Suicide Risk Assessment (SRA)

Suicide Risk Assessment (SRA)

Suicide Risk Assessment (SRA)

Primer

The Suicide Risk Assessment is an important part of the psychiatric interview. A suicide risk assessment is a comprehensive assessment that determines what an individual's risk is for suicide at a given point in time – a suicide risk assessment cannot predict the future.

Do Suicide Risk Assessments Work?

Suicide risk assessments setting have poor predictive value in identifying those at risk actually of completing suicide.^[1] However, a structured suicide risk assessment remains a core skill in order to appropriately plan disposition for patients with suicidal ideation and also for medicolegal record keeping.

Sobering Statistics

95% of “high risk” patients will not die by suicide^[2]
- There is no validated method to identify patients at high risk who would improve with treatment/hospitalization.
50% of suicides are from “low risk” patients.^[3]
50% of individuals who complete suicide have no prior history of suicide attempts.
Not all people who die by suicide have a psychiatric disorder.
- In Western high-income countries, the percentage of those who die by suicide with no psychiatric disorder is estimated to be between 5% and 40%. More robust studies estimate this to be at 20%.^[4]
There has been no improvement of accuracy of predicting suicides in the past 40 years, despite other advances in medicine, which speaks to the complexity of suicide as an outcome.

Assessment

Always ask about access to guns and firearms if there is serious suicidal intention. Death by suicide from a firearm is a major cause of death by suicide in many countries, including both Canada and the United States.^[5] Males are at a significantly higher risk of death by firearms than females.

Risk Factors

The mnemonic SAD PERSONS can be used to evaluate risk factors:^[6]

S - Sex (male > female)
A - Age (risk increases with age)
D - Depression
P - Previous attempt (this is the best indicator of suicide risk)
A - Alcohol abuse
R - Rational thinking loss (impulsive)
S - Social supports lacking
O - Organized plan
N - No spouse
S - Sickness

Protective Factors

Children
Social supports
Religious
Good health
Pregnant
Sense of responsibility

Screening and Rating Scales

Suicide Assessment Scales

Name	Rater	Description	Download
Columbia-Suicide Severity Rating Scale (C-SSRS)^[7]	Clinician	The Columbia-Suicide Severity Rating Scale (C-SSRS) is a tool that uses a series of questions to assess suicide risk.	Link

Documentation and Disposition

"CAIPS"

The mnemonic CAIPS can be a good way to structure your suicide risk assessment documentation on the medical record:

C - Chronic Factors
- (e.g. - Past history of suicide attempts, history of self-harm)
A - Acute Factors
- (e.g. - Recent break up, job loss, or acute crisis)
I - Imminent Warning Signs
- (e.g. - Means of death has been prepared, such as buying a gun, or having imminent access to the means of death)
P - Protective Factors
- (e.g. - “Supportive family, help-seeking, willing to safety plan, future-oriented, willing to attend follow up)
S - Summary Statement
- (e.g. - “Based on the factors above, patient is at [low/medium/high] risk for suicide)