Risk Assessment is not Suicide Prediction
Because suicide is a relatively rare event, and suicidal intent can change rapidly, it is not possible to predict which patient will or will not attempt or die by suicide at any given point in time. The clinician’s job is to identify patients at higher risk of suicide and take steps to lower that risk.
Determine Whether the Patient is Suicidal
In clinical practice, concern about suicide risk begins with one or more of the following situations:
- recognition that a patient is seriously distressed or mentally unwell
- a clear or covert statement indicating that the patient is considering suicide; for example, “I’m not sure how long I can go on like this” or “I’m just so tired of being down.”
- communication from a family member or friend who is concerned about the patient; for example, “He keeps talking about how we’d be better off without him.”
Ask About Suicide
You are responsible for investigating suicidal intent. The most direct, effective way to do this is to ask the patient:
- “Have things gotten so bad that you’ve thought about hurting yourself or ending your life?”
- “Sometimes when people feel the way you do right now, they start to have thoughts about suicide. Has this ever happened to you?”
Asking about suicidal intent does not plant this as an idea in the patient’s head. Rather, asking why now—identifying the final straw—can help you and your patient target interventions to reduce risk.
A calm, non-judgmental, concerned approach tells the patient that you care and that you will be able to cope with the answers.
Be sure to ask about suicidal intent in the following situations:
- After a romantic relationship has ended, ask whether the patient has thoughts about harming or killing the former partner and/or children.
- With a female patient who has postpartum depression and suicidality, ask about thoughts that the baby would be better off dead and about intent to harm the child.
Know the Limits of Screening Questions
Self-administered screening tests are usually brief and easy to use, and they can help you begin a difficult discussion or focus further questioning.
However, these tests often have a high rate of false positives and a low positive predictive value compared with the gold standard of the psychiatric interview or a more detailed clinician-administered assessment tool (Chan, 2016; LeFevre, 2014).
A single negative screen should not result in diminished clinical monitoring for suicidal ideation or intent. Ongoing assessment and a high index of suspicion are important with any patient who has significant risk factors.
Investigate the Severity of the Suicidal Intent
If the patient endorses suicidal thoughts, your next task is to determine how serious the suicidal intent is.
Ask the patient:
- “What kinds of thoughts have you been having?” (This is a high-yield question, so be sure to let the patient talk.)
- “How long have you been having these thoughts? When did they first start?”
- “How often are these thoughts happening? Daily? Weekly? All the time?”
Ask the patient to rate the severity of the suicidal thinking on a scale of 1 to 10, where 1 = very low intensity and 10 = extreme intensity or severity.
Ask the patient about a suicide plan and access to means:
- “Do you have a plan for how you would kill yourself?”
- “Have you thought about any other methods?” (Patients may not reveal the most lethal method at first-ask.)
- “Do you have any firearms or other weapons at home? Where are they?”
If the preferred method is overdose or hanging, ask:
- “Have you bought or saved pills? Do you have a rope?”
- “Have you ‘rehearsed’ or ‘gone through the motions’ of killing yourself?”
Assess the patient’s intent to act
Ask the patient:
- “In the next 24–48 hours, how likely is it that you will act on your suicidal plan?” (Ask the patient to rate the likelihood on a scale of 1 to 10, where 1 = very unlikely and 10 = certain.)
Consider whether the patient has a history of impulsivity (high-risk behaviours, overspending, fights, poorly thought-out decisions). If you do not know the patient well, ask:
- “Would you consider yourself an impulsive person?”
- “Have you recently felt out of control at times?”
Self-harm versus suicidality
Not all patients who harm themselves by cutting, burning or other mutilating behaviours are actively suicidal.
To differentiate self-harm from suicidal behaviour, ask about the patient’s intentions. Was the behaviour (e.g., cutting, burning) done to end the person’s life, to gain relief from emotional distress or to overcome a feeling of numbness?
Remember, patients who self-harm may have more than one intention for the behaviour, and self-harm is a risk factor for future suicide attempts. The co-existence of both behaviours is common in borderline personality disorder and other impulsive personality disorders.