Evidence-Based Reviews

Suicide risk assessment: Questions that reveal what you really need to know

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How to quickly identify high-risk and protective factors in patients with suicidal behavior.


 

References

You can make more-informed decisions about a patient’s acute suicide risk—such as over the phone at 3 AM—if you know what to ask the psychiatry resident or crisis worker. For suicide risk assessment—especially when you have not seen the patient—you need specific, high-yield questions to draw out danger signals from large amounts of data.

We are not suggesting that a short list of questions is sufficient for this extremely difficult task. Rather—because we recognize its complexity—we offer the questions we find most useful when evaluating patients with suicidal behaviors.

American Psychiatric Association practice guidelines1 provide a comprehensive discussion of assessing suicide risk. In addition, we teach clinicians we supervise to probe for high-risk and less-commonly explored “protective” factors.

High-risk factors

Mental health clinicians are more experienced in probing for high-risk factors than for protective factors. Because population studies offer limited help (Box 1),2 we ask clinicians these questions to evaluate the seriousness of a suicide attempt:

Box 1

Why research offers limited help in assessing acute suicide risk
  • Most studies of suicide risk factors focus on medium- to long-range risk
  • Population-based risk factors (such as being Caucasian, over age 65, or depressed) apply to so many patients that their clinical usefulness is limited1
  • Population-based risk factors often have high sensitivity but low specificity (recent loss is an important risk factor for attempting suicide, for example, but very few persons with a recent loss attempt suicide)
  • In an acute situation, the positive predictive value of suicide risk factors—alone or in combination—is not known

Table

3 important questions to ask in overdose cases

  • Did the patient purchase pills specifically for this purpose (an ominous sign) or use what was on hand?
  • Did the patient take all pills available (ominous) or only a portion? If not all, why did he or she stop?
  • What did the patient expect the pills’ effect would be?

What method was used? Methods other than taking an overdose or cutting the wrists may be more dangerous.

What amount was used? (in overdose or poisoning cases)

What treatment was needed? If the patient took an overdose of opioids and needs intubation, this indicates a relatively serious attempt. On the other hand, the psychiatric seriousness of an acetaminophen overdose depends on whether the patient realized the danger in taking high doses of acetaminophen. Additional questions can help determine the seriousness of suicide attempts by overdose (Table).

Was the attempt impulsive or planned? Planned attempts tend to be more serious.

What is the ‘risk-rescue ratio’? The potential lethality of the attempt and the likelihood of being saved must be evaluated together. Where did the attempt occur? In a setting where others were likely to intervene? Was the patient alone? Attempts in the presence of others may be considered less alarming.

What did the patient do immediately afterward? Did he tell anyone? How did he get to the hospital? Did he seek help on his own? Who called the ambulance?

How does the patient feel about the attempt now? Is she glad or disappointed she didn’t die? Does she regret the attempt?

Have there been past attempts? Does the patient have a history of suicide attempts or significant selfmutilation? If so, what was the most serious incident? Past attempts tend to predict future attempts.

Other considerations for patients who have attempted suicide and those who have not but are being evaluated for possible suicide risk include:

Mental state. To estimate a patient’s mental state and depth of negative affect, without having seen her yourself, three helpful questions are:

  • Does she still look upset, depressed, or angry? Anger and agitation tend to increase risk.
  • Can she smile or relax, even briefly?
  • Does she feel things are likely to improve?

Access to firearms. Suicide by firearms accounts for 55% of all suicides.3 Does the patient have access to a gun and bullets? If so, get details. Does he now keep the gun on his person instead of in a locked cabinet, as he did earlier? We find that questions about guns are all too frequently omitted.

Contract for safety. Can the patient reliably contract not to harm himself and to call for help in a crisis? Although contracts for safety have limited value—as will be discussed—a patient’s refusal to contract for safety may indicate a higher suicide risk.

Some patients may refuse to contract for safety in order to be hospitalized for other reasons. They may say they can’t be sure what they will do if not admitted or declare that the clinician will be blamed for their death.

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