SADPERSONS Should Not Be Used for Suicide Risk Assessment
The SADPERSONS scale should not be used as a suicide assessment tool in clinical practice, as it has been shown to have poor predictive validity and fails to identify the majority of patients who will attempt or die by suicide. 1, 2, 3, 4
Evidence Against SADPERSONS Use
Poor Predictive Performance
The SADPERSONS scale demonstrates unacceptably low sensitivity for predicting suicide outcomes:
At 12 months, the scale has only 49% sensitivity and 60% specificity, with a positive predictive value of just 0.9% and an area under the curve of 0.59 (barely better than chance). 1
Half of all suicides at 6- and 12-month intervals were classified as "low risk" by SADPERSONS at the index visit, meaning the tool misses the majority of patients who will die by suicide. 1
For predicting future suicide attempts, high-risk scores showed only 19.6% sensitivity with a positive predictive value of just 5.3%, and the scale did not predict attempts better than chance (AUC = 0.572). 4
Failure Across Clinical Outcomes
The scale performs poorly across multiple critical clinical endpoints:
Sensitivity for psychiatric hospital admission was only 2.0%, for community psychiatric aftercare was 5.8%, and for predicting repeat self-harm within 6 months was just 6.6%. 3
A systematic review found insufficient evidence to support SADPERSONS use in assessment or prediction of suicidal behavior, with only 3 studies examining suicide outcomes and none showing accurate prediction. 2
The most recent systematic review (2022) concluded there is insufficient evidence to support using any standalone risk assessment tool, including SADPERSONS, for self-harm and suicidality. 5
Guideline Recommendations on Structured Risk Assessment Tools
Expert Consensus Against Structured Tools
Some clinical practice guidelines explicitly recommend against using structured suicide prediction tools like SADPERSONS, based on multiple concerns: 6
All patients in high-risk settings (emergency departments with mental health crises, psychiatric hospitals) should be considered to have meaningfully elevated suicide risk and should receive in-depth clinical assessment focused on service needs rather than relying on prediction scales. 6
Structured tools are perceived by patients as superficial, requiring checkbox responses that fail to capture the complexity of their experiences and can interfere with establishing the therapeutic alliance needed for proper assessment. 6
Low positive predictive values mean that interventions focused on all "high-risk" patients would subject many who will never die by suicide to excessive intrusion, while low sensitivity means most patients who will die by suicide are excluded from high-risk classification. 6
Clinical Assessment Limitations
Clinical judgment alone is also not superior to structured tools - meta-analyses show that clinical assessments at discharge were not better predictors of subsequent suicides than individual risk factors from self-reports or administrative data. 6
Recommended Approach
Focus on Comprehensive Clinical Assessment
Instead of using SADPERSONS, conduct in-depth clinical psychosocial assessments that include: 6
- Multiple sessions with the patient when possible
- Collateral interviews with loved ones about severity of suicidal intent
- Assessment of precipitating problems (mental/physical health, life difficulties)
- Evaluation of risk factors (predispositions, warning signs for imminent risk)
- Identification of protective factors (social supports, coping styles)
Service Needs Over Risk Stratification
The primary goal should be assessing need for services rather than attempting to predict suicide risk, though understanding suicide risk should still inform treatment decisions about suicide-specific psychotherapies and medications. 6
Potential Role for Multistage Screening
If screening is necessary due to resource constraints, consider passive data collection (electronic medical records, administrative data) as a first-stage screen to identify who needs more detailed assessment, rather than relying on tools like SADPERSONS. 6
Critical Pitfall to Avoid
Do not use SADPERSONS scores to determine disposition or triage decisions - the scale's poor sensitivity means it will miss the majority of high-risk patients, and its use may provide false reassurance when patients score "low risk." 1, 3, 4