Quiblat, Rydell D.

February 1, 2011
BSN-4B Grp. # 33

Suicide Assessment
This step lays out helpful information on suicidal patients and interviewing them.

COMPONENTS OF SUICIDE ASSESSMENT

• Appreciate the complexity of suicide / multiple contributing factors
• Conduct a thorough psychiatric examination, identifying risk factors and distinguishing risk
factors which can be modified from those which cannot
• Ask directly about suicide; The Specific Suicide Inquiry
• Determine level of suicide risk: low, moderate, high
• Determine treatment setting and plan
• Document assessments

First, remember to do three things:

1) consult - this allows for another opinion, better care, and protects you
2) document, document, document! Everything you do, everyone you talk to, every question you ask the
client should be documented
3) evaluate the client's risk

RISK FACTORS (blue = modifiable)

Demographic male; widowed, divorced, single; increases with age; white

Psychosocial lack of social support; unemployment; drop in socio-economic status;

firearm access

Psychiatric psychiatric diagnosis; comorbidity

Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis;

systemic lupus erthematosis; pain syndromes; functional impairment;
diseases of nervous system

Psychological Dimensions hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-

esteem; fragile narcissism & perfectionism

Behavioral Dimensions impulsivity; aggression; severe anxiety; panic attacks; agitation;

intoxication; prior suicide attempt

Cognitive Dimensions thought constriction; polarized thinking

Childhood Trauma sexual/physical abuse; neglect; parental loss

 Genetic & Familial family history of suicide, mental illness, or abuse

Level of Risk
Low - no to some suicidal ideation, no plan
Moderate - ideation, vague plan, low on lethality, wouldn't do it
High - ideation, plan specific and lethal, would or wouldn't do it

Highest risk group has suicidal ideation (thoughts of killing self), a plan (any plan so long as it is definite
and detailed is high risk), high lethality (guns and walking in front of busses are more serious than
overdosing on Tylenol and slashing wrists), few inhibitors (few reasons not to kill self), low self-control
(especially drinking or using drugs - can decide not to kill self but fail to act to reverse events and
accidentally kill themselves)

DIRECT QUESTIONING ABOUT SUICIDE:

THE SPECIFIC SUICIDE INQUIRY
Ask About:
• Suicidal ideation
• Suicide plans
Give Added Consideration to:
• Suicide attempts (actual and aborted)
• First episode of suicidality
• Hopelessness
• Ambivalence: a chance to intervene
• Psychological pain history

COMPONENTS OF SUICIDAL IDEATION

 Intent: Subjective expectation and desire for a self-destructive act to end in death.
 Lethality: Objective danger to life associated with a suicide method or action. Lethality is
distinct from and may not always coincide with an individual’s expectation of what is medically
dangerous.
 Degree of ambivalence - wish to live, wish to die
 Intensity, frequency
 Rehearsal/availability of method
 Presence/absence of suicide note
 Deterrents (e.g. family, religion, positive therapeutic relationship, positive support system -
including work)

CHARACTERISTICS OF A SUICIDE PLAN

Risk / Rescue Issues:
 Method
 Time
 Place
 Available means
 Arranging sequence of events
DETERMINE TREATMENT SETTING AND PLAN
 Attend to issue of patient’s safety.
 Assess treatment plan/setting/alliance.
 Somatic treatment modalities:
• ECT – used to treat acute suicidal behavior
• Benzodiazepines – may reduce risk by treating anxiety
• Antidepressants - A mainstay treatment of suicidal patients with depressive
illness / symptoms. No conclusive evidence of suicide reduction.
• Lithium, Anticonvulsants - Lithium has a demonstrated anti-suicide effect;
anticonvulsants do not
• Antipsychotics, recent study on Clozapine – reduce suicidality in schizophrenia
and schizo-affective disorders
 Psychotherapeutic intervention – widely viewed as helpful for suicidal patients,
evidence is limited
 Provide education to patient and family.
 Monitor psychiatric status and response to treatment.
 Reassess for safety and suicide risk frequently.

Psychotherapy
Regardless of theoretical basis, key element is a positive and sustaining therapeutic relationship
Recommended (primarily from clinical consensus)
• To target issues
– Denial of symptoms
– Lack of insight
• To manage high risk symptoms
– Hopelessness
– Anxiety
Effective treatment in high risk diagnoses
– Depression
– Personality disorders (use of D.B.T.)

4) Empathize with the client

They are experiencing crises and stress, hopelessness, and helplessness. Offer that there is a part of
them that wants to live, since they were cooperative with you. Offer too that services and referrals, as
well as social support could be helpful to use now too.

Make a No-Suicide Contract

This is best when the client has support, is low risk, and can give clear reasons why they would not kill
themselves; the client agrees they won't hurt themselves, and if they feel they can't stop themselves,
they will call 911, an ER, a crises line, a therapist, or another designated special person, and will return
for help on next appointment. Make the patient sign it and get a witness.

Family Intervention
This is best if there is high support and low impulsiveness in the client. The clients agree with you to
contact their family. They stay with the family member until the suicidal thoughts have been addressed
in treatment, and the family is briefed on who to contact for help in an emergency. The family also takes
an active role to remove drugs, guns, or other means of suicide from the home, and promises 24 hour
supervision.

Hospitalization
This is best if there is little family support, or mental illness, substance use or impulsiveness. Try
voluntary admission, but use involuntary if needed.

WHEN TO DOCUMENT SUICIDE RISK ASSESSMENTS

 At first psychiatric assessment or admission.
 With occurrence of any suicidal behavior or ideation.
 Whenever there is any noteworthy clinical change.
 For inpatients:
• Before increasing privileges/giving passes
• Before discharge
 The issue of firearms:
• If present - document instructions
• If absent - document as pertinent negative

WHAT TO DOCUMENT IN A SUICIDE ASSESSMENT

 Document:
• The risk level
• The basis for the risk level
• The treatment plan for reducing the risk
Example:
This 62 y.o., recently separated man is experiencing his first episode of major depressive disorder. In
spite of his denial of current suicidal ideation, he is at moderate to high risk for suicide, because of his
serious suicide attempt and his continued anxiety and hopelessness. The plan is to hospitalize with
suicide precautions and medications, consider ECT w/u. Reassess tomorrow.

WHEN A SUICIDE OCCURS

Despite best efforts at suicide assessment and treatment, suicides can and do occur in clinical practice
Approximately, 12,000-14,000 suicides per year occur while in treatment.
To facilitate the aftercare process:
 Ensure that the patient’s records are complete
 Be available to assist grieving family members
 Remember the medical record is still official and confidentiality still exists
 Seek support from colleagues / supervisors
 Consult risk managers
 Suicide Risk Assessment Tool

Consumer:__________________________ CID#:___________________
Strengths :
Needs :
Abilities:
Preference :
DIRECTIONS: Assess the risk of the client in each of the following categories and add the points. If the question does not apply,
use zero.
QUESTION LOW MODERATE HIGH

1 point each 2 points each 3 points each

SCORE
Does the client have signs of Mild, able to carry out Low energy, apathetic, Severe, hopeless, helpless,
depression? (no enjoyment of daily functions withdrawn, not coping feelings of worthlessness, mood
life, hopelessness, difficulty well, some difficulty with swings, unable to function
sleeping and/or eating,)   daily function

Has the client ever attempted No attempts Previous thoughts, no Has attempted; hospitalized or
suicide? attempt; thoughts of E.R. care
death

Has a family member ever Rumored, but never Distant family member or Immediate family member or
attempted suicide? disclosed clearly friend loved one

Does client have a suicide Vague, fleeting thoughts, Frequent thoughts; Frequent or constant thoughts
plan? but no plan occasional ideas about a with a plan; giving away
plan possessions; expresses will to
die and has written a suicide
note

Does client have access to No access Has decided on a Immediate accessibility

whatever is necessary to carry method but does not
out his/her plan? have access

Is client isolated socially Begun to alienate family Alienated many family Socially isolated; alienated all
without friends? and friends and friends

Level of drug/alcohol use? Infrequently Frequently to excess Continual abuse; presently

intoxicated; withdrawal

Does the client have a chronic Mild Moderate Severe

physical illness and/or chronic
 QUESTION LOW MODERATE HIGH

1 point each 2 points each 3 points each

SCORE
pain

Does the client have a history None Within last six months Recent, within last month
of self destructive behaviors
(self mutilation, accident prone,
recklessness)?

Is client presently psychotic or No Somewhat disorganized; Severe; disoriented; extreme

paranoid? mild paranoia paranoia; psychotic thoughts
and behaviors

Has client sustained a recent Loss, which is not Recent death of friend or Death of a spouse, parent, child,
loss? (job, friend, loved one, significant to client yet is pet, demotion, money significant other; loss of job;
home, status) within three still a loss, job change, crunch, serious illness financial disaster; terminal
months? minor job problems, poor illness
health

Is the client willing to making a Willing Willing with some Not willing
no harm contract? reservations
 

What is the client’s level of None Some Severe

impulsivity?

What is the client’s level of None Some Severe

hostility?

Is client compliant with Takes as prescribed Takes infrequently Has discontinued meds
medication?

______ TOTAL POINTS

CIRCLE RISK CATEGORY LOW = 16 MODERATE = 17 - 32 HIGH = 33 – 48

Date: _________ Clinician Signature:_________________________ Clinician Name:_______________________