Critical Elements of Suicide Risk Assessment
A comprehensive suicide risk assessment must systematically evaluate multiple specific domains including current suicidal ideation and intent, psychiatric symptoms and diagnoses, historical risk factors (especially prior attempts), access to lethal means, protective factors, and social determinants of health. 1, 2
Core Assessment Domains
The most recent 2024 VA/DoD guidelines downgraded their recommendation from "strong for" to "weak for" regarding specific assessment factors, reflecting limited evidence, but these domains remain the foundation of clinical practice 1:
Current Suicidal Ideation and Intent
- Directly ask about active or passive thoughts of suicide or death 2
- Assess whether the patient has a specific plan and intended course of action if symptoms worsen 2
- Evaluate access to lethal means, particularly firearms 2
- Determine if the patient still wants to die after an attempt—this is a critical high-risk indicator 1
Psychiatric Symptoms and Mental Status
- Assess hopelessness, which is one of the strongest predictors of suicide risk 2
- Evaluate severity of depression, presence of psychosis, command hallucinations, and delusional guilt 2
- Screen for agitation, impulsivity, irritability, and mixed states (depression with manic features) 1, 2
- Identify comorbid substance abuse, which dramatically increases risk when combined with mood disorders 1, 2
Historical Risk Factors
- Prior suicide attempts are the single strongest predictor of future suicide, particularly in males 1
- Document lifetime history of self-directed violence and recent attempts 2
- Assess method of prior attempts—those using methods other than ingestion or superficial cutting carry higher risk 1
- Review history of childhood sexual or physical abuse 1
Demographic and Clinical Characteristics
- Older adolescents (16-19 years) and males are at highest risk for completed suicide 1
- Gay, lesbian, and bisexual youth face elevated risk due to multiple compounding factors 1
- Living alone increases risk 1
- Current mental disorders, especially mood disorders, are present in the majority of suicide attempters 1
Protective Factors and Social Support
- Evaluate reasons for living and quality of therapeutic alliance 2
- Assess availability and quality of social support networks 2
- Review psychosocial stressors such as relationship endings 1
Critical Pitfalls to Avoid
Never dismiss a suicide attempt as merely a "gesture"—this term is misleading and dangerous. Many adolescents who make seemingly mild attempts may eventually complete suicide, while others who make medically serious attempts may never repeat the behavior 1. The unpredictability of future suicidal behavior means every attempt must be taken seriously.
Do not rely solely on structured screening tools to determine risk level. The 2024 VA/DoD guidelines state there is insufficient evidence to recommend for or against specific tools or methods for risk stratification, despite it being an expected component of care 1. Clinical judgment informed by systematic assessment of the domains above remains essential 1.
Avoid using screening tools as a substitute for therapeutic engagement. While validated measures like the Columbia Suicide Severity Rating Scale Screener or PHQ-9 can be helpful 1, they should complement—not replace—a thorough clinical assessment 1. Some evidence suggests structured tools may interfere with establishing the therapeutic alliance needed for in-depth evaluation 1.
Information Gathering Strategy
Always draw assessment information from multiple sources 1:
- Direct interview with the patient
- Parents or guardians (especially for adolescents)
- School reports
- Other individuals close to the patient
- Medical records documenting prior attempts (noting that many attempts go unreported) 1
Special Considerations for High-Risk Patients
Patients at greatest immediate risk require urgent psychiatric evaluation and should not be discharged without it 1:
- Those still thinking of suicide after an attempt
- Males or patients living alone
- Presence of depression, mania, hypomania, severe anxiety, or mixed states
- Substance abuse alone or combined with mood disorder
- Irritability, agitation, threats of violence, delusions, or hallucinations 1
For depressed adolescents specifically, ascertain both the frequency of suicidal thoughts and any history of attempts, with ongoing monitoring if either is present 1.