The Geezer’s Dirty Dozen on Suicide Risk Assessment

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This is another GeezerVideo, which is a Dirty Dozen on suicide risk assessment. Suicide risk assessmet is arguably the most important thing psychiatrists do. While it may be debatable that we can ever prevent suicide in general psychiatric practice (see references), there are ways to develop a more systematic approach to suicide risk assessment.

Slide 3: This is an introductory slide with some basic facts on suicide, mainly statistics.

Slide 4: This slide lists a few of the psychiatric disorders with which suicide is associated. The Cluster B personality disorders most often associated with suicide are Borderline Personality Disorder and Antisocial Personality Disorder. That doesn’t mean that persons with other types of personality disorders never attempt or complete suicide.

Slide 5: This slide lists the bare bones of suicide risk assessment, which includes most importantly a suicide inquiry. This entails asking the person about suicide ideation, plan, and intent. It also means asking about whether or not the person has access to firearms. Protective factors are not absolute and there may be individualistic protective and risk factors. Finally you should plan an intervention and document what was discussed.

Slide 6: The link to the paper by my colleague, Dr. Jess Fiedorowicz, Dr. Kija Weldon (at the time of publication  resident in our Psychiatry Department), and Dr. George Bergus in the Family Medicine Department at The University of Iowa Hospitals and Clinics provided. It’s an absolute tour de force and I highly recommend reading it for the extremely thorough and practical approach to suicide risk assessment. The default plan would be to hospitalize those who have plan and intent for suicide. No suicide contracts or suicide prevention contracting (SPC) is to be discouraged. They don’t prevent suicide and can complicate risk assessment. A Safety Plan is not the same thing as a no suicide contract and should be thought of as an additional means for evaluating the strength of your alliance with the patient and her ability to participate meaningfully in working on ways to cope with immediate and chronic stressors which can trigger suicide ideation.

Slide 7: It can be very difficult to obtain a valid history of suicide ideation from someone who is determined to kill himself. Special care should be taken to listen for understanding, validate psychic pain, be sensitive for anxiety, severe pain, and sleeplessness and other modifiable factors that can fuel suicide thinking. Some patients simply lie to psychiatrists and other physicians. It may be critical to contact other persons for collateral information, even if the patient objects.

Slide 8: These are a couple of models for suicide risk assessment that seek to make the process easy to remember and conducive to gathering reliable information about risk factors and facilitate making plan for intervening, which includes but is not limited to treating depression and anxiety, helping to modify situational stressors, and hospitalization. There are links to the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) and the CASE approaches. A screenshot of the SAFE-T follows:

SAFE-T suicide risk pocket card

Slide 9: This slide is from an excellent paper by McDowell, Lineberry, and Bostwick on how busy family doctors can conduct suicide risk assessment. However, I would advise most non-psychiatric clinicians to have a low threshold for getting a psychiatric consultant involved early on, if available.

Slide 10: This is an interesting and long overdue attempt to create a more standardized method for evaluating a clinician’s ability to conduct a suicide risk assessment. The Competency-assessment instrument for suicide risk-assessment (CAI–S) is available from the authors of the study identified on the slide: Hung EK, Binder RL, Fordwood SR, Hall SE, Cramer RJ, McNiel DE. A method for evaluating competency in assessment and management of suicide risk. Acad Psychiatry. 2012;36(1):23-8.

Slides 11 and 12: References and resources for suicide risk assessment

Amos, J. J., M.D. (2010). Suicide risk assessment. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. amos, M.D., and R. G. Robinson, M.D. New York, Cambridge University Press: 51-57.

Bleich, A., Y. Baruch, et al. (2011). “Management of the suicidal patient in the era of defensive medicine: focus on suicide risk assessment and boundaries of responsibility.” Isr Med Assoc J 13(11): 653-656.

Suicide is universal within the range of human behaviors and is not necessarily related to psychiatric morbidity, though it is considerably more prevalent among psychiatric patients. Considering the limitations of medical knowledge, psychiatrists cope with an unfounded and almost mythical perception of their ability to predict and prevent suicide. We set out to compose a position paper for the Israel Psychiatric Association (IPA) that clarifies expectations from psychiatrists when treating suicidal patients, focusing on risk assessment and boundaries of responsibility, in the era of defensive medicine. The final draft of the position paper was by consensus. The IPA Position Paper established the first standard of care concerning expectations from psychiatrists in Israel with regard to knowledge-based assessment of suicide risk, elucidation of the therapist’s responsibility to the suicidal psychotic patient (defined by law) compared to patients with preserved reality testing, capacity for choice, and responsibility for their actions. Therapists will be judged for professional performance rather than outcomes and wisdom of hindsight. This paper may provide support for psychiatrists who, with clinical professionalism rather than extenuating considerations of defensive medicine, strive to save the lives of suicidal patients.

Durkee, T., G. Hadlaczky, et al. (2011). “Internet pathways in suicidality: a review of the evidence.” Int J Environ Res Public Health 8(10): 3938-3952.

The general aim of this study was to review the scientific literature concerning the Internet and suicidality and to examine the different pathways by which suicidal risks and prevention efforts are facilitated through the Internet. An online literature search was conducted using the MEDLINE and Google Scholar databases. The main themes that were investigated included pathological Internet use and suicidality, pro-suicide websites, suicide pacts on the Internet, and suicide prevention via the Internet. Articles were screened based on the titles and abstracts reporting on the themes of interest. Thereafter, articles were selected based on scientific relevance of the study, and included for full text assessment. The results illustrated that specific Internet pathways increased the risk for suicidal behaviours, particularly in adolescents and young people. Several studies found significant correlations between pathological Internet use and suicidal ideation and non-suicidal self-injury. Pro-suicide websites and online suicide pacts were observed as high-risk factors for facilitating suicidal behaviours, particularly among isolated and susceptible individuals. Conversely, the evidence also showed that the Internet could be an effective tool for suicide prevention, especially for socially-isolated and vulnerable individuals, who might otherwise be unreachable. It is this paradox that accentuates the need for further research in this field.

Edwards, S. J. and M. D. Sachmann (2010). “No-suicide contracts, no-suicide agreements, and no-suicide assurances: a study of their nature, utilization, perceived effectiveness, and potential to cause harm.” Crisis 31(6): 290-302.

BACKGROUND: Suicide prevention contracting (SPC) procedures are often afforded clinical practice validity in the absence of evidence attesting to their efficacy and validity. AIMS: This study sought to develop a contemporary profile of SPC, identifying factors associated with utilization, perceived effectiveness, and to describe potentially detrimental factors when activating SPC. METHODS: A questionnaire was mailed to a sample of mental health practitioners comprising physicians, mental health nurse practitioners, and allied health practitioners to inquire about their practices and experiences with SPC. RESULTS: There were 420 valid responses, a response rate of 31%. Participants confirmed three types of SPC procedures in operation: (1) 355 (85%) having used verbal no-suicide assurances (NSAs); (2) 317 (76%) using verbal no-suicide agreements (NSAg); and, (3) 154 (37%) using written no-suicide contracts (NSC). The profiled procedures and their clinical application indicate that participants perceived differences in the diagnostic, therapeutic, and medico-legal utility of all three SPC procedures. Importantly, SPC procedures were shown to have a multifaceted potential for detrimental outcomes for patients and practitioners. CONCLUSIONS: Until now, SPC had represented a poorly understood and remains a questionable clinical practice intervention. Education initiatives are required that alert mental health practitioners to the dangers of SPC for patients and practitioners alike, and to present alternative interventions containing less risk.

Fiedorowicz, J. G., K. Weldon, et al. (2010). “Determining suicide risk (hint: a screen is not enough).” J Fam Pract 59(5): 256-260.

An individualized assessment is essential to identifying relevant risk factors. Use direct questions, such as, “Have you had any thoughts about killing yourself?” to screen for suicidal ideation. Ask a family member or close friend to ensure that any guns or other lethal means of suicide are inaccessible to the patient at risk. Avoid the use of “no harm” contracts, which are controversial and lack demonstrated effectiveness.

Fowler, J. C. (2012). “Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments.” Psychotherapy 49(1): 81-90.

This practice review focuses on the challenges of conducting sensitive and accurate assessments of the relative risk for suicide attempts and completed suicides. Suicide and suicide attempts are a frequently encountered clinical crisis, and the assessment, management, and treatment of suicidal patients is one of the most stressful tasks for clinicians. An array of risk factors, warning signs, and protective factors associated with suicide risk are reviewed; however, we are not yet in possession of evidence-based diagnostic tests that can accurately predict suicide risk on an individual level without also creating an inordinate number of false-positive predictions. Given the current limitations of assessment strategies, clinicians are advised to keep in mind that patients contemplating suicide are under enormous psychological distress, requiring sensitive and thoughtful engagement during the assessment process. An overarching goal of these assessments should be conducted within the therapeutic frame, in which efforts are made to enhance the therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. Within this treatment heuristic, the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) is recommended as a pragmatic multidimensional assessment protocol incorporating the best known risk and protective factors. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Goldney, R. D. (2012). “Problems with suicide risk assessment.” Australian and New Zealand Journal of Psychiatry 46(2): 172-173.

Goodman, M., T. Roiff, et al. (2012). “Suicidal Risk and Management in Borderline Personality Disorder.” Current Psychiatry Reports 14(1): 79-85.

This paper reviews recent advances in our understanding of suicidality in borderline personality disorder (BPD), with a focus on suicide risk assessment, guidelines for treatment, and medicolegal concerns. Relevant material on distinctions between suicide completers and suicide attempters, contributions of published American Psychiatric Association Guidelines, the controversial role of hospitalization, and management strategies regarding litigation is addressed. Despite accumulating data on suicidality in BPD, the current state of knowledge offers only partial clues to help identify the BPD patients most at risk of death by suicide, and offers a limited armamentarium of treatment targeted to suicide prevention, creating discomfort in clinicians and fears regarding litigation in the event of a successful suicide. Promising new interventions include less resource-intensive psychotherapies as well as brief crisis intervention.

Hung, E. K., R. L. Binder, et al. (2012). “A method for evaluating competency in assessment and management of suicide risk.” Acad Psychiatry 36(1): 23-28.

OBJECTIVE: Although health professionals increasingly are expected to be able to assess and manage patients’ risk for suicide, few methods are available to evaluate this competency. This report describes development of a competency-assessment instrument for suicide risk-assessment (CAI-S), and evaluates its use in an objective structured clinical examination (OSCE). METHOD: The authors developed the CAI-S on the basis of the literature on suicide risk-assessment and management, and consultation with faculty focus groups from three sites in a large academic psychiatry department. The CAI-S structures faculty ratings regarding interviewing and data collection, case formulation and presentation, treatment-planning, and documentation. To evaluate the CAI-S, 31 faculty members used it to rate the performance of 31 learners (26 psychiatric residents and 5 clinical psychology interns) who participated in an OSCE. After interviewing a standardized patient, learners presented their risk-assessment findings and treatment plans. Faculty used the CAI-S to structure feedback to the learners. In a subsidiary study of interrater reliability, six faculty members rated video-recorded suicide risk-assessments. RESULTS: The CAI-S showed good internal consistency, reliability, and interrater reliability. Concurrent validity was supported by the finding that CAI-S ratings were higher for senior learners than junior learners, and were higher for learners with more clinical experience with suicidal patients than learners with less clinical experience. Faculty and learners rated the method as helpful for structuring feedback and supervision. CONCLUSION: The findings support the usefulness of the CAI-S for evaluating competency in suicide risk-assessment and management.

McDowell, A. K., T. W. Lineberry, et al. (2011). “Practical suicide-risk management for the busy primary care physician.” Mayo Clin Proc 86(8): 792-800.

Suicide is a public health problem and a leading cause of death. The number of people thinking seriously about suicide, making plans, and attempting suicide is surprisingly high. In total, primary care clinicians write more prescriptions for antidepressants than mental health clinicians and see patients more often in the month before their death by suicide. Treatment of depression by primary care physicians is improving, but opportunities remain in addressing suicide-related treatment variables. Collaborative care models for treating depression have the potential both to improve depression outcomes and decrease suicide risk. Alcohol use disorders and anxiety symptoms are important comorbid conditions to identify and treat. Management of suicide risk includes understanding the difference between risk factors and warning signs, developing a suicide risk assessment, and practically managing suicidal crises.

Shea, S. C. (1998). “The chronological assessment of suicide events: a practical interviewing strategy for the elicitation of suicidal ideation.” J Clin Psychiatry 59 Suppl 20: 58-72.

Suicide assessment is one of the cornerstones of daily clinical practice for both mental health professionals and primary care clinicians. A practical interviewing strategy for efficiently eliciting valid suicidal ideation is presented. The strategy is illustrated via a reconstructed interview designed to highlight key teaching points. The strategy, the Chronological Assessment of Suicide Events (CASE Approach), helps the clinician to uncover critical data in four contiguous time frames: (1) presenting suicidal ideation/behavior, (2) recent suicidal ideation/behaviors, (3) past suicidal ideation/behaviors, and (4) immediate suicidal ideation. The CASE Approach is an easily learned interviewing strategy, designed for busy, frontline clinicians in both the mental health and primary care settings.

Szmukler, G. (2012). “Risk assessment for suicide and violence is of extremely limited value in general psychiatric practice.” Australian and New Zealand Journal of Psychiatry 46(2): 173-174.

Suicide Risk Assessment Quiz:

1. Modifiable risk factors for suicide include all of the following except:

A. Major Depressive Disorder

B. Male gender

C. Global insomnia

D. Severe anxiety and agitation

2. Suicide prevention contracts (SPC) are effective at preventing suicide.

A. True

B. False

3. The SAFE-T method of suicide risk assessment involve the following steps:

A. Identifying risk factors

B. Identifying protective factors

C. Conducting a suicide inquiry

D. Determining the level of risk and intervention and documenting the assessment thoroughly

E. All of the above

4. About 95% of suicides are related to a psychiatric illness:

A. True

B. False

5. It is never appropriate to gather collateral information from others when a patient at high risk for suicide denies permission to contact friends and family:

A. True

B. False

Suicide Risk Assessment Quiz Answer Key:

1. B; 2. B; 3. E; 4. A; 5. B



  1. Thank you for sharing this presentation. It was both interesting and informative.


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