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
  • 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.[4] 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:[5]

  • 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)[6] 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)

Other Considerations

Consider the other following factors in your decision to discharge/admit:

  1. Diagnosis
  2. Severity of suicidal ideation
  3. Coping skills
  4. Living situation
  5. Social supports
  6. Risk factors
  7. Access to follow-up
  8. What is the intent, lethality, and access to means?

Tools

Safety Planning

PDFs

Resources

Articles

References

1) Large, M., Kaneson, M., Myles, N., Myles, H., Gunaratne, P., & Ryan, C. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time. PloS one, 11(6), e0156322.
2) Large, M., Kaneson, M., Myles, N., Myles, H., Gunaratne, P., & Ryan, C. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time. PloS one, 11(6), e0156322.
3) Large, M., Kaneson, M., Myles, N., Myles, H., Gunaratne, P., & Ryan, C. (2016). Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time. PloS one, 11(6), e0156322.
4) Suicide rates: An overview Statistics Canada Catalogue no. 82-624-X by Tanya Navaneelan
5) Patterson, W. M., Dohn, H. H., Bird, J., & Patterson, G. A. (1983). Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics, 24(4), 343-345.
6) Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., ... & Mann, J. J. (2011). The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. American journal of psychiatry, 168(12), 1266-1277.