Suicide Risk Assessment
Suicide risk assessment is a core clinical skill involving systematic evaluation of risk and protective factors to guide management decisions. It should use structured professional judgment.
Key Facts
Structured professional judgment is recommended over risk prediction tools — no tool can accurately predict suicide Assessment should evaluate current ideation, plan, intent, means, and access to means Hopelessness is the strongest psychological predictor of suicide (Beck Hopelessness Scale) Previous self-harm is the strongest overall predictor — 50-100× increased risk Recent psychiatric discharge (first 3 months, especially first week) is a high-risk period Assessment must include protective factors: Social support, children, religious beliefs, therapeutic relationship, future-oriented thinking Safety planning is more effective than 'no-suicide contracts' (which have no evidence base) All clinicians should be competent in suicide risk assessment — it is not limited to psychiatrists
Overview
Key Facts
Suicide risk assessment is a fundamental clinical skill required across all medical specialties. It is not about predicting suicide (which is impossible with current tools) but about understanding individual risk, identifying modifiable factors, and guiding appropriate care.
Epidemiology
Approximately 6,000 people die by suicide annually in the UK. ~75% are male. Highest rates in men aged 45-49. ~27% had contact with mental health services in the year before death. ~50% had visited their GP in the month before death.
Aetiology
Suicide risk is determined by the interaction of:
- Static (historical) risk factors: Previous attempts, family history, childhood adversity, male sex
- Dynamic (current) risk factors: Current mental illness, substance intoxication, hopelessness, recent stressors
- Protective factors: Social connectedness, children, religious beliefs, therapeutic relationship, reasons for living
Pathophysiology
- Interpersonal Theory of Suicide (Joiner): Suicide requires (1) perceived burdensomeness, (2) thwarted belongingness, AND (3) acquired capability for suicide
- Integrated Motivational-Volitional model (O'Connor): Defeat/entrapment → suicidal ideation → moderated by capability/means → suicidal behaviour
- These models emphasise that ideation alone does not predict behaviour — capability and access to means are critical modulators
Clinical Presentation
Structured Risk Assessment Framework
1. Current Presentation
- Current suicidal ideation (frequency, intensity, duration)
- Plan: Specific method, time, place
- Intent: Desire to die vs desire for situation to change
- Access to means
- Preparatory behaviours (suicide note, giving away possessions, researching methods)
2. Risk Factors
- Psychiatric: Depression, psychosis, substance misuse, personality disorder, anxiety
- Historical: Previous attempts (method, number, lethality), family history of suicide
- Psychological: Hopelessness, impulsivity, agitation, insomnia
- Social: Isolation, relationship breakdown, unemployment, financial crisis, bereavement
- Demographic: Male, 45-54, single/divorced
3. Protective Factors
- Social support, dependent children, religious beliefs
- Future plans, reasons for living, engagement with services
- Problem-solving ability, therapeutic alliance
4. Mental State Examination
- Mood, affect, hopelessness, psychotic symptoms
- Cognitive state, insight, judgment
- Substance intoxication/withdrawal
Red Flags
- Stated intent to die with specific plan
- Access to lethal means (firearms, medications, height)
- Recent psychiatric discharge (first week highest risk)
- Command hallucinations to harm self
- Final acts (will changes, giving away possessions, saying goodbye)
- Sudden calmness after period of agitation (may indicate decision made)
Differential Diagnosis
| Risk Level | Features | Management |
|---|---|---|
| Low | Fleeting ideation, no plan, good social support, protective factors | Safety plan, GP follow-up, crisis numbers |
| Moderate | Recurrent ideation, vague plan, some risk factors, some protective | Safety plan, crisis team referral, close follow-up |
| High | Active ideation with plan and intent, few protective factors | Crisis team, consider admission (voluntary or MHA) |
| Imminent | Actively suicidal, access to means, refusing help | Emergency admission, MHA assessment if necessary |
Diagnosis / Investigation
Bedside
- Clinical interview: Empathic, direct questioning about suicidal thoughts (does NOT increase risk)
- Collateral history: From family, friends, GP, mental health team
- Mental state examination: Comprehensive
- PHQ-9: Item 9 specifically asks about self-harm/suicidal ideation
- Beck Hopelessness Scale: 20-item measure of hopelessness
- Columbia Suicide Severity Rating Scale (C-SSRS): Structured interview for ideation and behaviour
Bloods
- As clinically indicated for underlying conditions
- Alcohol level, urine drug screen if substance use suspected
Special Tests
- Risk assessment tools (SAD PERSONS, Patterson) have poor predictive value — use as aide-memoire only, NOT as clinical decision-making tools
Management
Non-pharmacological
- Safety planning (Stanley & Brown): Collaborative 6-step plan — (1) warning signs, (2) internal coping strategies, (3) social contacts for distraction, (4) contacts to ask for help, (5) professionals to contact, (6) means restriction
- Means restriction counselling: Advise safe storage/removal of medications, sharp objects, firearms
- Follow-up: Timely contact after assessment (within 48 hours of ED discharge, within 7 days of psychiatric discharge)
- Therapeutic relationship: Non-judgmental, empathic engagement
- Crisis planning: Written plan with patient — who to contact, what to do
Pharmacological
- Treat underlying mental illness appropriately
- Lithium: ~60% reduction in suicide risk in mood disorders
- Clozapine: Reduces suicidality in schizophrenia
- SSRIs: Treat depression (avoid TCAs if overdose risk)
- Ketamine/esketamine: Rapid reduction in suicidal ideation (emerging evidence)
Referral Criteria
- High risk — crisis team or inpatient admission
- MHA assessment if refusing treatment and risk to life
- Moderate risk — crisis team, urgent outpatient psychiatry
- All self-harm — psychosocial assessment before discharge
Prognosis
- No tool can reliably predict suicide at the individual level
- ~5% of 'high-risk' patients will die by suicide; ~50% of suicides occur in patients assessed as 'low risk'
- Protective factors are as important as risk factors in clinical decision-making
- Safety planning reduces repeat suicidal behaviour by ~50%
- Continuity of care and follow-up after discharge significantly reduce suicide risk
- Zero suicide policies aim for culture change rather than elimination of all deaths (which is not achievable)
Other Relevant Information
Stanley & Brown Safety Plan (6 Steps)
| Step | Action |
|---|---|
| 1 | Recognise warning signs (thoughts, feelings, behaviours) |
| 2 | Internal coping strategies (distraction, self-soothing) |
| 3 | Social contacts who can help distract |
| 4 | People I can ask for help |
| 5 | Professionals and agencies to contact (crisis team, Samaritans 116 123) |
| 6 | Making my environment safer (means restriction) |