Suicide risk assessment: Questions that reveal what you really need to know
How to quickly identify high-risk and protective factors in patients with suicidal behavior.
Protective factors
A patient’s high-risk clinical features must be balanced against factors that may reduce suicide risk.
How much social support? Can family or friends constantly stay with the patient, watch him closely, and get help if the situation worsens? This is the simplest and most relevant method to assess the availability of protective support.
How much mental health support? Does the patient have a good relationship with a psychiatrist or therapist who can see the patient soon?
Have circumstances changed? Has the stressor that led to suicidal behavior resolved, at least in part? For example, if a patient’s fight with her boyfriend led to her taking an overdose, have they made up?
Four common myths. Clinicians assessing patients for acute suicide risk often overestimate the protective value of some factors. They may tell you:
- The patient only tried to harm himself while he was intoxicated. He’s not intoxicated now and therefore is not at high risk. The patient will likely get intoxicated again, despite his protestations to the contrary. Substance intoxication and withdrawal tend to worsen depression and diminish inhibitions, making suicide more—not less—likely.
- The patient contracts for safety. A contract for safety may have some value,4 but its clinical and legal merits in suicide risk assessment are overestimated.5 We are concerned about how often we see clinicians judge that a contract for safety overrides numerous high-risk factors.
- The patient was only trying to get attention. It is difficult for mental health professionals—and even for patients—to reliably ascertain what motivates someone to attempt suicide. Multiple motivations and ambivalence are common.
- The patient is ‘just a borderline.’ Because patients with borderline personality disorder tend to make repeated suicide gestures, clinicians may not take their suicide attempts seriously. This statement reveals ignorance about the suffering of persons with borderline personality disorder; their rate of completed suicide is approximately 10%.6
- When a suicide assessment is inconclusive, draw two columns on a sheet of paper. List the patient’s high-risk factors on one side and protective factors on the other
- Seeing the information in black and white often helps clarify the assessment
- Consider both the number of factors in each column and your clinical sense of each factor’s importance and intensity. Place a check mark next to particularly important factors
- This balance sheet can remind you of further questions to ask and often reveals that either the high-risk or protective factors far outweigh the others in number and/or intensity
Practical advice
Distinguish short-term vs long-term risk. Based on the questions above, we often conclude that a patient is at high long-term risk of suicide, but the immediate risk is much lower. Acute hospitalization is unlikely to alleviate the long-term risk (though sometimes is the only way to get the patient into psychiatric treatment).
Consider the source. Never disregard the “gut feeling” of the person who interviewed the patient, but also factor in your assessment of that clinician’s judgment. Sometimes inexperienced staffs’ intuitions may derive more from countertransference than from objective assessment.
Write it down. In cases where suicide risk seems unclear, it may help to list a patient’s risk and protective factors (Box 2). We have found this technique to be a useful teaching tool as well.
Be flexible. Because no method for assessing shortterm suicide risk is foolproof, be ready to re-evaluate your assessment and—if you are unsure—to take action to protect the patient.
