Assess risk​

Risk assessment is not suicide prediction

Because suicide is a relatively rare event, it is not possible to predict which individual will or will not attempt or complete suicide at any given point in time. The clinician's job is to identify individuals at higher risk of suicide and take steps to lower that risk.

Do screening questionnaires help?

Clinical assessment is the gold standard. Suicide screening instruments and scales are not reliable for various reasons:

• unacceptably high false positive and false negative rates
• poor generalizability
• limited usefulness, functioning primarily as memory aids for the clinician

Is your patient suicidal?

Men die by suicide three to four times more often than women, but women are three to four times more likely to attempt suicide. Suicide rates are higher in young people aged 15 to 24 and in elderly males compared to the general population.

In clinical practice, concern about suicide risk begins with one or more of the following:

• recognition that a patient is seriously distressed or mentally unwell
• a clear or covert statement by the patient that he or she is considering suicide: "I'm not sure how long I can go on like this." "I'm just so tired of being down."
• communication from a family member or friend who is concerned about the patient: "He keeps talking about how we'd be better off without him."

Ask about suicide

The clinician's responsibility is to investigate suicidal intent in the patient. The most direct, effective way to do this is to ask the patient:

• "Have things gotten so bad that you've thought about hurting yourself or ending your life?"
• "Sometimes when people feel the way you do right now, they start to have thoughts about suicide. Has this ever happened to you?"

A calm, non-judgmental, concerned approach will tell the patient that you care, and that you will be able to cope with the answer.

Note: Asking about suicidal intent does not "plant" this as an idea in the patient.

Special situations

• After a romantic relationship has ended, ask the patient whether he or she has thoughts about killing the former partner and/or children.
• In a female patient with postpartum depression and suicidality, ask about thoughts that the baby would be better off dead, intent to harm the child, and so on.

Investigate the severity of the suicidal intent

If the patient endorses suicidal thoughts, the clinician's next task is to determine how serious the suicidal intent is.

• Ask the patient:
  • "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.
• 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 the patient's intent to act

• Ask the patient:
  • "In the next 24–48 hours, how likely is it that you will act on your suicidal plan?" (Ask the patient to rate the likelihood on a scale of 1 to 10, with 1 being very unlikely and 10 being certain.)
• 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?"

Self-harm versus suicidality

Not all patients who harm themselves by cutting, burning or other mutilating behaviours are actively suicidal.

To differentiate self-harm from suicidal behaviour, ask about the person's intentions. Was the cutting (burning, etc.) done to end the person's life, to gain relief from emotional distress or to overcome a feeling of numbness?

Remember, patients who self-harm may have more than one intention for the behaviour, and self-harm is a risk factor for future suicide attempts. Coexistence of both behaviours is more the rule than the exception in borderline personality and other impulsive personality disorders.

Identify factors that significantly increase risk

Impaired reality testing

• Psychosis
• Intoxication with alcohol or other drugs

Note: Do not permit the intoxicated suicidal patient to go home. Transfer the patient to an emergency room.

Hopelessness

Ask the patient:

• "Are you feeling hopeless?" or "Can you see things getting better for you?"

Previous attempted suicide

• The more lethal the method used, the higher the risk.
• The risk increases with each attempt.
• People who have had multiple suicide attempts should be considered chronically at risk.
• People who were recently discharged from an inpatient psychiatric ward, particularly if suicide was attempted, are at risk.

Current severe psychiatric disorder

• Major depression
• Schizophrenia
• Alcohol use problems
• Borderline and antisocial personality disorders, especially in combination with major depression

Other factors known to increase risk

• Family history of suicide (there is likely a genetic as well as a family environment contribution.)
• Alcohol abuse 
• Debilitating medical illness
• Recent loss (divorce, unemployment, death of someone close)

Assess reasons for living and protective factors

Ask the patient:

• "Things have been pretty rough. What keeps you going?"
• "You've been thinking about suicide, but you say you wouldn't follow through. What keeps you from harming yourself?"

Factors that may be associated with lower suicidal risk include:

• religious beliefs that suicide is wrong
• married state
• children under 18 years of age living at home
• employment
• strong therapeutic relationship
• good problem-solving skills
• generally higher level of self-esteem