What are the key components of a comprehensive suicide risk assessment?

Comprehensive Suicide Risk Assessment Framework

A comprehensive suicide risk assessment must include evaluation of current suicidal thoughts, past suicide attempts, psychiatric conditions, social determinants, access to lethal means, and demographic risk factors to effectively identify individuals at risk and implement appropriate interventions.

Initial Screening and Assessment

• Begin with validated screening tools such as the Columbia Suicide Severity Rating Scale Screener, Patient Health Questionnaire-9, or Beck Scale for Suicidal Ideation to identify patients at risk for suicide-related behavior 1, 2
• Ask directly about suicidal thoughts using clear, non-judgmental language, as research shows that asking about suicide does not increase risk and leads to better outcomes 3, 4
• Consider using an introductory statement such as "This is a question we have to ask everyone" to normalize the assessment and reduce stigma 4
• Use the Chronological Assessment of Suicide Events (CASE) approach to systematically evaluate: presenting suicidal ideation/behavior, recent suicidal ideation/behaviors, past suicidal ideation/behaviors, and immediate suicidal ideation 5

Key Risk Factors to Assess

Self-Directed Violence History

• Evaluate previous suicide attempts, including method, intent, and circumstances 1
• Assess for history of non-suicidal self-injury, as this increases risk for future suicidal behavior 1
• Note that previous suicide attempts greatly increase risk, particularly in males 1

Current Suicidal Ideation and Planning

• Assess frequency, intensity, and duration of suicidal thoughts 2
• Evaluate specificity of suicide plan, including method, access to means, and preparations made 2, 6
• Determine the patient's intent to act on suicidal thoughts 1

Psychiatric Conditions and Symptoms

• Screen for current psychiatric disorders, especially mood disorders, psychosis, and substance use disorders 1
• Assess for symptoms of depression, including hopelessness, worthlessness, and anhedonia 1, 2
• Evaluate for agitation, irritability, impulsivity, and hostility 7, 8
• Consider comorbid conditions, as multiple diagnoses increase risk 1, 2

Social and Environmental Factors

• Assess availability and quality of social support systems 1, 2
• Evaluate recent stressful life events or losses 1, 2
• Screen for history of childhood trauma, abuse, or neglect 1
• Assess for sexual orientation and gender identity concerns, as LGBTQ+ youth face increased risk 1

Access to Lethal Means

• Inquire specifically about access to firearms, medications, and other potential methods 2
• Assess knowledge of and ability to obtain lethal means 1, 2

Demographic and Other Risk Factors

• Consider age and gender (older males are at highest risk) 1
• Assess for chronic pain or debilitating physical conditions 1, 2
• Evaluate history of impulsivity and aggression 1, 2

Protective Factors Assessment

• Identify reasons for living and future plans 2, 6
• Assess religious or spiritual beliefs that discourage suicide 2
• Evaluate social connectedness and sense of purpose 2
• Assess willingness to engage in treatment and safety planning 2

Risk Stratification

• Recognize that risk stratification tools have limitations and should not be used in isolation 1
• Consider patients at highest risk if they have:
  • Current suicidal intent with specific plan and means 1, 2
  • Recent suicide attempt using highly lethal methods 1
  • Persistent suicidal ideation despite interventions 1, 2
  • Severe hopelessness, agitation, or impulsivity 1, 2
  • Limited social support or unwillingness to engage in safety planning 2

Safety Planning and Intervention

• Develop a collaborative safety plan that includes:
  • Recognition of warning signs and triggers 2
  • Internal coping strategies 2
  • Social contacts who can provide distraction 2
  • Family and friends who can help during crisis 2
  • Professional resources and crisis contacts 2
  • Steps to restrict access to lethal means 2
• Consider cognitive behavioral therapy (CBT) focused on suicide prevention for patients with recent suicidal behavior 1, 2
• Evaluate need for dialectical behavior therapy (DBT) for patients with borderline personality disorder and suicidal behavior 1
• Consider pharmacological interventions when appropriate:
  • Clozapine for patients with schizophrenia and suicidal ideation 1, 2
  • Ketamine infusion as adjunctive treatment for short-term reduction of suicidal ideation in major depression 1, 2
  • Lithium for patients with bipolar disorder or unipolar depression 1

Follow-up and Monitoring

• Implement periodic caring communications (letters, postcards, texts) for at least 12 months after hospitalization for suicidal ideation or attempts 1, 2
• Recognize that risk is highest in the months immediately following a suicide attempt 2
• Monitor for medication-related risk, as antidepressants may increase suicidal ideation in children, adolescents, and young adults (ages 18-24) 7, 8
• Watch for emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, or mania in patients starting antidepressants 7, 8

Common Pitfalls to Avoid

• Avoid using the term "gesture" to describe seemingly less serious attempts, as this minimizes potential risk 1
• Don't rely exclusively on any single assessment tool or method 1, 9
• Remember that many suicide attempts are impulsive, with 24% of patients implementing their plan within 5 minutes of deciding 2
• Be aware that only about half of suicide completers have a known previous attempt 1
• Recognize that screening tools often have high false-positive rates and may miss true cases 1