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 risk assessment remains a core skill in order to appropriately plan disposition for patients with suicidal ideation and also for medicolegal purposes.

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
  • 50% of individuals who successfully commit suicide have no prior history of suicide attempts
  • There has been no improvement of accuracy of predicting suicides in the past 40 years

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.[3] 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:[4]

  • 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

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
  • A - Acute Factors
  • I - Imminent Warning Signs
  • P - Protective Factors
  • S - Summary Statement

Other Considerations

Consider the following in your decision to discharge:

  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) Suicide rates: An overview Statistics Canada Catalogue no. 82-624-X by Tanya Navaneelan
4) 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.