the following points in care (Centre for Addiction and Mental Health, 2010):
- at first psychiatric assessment and/or triage (including intake to a service or admission to an inpatient unit)
- whenever there is a change in the patient's clinical state (e.g., change in mood, new occurrence of suicidal ideation or behaviour, change in life situation)
- when family, friends or staff express concerns about suicidality
- with any major shift in the treatment plan
- at any change in the level of care (e.g., change in precautions or observation, including before increasing inpatient privileges)
- before terminating a therapeutic relationship (including at discharge from the inpatient unit), with consideration for both immediate and chronic risk.
SAFE-T is a simple five-step protocol developed by the Substance Abuse and Mental Health Services Administration (2009) for performing a thorough assessment of suicide risk in primary care settings. The five steps are:
- Step 1: Identify risk factors
- Step 2: Identify protective factors
- Step 3: Conduct suicide inquiry
- Step 4: Determine risk level and appropriate intervention
- Step 5: Document
Step 1: Identify risk factors
- Suicidal behaviour: history of prior suicide attempts or self-directed violence
- Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol and other substance abuse, attention-deficit/hyperactivity disorder, posttraumatic stress disorder
- Key symptoms: anhedonia, impulsivity, aggression, hopelessness, anxiety, insomnia
- Family history: suicide, attempts, child maltreatment, Axis I psychiatric disorders requiring hospitalization
- Stressors: triggering events leading to humiliation, shame or despair; ongoing medical illness; intoxication; family distress; history of physical or sexual abuse; social isolation; loss of primary relationships, culture or sense of community
- Access to methods: firearms, pesticides or other lethal means
Step 2: Identify protective factors
- Family and community support, feelings of connectedness
- Support from ongoing medical and mental health care relationships
- Skills in problem solving, coping with stress, resolving conflict and using nonviolent ways of handling disputes
- Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
- Responsibility to children or beloved pets
Step 3: Conduct suicide inquiry
- Ideation: frequency, intensity, duration (in the last 48 hours, past month, worst ever). Ask:
- What kinds of thoughts have you been having?
- How long have you been having these thoughts? When did they first start?
- Suicide plan: timing, location, lethality, access to means, preparatory acts. Ask:
- Do you have a plan of how you would kill yourself?
- Do you have any firearms or other weapons at home?
- Intent: extent to which the patient expects to carry out the plan and believes the plan/act to be lethal or self-injurious. Ask:
- In the next 24-48 hours, how likely is it that you will act on your suicide plan? (Ask the patient to rate the likelihood on a scale of 1 to 10, with 1 = very unlikely and 10 = certainly.)
- Explore ambivalence: reasons to die and reasons to live.
Step 4: Determine risk level and appropriate intervention
Assessing suicide risk level is based on clinical judgement, after completing steps 1-3. Click here to go to the "Formulating risk" page for resources about determining risk level and selecting appropriate interventions.
Step 5: Document
As outlined earlier, documentation should occur at first assessment and/or triage, whenever there is a change in clinical state, with any major shifts in treatment plan, at any change in the level of care and before terminating a relationship.
Also document the following:
- risk level and rationale
- treatment plan to address/reduce current risk
- firearms instructions, if relevant
- follow-up plan
- for youth, treatment plan should include and document role for patient/guardian.
See the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) pocket card for clinicians for more information about this assessment protocol.
Clinicians and patients may have different theories of suicide rooted in diverse cultural or religious beliefs. One tool for identifying and exploring a patient's explanatory model of suicide is the Cultural Health Assessment Tool (CHAT). It uses an open-ended approach to explore cultural differences in beliefs about health and health care. Ask:
- What do you think has caused your problem?
- Why do you think it started when it did?
- What do you think your sickness does to you? How does it work?
- How severe is your sickness? Will it have a short or long course?
- What kind of treatment do you think you should receive?
- What are the most important results you hope to receive from this treatment?
- What are the chief problems your sickness has caused for you?
- What do you fear most about your sickness?
InterRAI Severity of Self-Harm Scale (InterRAI SoS)
The SoS is a predictive algorithm for risk of harm to self. It was derived from clinician ratings of severity of risk of harm to self and validated against reasons for admission and future self-harm events in inpatient settings.
The rating scale ranges from from 0 to 6, where higher scores indicate increased risk for self-harm. Individuals who score at the highest risk level demonstrate or report suicide ideation in the last 24 to 72 hours, have made previous suicide attempts and have more depressive symptoms.
The risk of harm to self is based on past and current suicidal ideation, on plans and behaviours, and on indicators of depression, hopelessness, positive symptoms, cognitive functioning and family concern over the person´s safety.
For more information about suicide risk assessment tools, see:
- Suicide Risk Assessment Guide: A Resource for Health Care Organizations
- A Review of Suicide Assessment Measures for Intervention Research with Adults and Older Adults
Centre for Addiction and Mental Health. (2010). CAMH Suicide Prevention and Assessment Handbook. Toronto: Author.
Craven, M.A., Links, P.S. & Novak, G. (2011). Assessment and management of suicide risk. In D. Goldbloom & J. Davine (Eds.), Psychiatry in Primary Care: A Concise Canadian Pocket Guide (pp. 237-248). Toronto: Centre for Addiction and Mental Health.
Perlman, C., Neufeld, E., Martin, L., Goy, M. & Hirdes, J. P. (2011). Suicide Risk Assessment Guide: A Resource for Health Care Organizations. Toronto: Ontario Hospital Association and Canadian Safety Institute.
Stovall, J. & Domino, F.J. (2003). Approaching the suicidal patient.American Family Physician,68, 1814-1818.
Substance Abuse and Mental Health Services Administration. (2009). Suicide Assessment Five-Step Evaluation and Triage (SAFE-T): Pocket Card for Clinicians. Rockville, MD: Author.
U.S. Department of Veterans Affairs. (2007). Suicide Risk Assessment Guide Reference Manual. Washington, DC: Author.
- The Suicide Risk Assessment and Management Toolkit
- Attitudes and approach
- Understanding suicide
- Collecting accurate assessment information
- Formulating suicide risk
- Developing a treatment and services plan
- Managing care for suicide-related behaviour
- Understanding legal and regulatory issues around suicide
- Tools for assessing suicide risk and managing suicide-related behaviour