Suicide Risk Assessment and Prevention: Key References
The most authoritative and recent guidance on suicide risk assessment and prevention comes from the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines, published in the Annals of Internal Medicine 1. This represents the highest quality, most current evidence-based framework available for clinicians managing patients at risk for suicide.
Primary Reference Source
The 2024 VA/DOD Clinical Practice Guideline provides comprehensive, algorithmically structured recommendations covering screening, risk assessment, intervention strategies, and post-acute care management 1. This guideline synthesizes evidence across multiple domains including:
- Screening and risk stratification tools for identifying at-risk patients in clinical settings 1
- Suicide-specific psychotherapeutic interventions, with strong support for cognitive behavioral therapy (CBT) focused on suicide prevention 1
- Pharmacotherapy options, including evidence for lithium in mood disorders and ketamine for acute suicidal ideation 1
- Post-discharge interventions, particularly periodic caring communications (postal mail or text messages) sent over 12 months to reduce suicide attempt risk 1
- Lethal means safety counseling as a critical component of risk mitigation 1
Supplementary High-Quality References
The 2019 VA/DOD guideline (also published in Annals of Internal Medicine) provides foundational evidence and developed three clinical algorithms for identification, evaluation, and management of acute suicide risk 1. This earlier version established the framework for screening all patients for suicide risk and conducting multifactorial psychiatric evaluations for those at elevated risk 1.
The American Psychiatric Association guidelines recommend comprehensive psychiatric evaluation for any patient at increased risk, assessing current suicidal ideation, psychiatric symptoms, historical factors, protective factors, and social determinants 2, 3, 4.
Critical Knowledge Gaps Identified
The guidelines explicitly acknowledge that suicide death is a low-frequency event, making adequately powered randomized controlled trials challenging to conduct 1. The Work Group recommends:
- System-wide approaches such as suicide prevention trial networks and multistudy repositories 1
- Expansion to rigorous observational studies given the evolution of methodological frameworks 1
- Priority research areas including biological pathways, digital technology for risk assessment, family-based interventions, and community-based strategies 1
Evidence Limitations
Despite widespread use of community-based interventions (gatekeeper training, crisis lines, peer counseling), evidence remains insufficient to recommend for or against these approaches 1. The guidelines found very low confidence in evidence for population-level interventions, with inadequate assessment of confounders and unclear benefit-to-harm ratios 1.
Current screening tools demonstrate unacceptably high false-positive rates and low accuracy for identifying true cases, though PHQ-9 item 9 and the Columbia-Suicide Severity Rating Scale (C-SSRS) show some promise in specific populations 1.
Accessing the Full Guidelines
The complete 2024 VA/DOD Clinical Practice Guideline, including detailed algorithms and clinician summaries, is available at www.healthquality.va.gov 1. This resource provides the most comprehensive, evidence-based framework currently available for suicide risk assessment and prevention in clinical practice.