Module 4 – Suicide Risk Assessment

About 3% of adults (and a much higher percentage of youths) are entertaining thoughts of suicide
at any given time; however, there is no certain way to predict who will go on to attempt suicide.

Key components of a suicide risk assessment

1. Assess risk factors
2. Suicide Inquiry: thoughts/plan /intent/access to means
3. Assess protective factors
4. Clinical judgment
5. Document

1. Risk Factors
Suicidal behavior is associated with many different types of events, illnesses, and life
circumstances.25
The strongest predictor of suicide is one or more previous attempts; however, most people
who die by suicide die on their first attempt.
There are many factors that increase risk for suicide. A greater number of identified risk factors is
suggestive of greater risk.26

Individual Risk Factors

ffPrevious suicide attempt
ffMajor physical illnesses, especially with chronic pain
ffCentral nervous system disorders, including TBI
ffMental disorders, particularly mood disorders, schizophrenia, anxiety disorders (e.g., PTSD), and
certain alcohol and other substance use disorders; personality disorders (such as Borderline PD,
Antisocial PD, and Obsessive-Compulsive PD). In youths: ADHD and conduct disorders (antisocial
behavior, aggression, impulsivity)
ffPsychiatric symptoms/states of mind: anhedonia, severe anxiety/panic, insomnia, command
hallucinations, intoxication, self-hate
ffImpulsive and/or aggressive tendencies
ffHistory of trauma or abuse
ffFamily history of suicide
ffPrecipitants/triggering events leading to humiliation, shame, or despair (e.g., loss of
relationship, health or financial status – real or anticipated

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 Social/Environmental Risk Factors
ffChaotic family history (e.g., separation or divorce, change in caretaker, change in living situation
or residence, incarcerations)
ffLack of social support and increasing isolation
ffEasy access to/familiarity with lethal means (e.g., guns, illicit drugs, medications)
ffLocal clusters of suicide that have a contagious influence
ffLegal difficulties/contact with law enforcement/incarceration
ffBarriers to accessing health care, especially mental health and substance abuse treatment

Societal Risk Factors

ffCertain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of
a personal dilemma)27
ffExposure to, including through the media, and influence of others who have died by suicide

2. Suicide Inquiry
ffIf any suicide warning signs are evident or if significant risk factors are
present, an initial suicide inquiry is warranted. Patients will generally
not spontaneously report suicidal ideation, but 70% communicate
their intentions or wish to die to significant others. Ask patients
directly about suicide and seek collateral information from other
clinicians, family members, friends, EMS personnel, police, and others.28
How you ask the question affects the likelihood of getting a truthful
response. Use a non-judgmental, non-condescending, matter-of-fact
approach.

ffNEVER ask leading questions like:

“You’re not thinking of suicide, are you”?

ffPractice questions several times prior to a clinical encounter; asking about suicide for the
first time may be harder than you think.

Thoughts of Suicide
Ask patients you suspect may be feeling suicidal about thoughts or feelings related to suicide. The
sample questions below will help you ease into the subject in a non-threatening way.

Sample questions to uncover suicidal thinking:29

• Sometimes, people in your situation (describe the situation) lose hope; I’m wondering if
you may have lost hope, too?
• Have you ever thought things would be better if you were dead?
• With this much stress (or hopelessness) in your life, have you thought of hurting yourself?
• Have you ever thought about killing yourself?

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 ffPrior Attempt

A history of a prior attempt is the strongest predictor of future suicidal behavior. Always ask
if the patient has attempted suicide in the past, even if there is no evidence of recent suicidal
thinking.

Sample question to assess prior attempt:

• Have you ever tried to kill yourself or attempt suicide?

ffIf your questioning reveals no evidence of suicidal ideation, you may end the inquiry here
and document the finding.

ffIf your patient initially denies suicidal thoughts but you have a high degree of suspicion
or concern due to agitation, anger, impaired judgment, etc., ask as many times as
necessary in several ways until you can reconcile the disagreement about what you see
and what the patient says.

ffIf your patient is having suicidal thoughts, ask specifically about frequency, duration, and
intensity.

Sample questions to assess suicidal ideation:

• When did you begin having suicidal thoughts?
• Did any event (stressor) precipitate the suicidal thoughts?
• How often do you have thoughts of suicide? How long do they last? How strong are they?
• What is the worst they have ever been?
• What do you do when you have suicidal thoughts?
• What did you do when they were the strongest ever?

Plan
After discussing the character of suicidal thoughts, providers should inquire about planning.30 Ask
whether the patient has a plan and, if so, get the specifics.

Sample questions to assess suicidal planning:

• Do you have a plan or have you been planning to end your life? If so, how would you do
it? Where would you do it?
• Do you have the (drugs, gun, rope) that you would use? Where is it right now?
• Do you have a timeline in mind for ending your life? Is there something (an event) that
would trigger the plan?

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 Intent
Determine the extent to which the patient expects to carry out the plan and believes the plan
or act to be lethal vs. self-injurious. Also explore the patient’s reasons to die vs. reasons to live.
Inquire about aborted attempts, rehearsals (such as tying a noose or loading a gun), and non-
suicidal self-injurious actions, as these are indicators of the patient’s intent to act on the plan.31
Consider the patient’s judgment and level of impulse control. Administer mental status exam if in
doubt about mental status.

Sample questions to assess intent:

• What would it accomplish if you were to end your life?
• Do you feel as if you’re a burden to others?
• How confident are you that this plan would actually end your life?
• What have you done to begin to carry out the plan?
For instance, have you rehearsed what you would do (e.g., held the pills or gun, tied the
rope)?
• Have you made other preparations (e.g., updated life insurance, made arrangements for
pets)?
• What makes you feel better (e.g., contact with family, use of substances)?
• What makes you feel worse (e.g., being alone, thinking about a situation)?
• How likely do you think you are to carry out your plan?
• What stops you from killing yourself?

Look for disagreement between what you see (objective findings) and what the patient tells
you about their suicidal state (subjective findings). When possible, and always with adolescents,
seek to confirm the patient’s reports with information from a family member, spouse, or close
friend. Patients are more likely to tell a family member than a PCP that they are suicidal.32
It may also be helpful to explore the patient’s cultural and/or religious beliefs about suicide and
death.33

3. Protective Factors
While protective factors provide a poor counterbalance to individuals who are high-risk for
attempting suicide (i.e., someone with strong ideation, intent, a plan, preparatory behaviors,
and impaired judgment), protective factors can mitigate risk in a person with moderate to
low suicide risk. Strengthening protective factors can be a part of safety planning, which will be
discussed in Module 5.

Some important protective factors are:34

ffSense of responsibility to family
ffLife satisfaction
ffSocial support; belongingness

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 ffCoping skills
ffProblem-solving skills
ffStrong therapeutic relationship
ffReality testing ability
ffReligious faith

4. Clinical Judgment of Suicide Risk

Assessing suicide risk in primary care is complex when patients have medical illnesses, mental
health and substance abuse problems, and myriad family, contextual and environmental risk and
protective factors. At the low end of the risk spectrum are patients with thoughts of death or
wanting to die, but without suicidal thoughts, intent or a plan. Those with highly specific suicide
plans, preparatory acts or suicide rehearsals, and clearly articulated intent are at the high end.
Impaired judgment (intoxication, psychosis, TBI, impulsiveness) further exacerbates that heightened
risk. There is no screening tool or questionnaire that can accurately predict which patients from
among the many with suicidal risk will go on to make a suicide attempt, either fatal or non-fatal.
The decision tree below is a snapshot of the pocket guide developed by the WICHE Mental Health
Program and Suicide Prevention Resource Center for use by primary care professionals in assessing
suicide risk and determining appropriate interventions (covered in Module 5). The copy of the
pocket guide is also available as a separate document/tool for reference.

Suicide Risk and Protective Factors1

Assessment and Interventions with Potentially Suicidal Patients
RISK FACTORS
Patient has suicidal ideation or any past attempt(s) within the past two months. See right for risk factors and back for assessment questions. ffSuicidal behavior: history of prior suicide attempts,
aborted suicide attempts or self-injurious behavior.
ffFamily history: of suicide, attempts, or psychiatric
High Risk Moderate Risk Low Risk diagnoses, especially those requiring hospitalization.
ffCurrent/past psychiatric disorders: especially mood
Patient has a suicide plan with preparatory or Patient has suicidal ideation, but limited suicidal intent and Patient has thoughts of death only; disorders (e.g., depression, Bipolar disorder), psychotic
rehearsal behavior no clear plan; may have had previous attempt no plan or behavior disorders, alcohol/substance abuse, TBI, PTSD,
personality disorders (e.g., Borderline PD).
Co-morbidity with other psychiatric and/or substance
Patient has severe Patient does not have abuse disorders and recent onset of illness increase risk.
psychiatric symptoms and/ access to lethal means, ffKey symptoms: anhedonia, impulsivity, hopelessness,
or acute precipitating event, has good social support, anxiety/panic, insomnia, command hallucinations,
access to lethal means, poor intact judgment; psychiatric intoxication. For children and adolescents:
social support, impaired symptoms, if present, have Evaluate for psychiatric disorders, stressors, and additional risk factors oppositionality and conduct problems.
judgement been addressed ffPrecipitants/stressors: triggering events leading to
humiliation, shame or despair (i.e., loss of relationship,
Hospitalize, or call 911 or Take action to prevent the plan financial, or health status – real or anticipated).
local police if no hospital is ffChronic medical illness (esp. CNS disorders, pain).
available. If patient refuses Consider (locally or via telemedicine): ffHistory of or current abuse or neglect.
hospitalization, consider 1) psychopharmacological treatment with psychiatric consultation
involuntary commitment if 2) alcohol/drug assessment and referral, and/or PROTECTIVE FACTORS
state permits 3) individual or family therapy referral Protective factors, even if present, may not counteract
significant acute risk.
Encourage social support, involving family members, close friends and community resources. If patient has therapist, call him/her in presence of patient. ffInternal: ability to cope with stress, religious beliefs,
frustration tolerance.
Record risk assessment, rationale, and treatment plan in patient record. Complete tracking log entry, and continue to monitor patient status via repeat interviews, follow-up contacts, ffExternal: responsibility to children or pets, positive
therapeutic relationships, social supports.
and collaboration with other providers. Make continued entries in tracking log.

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