Suicide risk assessment is a gateway to patient treatment and management. It is a core competency requirement for psychiatric residents.1 It is no longer assumed that psychiatrists will somehow acquire this skill during their careers. The purpose of suicide risk assessment is to identify treatable and modifiable risks and protective factors that inform the patient’s treatment and safety management requirements. Patients at risk for suicide often confront the psychiatrist with life-threatening emergencies. Most clinicians rely on the clinical interview and certain valued questions and observations to assess suicide risk.2
Unlike general physicians, psychiatrists do not have laboratory tests and sophisticated diagnostic instruments available to assess suicidal patients. In evaluating an emergency cardiac patient, the clinician can order a number of diagnostic tests and procedures (eg, ECG, serial enzyme levels, imaging, catheterization). However, the quintessential diagnostic instrument available to psychiatrists is systematic suicide risk assessment informed by evidence-based psychiatry.
No suicide assessment method has been empirically tested for reliability and validity.3 The standard of care encompasses a range of reasoned clinical approaches to suicide risk assessment based on the clinician’s training, experience, and familiarity with the evidence-based psychiatric literature. Systematic suicide risk assessment is an example of a comprehensive methodological approach.
Commonly occurring pitfalls
Quality assurance reviews of clinical records and the analyses of litigated suicide cases reveal commonly occurring shortcomings in suicide risk assessment.
No assessment. Next to conducting no suicide risk assessment, the all too familiar notation “No SI, HI, CFS” (no suicidal ideation, homicidal ideation, contracts for safety) is little improvement. The clinician must do more. Approximately 25% of suicidal patients deny suicidal ideation when asked.4 When the patient denies suicidal ideation, additional questions should be asked about prior suicide attempt(s) and family history of mental illness and/or suicide. For patients who are determined to commit suicide, the clinician is their enemy.5 Denial of suicidal ideation should not end the suicide risk assessment process but be the beginning of a systematic inquiry.
Delegating risk assessment. On most inpatient units, the overall care of the patient is directed by the treatment team. The psychiatrist sees the patient briefly, usually for medication management. Nonetheless, the psychiatrist is responsible for independently conducting suicide risk assessments. It cannot be delegated solely to other members of the treatment team. The input from team members is critical, however, since the staff observes and interacts with the patient 24 hours a day, 7 days a week. In outpatient split-treatment settings, both psychiatrist and therapist conduct suicide risk assessments independently, but they need to share their findings with each other. Each clinician’s suicide risk assessment is derived from a different clinical perspective, even though it is the same patient.
Documenting assessments. The standard of care requires that important evaluations, such as suicide risk assessments, be documented. Suicide risk assessment is a process, not an event. Continuing documentation of suicide risk assessments is necessary at important clinical junctures (eg, inpatient admission, change of safety status, discharge). If a malpractice suit is filed following a patient’s suicide, the clinician who has not documented the suicide risk assessments is vulnerable to the plaintiff’s attorney’s argument that no suicide risk assessments were performed.
A documented, concise narrative is sufficient; however, merely checking off boxes on a risk-assessment form is insufficient. Worse than no documentation is documentation of a substandard suicide risk assessment. Documentation of suicide risk assessments facilitates continuity of care and promotes communication between staff members across changing shifts. It is easy for suicidal patients to “fall through the cracks” of a busy psychiatric unit that has rapid patient turnover of admissions and discharges.
Time constraints. William Osler, a much revered physician in his day, advised, “Care more particularly for the individual patient than for the special features of the disease.”6 Currently, mainly very sick, suicidal patients are admitted to inpatient units. The length of stay in some inpatient facilities is under 5 days. The clinician may see the patient only briefly, sometimes just for 5-minute medication checks. The goal of treatment is rapid stabilization, diminished suicide risk, and discharge.
Most suicidal inpatients are discharged at some level of suicide risk. It is usually not possible to reduce suicide risk totally, given the short duration of most hospital stays. Sudden improvement in high-risk suicidal patients is suspect.7 A comprehensive suicide risk assessment is an essential part of the discharge process.
In outpatient settings, brief, 15-minute “med checks” are commonplace. Many challenging patients at suicide risk are not admitted to inpatient facilities but are treated as outpatients. Screening for suicide risk is essential (R. I. Simon, unpublished data, 2011). Documented, systematic suicide risk assessments are a rarity. Instead, unwarranted reliance is often placed on suicide risk assessment forms that can be checked off rapidly and on patient safety contracts.
“Gut” assessments. Some clinicians rely on what they call gut assessments of suicide risk. It is not clear what “gut” means other than perhaps something akin to intuition or a hunch. It may be as amorphous as detecting a scent of suicide in the air or it may be synonymous with the clinician’s experience. Highly subjective, often idiosyncratic determinations of suicide risk are influenced by the vagaries of human vicissitudes. What is the gut assessment of a patient’s suicide risk if the clinician has just come from an argument with a spouse or partner or has endured a bad night’s sleep? Will the clinician’s suicide risk assessment of the patient be overly optimistic on a bright sunny day when all is going well?
Suicide risk assessment is fundamentally a reasoned clinical judgment call.8 This may be what some clinicians refer to as a gut assessment. Intuition can provide important information, but it cannot be a substitute for a reasoned clinical judgment informed by systematic suicide risk assessment. Moreover, gut assessments tend to be predictions, ie, the patient will or will not attempt or complete suicide. It is firmly established that clinicians cannot predict “when or if” a suicide will occur.9
If a defendant clinician who is sued for negligent discharge of a suicidal patient deemed to be at low suicide risk testifies that he or she relied on a gut assessment of suicide risk, the plaintiff’s expert witness will likely explain to the court that the patient displayed a number of evidence-based risk factors that if adequately assessed would have indicated a high risk of suicide. The patient should not have been discharged from the hospital.
Risk assessment forms. Suicide risk assessment forms are favored by clinicians who treat patients in settings with rapid patient turnover.10 Seriously ill, high-risk suicidal inpatients often evoke anxiety among the clinical staff, who then place their confidence in checked-off suicide risk assessment forms. It is much quicker to check off a form than to conduct a thorough suicide risk assessment. Form trumps substance.
If the clinician uses forms for suicide risk assessment, an accompanying documented narrative is needed that explains his reasoning process. A fundamental flaw of suicide risk forms is the absence of a process of analysis and synthesis. The clinician does not identify, prioritize, and integrate risk and protective factors into an overall assessment of the patient’s suicide risk. Assessment forms, unaided by a descriptive narrative, merely create the illusion of adequacy. Also, protective factors are usually not included on the form, creating a one-sided, risk-based assessment.
“No harm” contract. Suicide prevention contracts are widely used in a variety of clinical settings. However, there is no evidence that suicide prevention contracts decrease or prevent suicide.11 The road to patient suicide is strewn with broken safety contracts. The suicidal patient who rejects a no harm contract will at least disabuse the clinician of a false sense of safety.
Unfortunately, safety contracts often take the place of adequate suicide risk assessment. If the clinician uses a safety contract, he is on notice that a systematic suicide risk assessment needs to be done.
Systematic suicide risk assessment
The most glaring deficiency in suicide risk evaluations is the failure to conduct systematic assessments. Given the high stakes, getting the suicide risk assessment right is of critical importance. “The [suicide risk] assessment is comprehensive in scope, integrating knowledge of the patient’s specific risk factors, clinical history, including psychopathological development and interaction with the clinician.”8 When the suicide risk assessment is not systematic, omissions of important risk and protective factors create substandard assessments.
Systematic assessment also gathers essential information or reveals a lack thereof. Risk factor omissions may include, for example, a history of child abuse, a family history of mental illness or suicide, guns at home, melancholic features of major depression, and perceived burdensomeness.12 As noted above, protective factors are frequently overlooked in clinical assessments and suicide risk assessment forms. Focusing only on risk ensures incomplete, flawed assessments.
Most clinicians rely on general suicide risk factors derived from community-based psychological autopsy studies as well as cohort and case-control studies.13 Important omissions occur when individual risk and protective factors are not assessed along with general risk factors. Identifying and assessing individual risk and protective factors requires spending time with the patient. Suicidal patients often display unique, “signature” prodromal risk factors. Knowledge of the progression of suicide risk informs the clinician’s interventions. For example, a stuttering schizophrenic patient spoke clearly when she became suicidal, enabling the clinician to make sound judgments about hospitalization and discharge. Significant others often provide information about the patient’s suicide risk prodrome. A review of prior hospitalization records can also be informative.
During recurrent episodes of illness, the patient’s prodromal patterns can change. Suicide risk and protective factors vary over time and circumstances. A systematic review of 1397 suicide attempters revealed that 82% used at least 2 different methods during suicide attempts.14 While a suicide rehearsal is an indicator of high risk, the method of suicide attempt can change, although the patient’s suicide intent remains unchanged.
No pathognomonic risk factor predicts suicidal behavior. A single suicide risk factor does not have adequate statistical power on which to base an assessment.15 Moreover, no risk factors can predict suicide in the short term (eg, minutes, hours, days, weeks, months). A 10-year cohort study of individuals with major affective disorders found risk factors predictive of suicide within 1 year of evaluation.16 Although this is an important finding, the clinician cannot identify specifically when or if the patient will attempt suicide during the 1-year period. “Imminent” suicide, a non-clinical term used frequently, is a predictive illusion.17 Can the clinician state what the time parameters are for predicting “imminent” suicidal behavior?
The process of suicide risk assessment encompasses identification, analysis, and synthesis of risk and protective factors that inform treatment and safety management of the patient. Overall suicide risk is determined along a continuum of low, moderate, and high. It becomes readily apparent why “No SI, No HI, CFS” is grossly deficient.
The documentation of the suicide risk assessment should be separately labeled in the psychiatric evaluation and in the progress notes because of its singular importance. Identifying risk and protective factors that are scattered throughout the psychiatric evaluation does not constitute an adequate assessment. Risk and protective factors must be pulled together into the process of analysis and synthesis. Suicide risk assessment allows the clinician to piece together (identify and prioritize) risk and protective factors to construct a clinical mosaic (synthesis) of the suicidal patient.18
Suicide risk assessment is a core competency requirement for psychiatrists. The purpose of suicide risk assessment is to identify treatable and modifiable risk and protective factors that informs the patient’s treatment and safety management.
If the suicide assessment methodology is faulty, the patient’s treatment and safety management will be adversely affected. Given the high stakes, getting the suicide risk assessment right is of critical importance.
1. Scheiber, SC, Kramer TAM, Adamowski SE. Core Competencies for Psychiatric Practice: What Clinicians Need to Know. A Report of the American Board of Psychiatry and Neurology. Washington, DC: American Psychiatric Publishing; 2003.
2.Sullivan GR, Bongar B. Psychological testing in suicide risk management. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Washington, DC: American Psychiatric Publishing; 2006:177-196.
3. Busch KA, Clark DC, Fawcett J, et al. Clinical features of inpatient suicide. Psychiatr Ann. 1993;23:256-262.
4. Robins E. The Final Months: A Study of the Lives of 134 Persons Who Committed Suicide. New York: Oxford University Press; 1981.
5. Resnick PJ. Recognizing that the suicidal patient views you as an ‘adversary.’ Curr Psychiatry. 2002;1:8.
6. Silverman ME, Murray TJ, Bryan CS, eds. The Quotable Osler. Philadelphia: American College of Physicians; 2003.
7. Simon R, Gutheil TG. Sudden improvement among high-risk suicidal patients: should it be trusted? Psychiatr Serv. 2009;60:387-389.
8. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors [published correction appears in Am J Psychiatry. 2004;161:776]. Am J Psychiatry. 2003;160(11 suppl):1-60.
9. Pokorny AD. Prediction of suicide in psychiatric patients. Report of a prospective study. Arch Gen Psychiatry. 1983;40:249-257.
10. Simon RI. Suicide risk assessment forms: form over substance? J Am Acad Psychiatry Law. 2009;37:290-293.
11. Stanford EJ, Goetz RR, Bloom JD. The no harm contract in the emergency assessment of suicidal risk. J Clin Psychiatry. 1994;55:344-348.
12. Van Orden KA, Lynam ME, Hollar D, Joiner TE Jr. Perceived burdensomeness as an indicator of suicidal symptoms. Cognit Ther Res. 2006;30:457-467.
13. Simon RI. Suicide risk: assessing the unpredictable. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Washington, DC: American Psychiatric Publishing; 2006:1-32.
14. Isometsä ET, Lönnqvist JK. Suicide attempts preceding completed suicide. Br J Psychiatry. 1998;173:531-535.
15. Meltzer HY, Conley RR, de Leo D, et al. Intervention strategies for suicidality. J Clin Psychiatry Autograph Series. 2003;6(2):1-16.
16. Fawcett J, Scheftner WA, Fogg L, et al. Time-related predictors of suicide in major affective disorder. Am J Psychiatry. 1990;147:1189-1194.
17. Simon RI. Preventing Patient Suicide: Clinical Assessment and Management. Washington, DC: American Psychiatric Publishing; 2011.
18. Simon RI: Suicide risk assessment: what is the standard of care? J Am Acad Psychiatry Law. 2002;30:340-344.