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Med Clin North Am. Author manuscript; available in PMC 2018 May 01.
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Published in final edited form as:

Med Clin North Am. 2017 May ; 101(3): 553–571. doi:10.1016/j.mcna.2016.12.006.

Psychiatric Emergencies: Assessing and Managing Suicidal

Ideation
Andrea N. Webera,b, Maria Michaile, Alex Thompsonb, and Jess G. Fiedorowicza,b,c,d,f
aDepartment of Internal Medicine, The University of Iowa, Iowa City, IA, USA
bDepartment of Psychiatry, Carver College of Medicine, The University of Iowa, Iowa City, IA,
USA
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cDepartment of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
dAbboud Cardiovascular Research Center, The University of Iowa, Iowa City, IA, USA
eSchool of Health Sciences, University of Nottingham, Nottingham, UK

SYNOPSIS
The assessment of suicide risk is a daunting, but increasingly frequent task for the outpatient
practitioner. Guidelines for depression screening identify more individuals at risk for treatment
and mental health resources are not always easily accessible. For those patients identified as in
need of a formal risk assessment, this article reviews established risk and protective factors for
suicide and provides a framework for the assessment and management of individuals at risk of
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suicide. The assessment should be explicitly documented with a summary of the most relevant
risk/protective factors for that individual with a focus on interventions that may mitigate risk such
as means restriction, psychotherapy and pharmacotherapy for psychiatric disorders or substance
use, hospitalization, and safety planning.

Keywords
Depression; Mental Health; Prevention; Primary Health Care; Risk Assessment; Suicide

INTRODUCTION
Suicide is a complex personal and sociological phenomenon accounting for 1.6% of all
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deaths in the US. According to the Centers for Disease Control and Prevention (CDC), there
were 42,773 suicides reported in the United States in 2014 (a rate of 13.4/100,000), which
represents a 24% increase since 1999. Suicide is the 10th leading cause of death in all age
groups with approximately 50% of those deaths involving firearms. Firearms account for
55% of suicides in males while poisoning is the most common means of suicide in females.

f
Corresponding Author: J. G. Fiedorowicz, jess-fiedorowicz@uiowa.edu.
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For those aged 10–34, suicide remains the second leading cause of death behind
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unintentional injury. For those aged 35–54, it is the fourth leading cause of death in the
United States, killing more people than liver disease, diabetes, stroke, or infection.1

While suicide remains the most common psychiatric emergency encountered by mental
health providers, its management and risk factors are more commonly treated by primary
care providers. Over 90% of individuals who complete suicide will present to their primary
care provider within weeks to months of their death.2–5 A primary care provider with a
practice of approximately 2,000 patients will, on average, lose a patient to suicide every 3
years.6 Growing requirements for depression screening in primary care render screening,
assessing, and managing suicidal ideation and behaviors a more common element of
practice. Yet, a majority of providers fail to screen for suicidal ideation and feel unprepared
to do so. When evaluating standardized patients presenting with depressive symptoms, only
36% of providers screened for suicidal ideation with many potential barriers identified.7
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Over 40% of patients who present to primary care are hesitant to discuss their depressive
symptoms, noting stigma, belief that depression is not a primary care problem, and belief
that they should be able to control their own symptoms.8 Many providers lack the time,
space, access to subspecialty care, and mental health training to appropriately assess and
manage suicidal patients.9,10 In a study of 50 primary care providers who lost a patient to
suicide, 88% of these patients endorsed suicidal ideation at their last visit, but such
comments were at times felt to be attention-seeking or not significantly different from
baseline. Providers also struggled with limited access to mental health services for their
patients.5 This challenge is also described when working with adolescent populations where
risk factors are often interpreted as attention-seeking or part of normal development. In
younger populations, open communication can be difficult and involving a support system
can be more challenging.11
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The aforementioned challenges make the process of assessing for suicide risk a daunting
task for the busy practitioner. The purpose of this article is to cogently summarize the latest
evidence and guidelines for suicide risk assessment and management with a focus for
application in busy outpatient settings.

CHALLENGE
Suicidal ideation and behaviors, akin to the symptoms of an acute coronary syndrome or
stroke, require immediate attention. Unlike their vascular emergency counterparts, however,
no evidence-based algorithms exist to reliably assess, manage, and prevent suicide.12 The
low frequency of suicide is partly responsible for this difficulty. Suicides accounted for 1.6%
of all deaths in the US in 2014. Even in higher risk demographic, such as older men, the
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overall prevalence of suicide is very low, particularly within a narrow time frame. Even
when protocols have been applied to an inpatient psychiatric population with a higher
baseline risk for suicide, positive predictive values remain less than 11%.13 Adding to the
complexity, the impact many of the variables associated with suicide at a population level
may have varied impact at the level of the individual. For instance, marriage is generally
protective of suicide,14 but for a given patient it may be a key stressor driving suicidal
thoughts, the primary reason to not act on suicidal thoughts, and everything in between. This

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necessitates a contextual model of clinical decision making in what has been called the
“quintessential clinical judgment.”15
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While our ability to predict suicide may seem grim, there has been increasing evidence that
education of primary care providers, population-based suicide prevention strategies (such as
media desensationalization and gun reform), and collaborative care models can reduce the
rate of suicide through the identification and modification of certain risk factors and limiting
access to lethal means.

MANAGEMENT GOALS
Management of suicide includes screening for suicidal ideation or behaviors, performing an
assessment of the individual’s current risk of imminent harm, and creating a treatment plan
in collaboration with the patient and any involved supports. This process needs to be
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individualized, collaborative, and completed using a calm, cooperative, and curious

interview style.

Screening Goals
The goal of suicide screening is to determine if an actionable risk is present. In a primary
care setting, this screen should be efficient, easily completed by a front-office staff, and have
high sensitivity (or low false negative rate).16

How to Screen
The Patient Health Questionaire-9 (PHQ-9) is a quick, subjective reporting scale that can
be incorporated into the medical record. Affirmative responses to item 9 regarding thoughts
of death or self-harm have a hazard ratios of 10 and 8.5 for attempts and deaths in a
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community setting, respectively.17 It is in the public domain and available with instructions
through the Substance Abuse and Mental Health Services Administration (SAMSHA)
website (www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf). While
many clinics defer to the PHQ-2 for depression screening, the cut-off for further depression
assessment is typically three and can miss 50–60% of patients who would otherwise endorse
suicidal ideation on item 9 of the extended version.18

The Columbia Suicide Severity Rating Scale (C-SSRS) is a public forum questionnaire
that can help screen for suicide and form a detailed account of an individual’s suicidal
ideations or behaviors. It is easy to administer with minimal training, available in multiple
languages, and easily included in an electronic medical record. In studies, it has reported
sensitivity of 67%, specifically of 76%, positive predictive values of 14%, and negative
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predictive values of 98%.19,20

Table 1 includes types of screening questions that can help identify current suicide risk
factors and depressive symptoms while enabling the general practitioner to discuss sensitive
topics in an honest and comfortable environment.21

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Who to Screen
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There is no current consensus on who should be screened for suicidal ideation or plans. The
World Health Organization (WHO) currently recommends that all individuals over the age
of 10 with any mental health disorder, epilepsy, interpersonal conflict, recent severe life
event, or other risk factor for suicide should be asked about thoughts or plans to self-harm or
attempt suicide.20 Similarly, the Joint Commission recommends that all individuals with a
behavioral or emotional disorder be screened for suicide.22 In an updated review, the United
States Protective Task Force (USPTF) found insufficient evidence to recommend suicide
screening for the general population, noting that routine screening does not identify
individuals at risk for suicide more than screening individuals with mental health disorders,
emotional distress, or a history of suicide attempts.23 Only the CDC currently recommends
that all primary physicians screen the general population for both depression and suicide.22
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In addition to the above guidelines, specific complaints or patient characteristics may

warrant suicide screening. These include:

• Changes in mood, including any depressive symptoms, emotional distress, anger,

irritability, or aggression24,25

• Anxiety or agitation26,27

• Sleep complaints24

• Evidence of unpredictable or impulsive behavior25

• Sudden change in life circumstances28

• Increase in alcohol or other drug use

• Increasing healthcare utilization, including hospitalizations, office visits, and

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emergency room visits29

• Therapy non-adherence, including medications, physical therapy, and

psychotherapy

• Presentation because of family/friend – more than 50% of individuals who

presented to primary care providers before suicide were convinced to do so by
family or friends30

Despite concerns reported by both patients and general practitioners, a systematic review
found no significant increase in suicidal ideation or behaviors when patients were asked
about suicide, regardless of age, current level of depression, or history of suicidal behaviors.
31,32
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Assessment Goals
After screening has identified an individual at risk, a formal suicide risk assessment should
occur with the following goals: identify modifiable and fixed risk factors, identify protective
factors, clarify the current level of suicidal intent and planning, and estimate the current risk
as low, moderate, or high to guide treatment and disposition.

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Current Assessment Guidelines

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In a 2014 review of 10 published guidelines on suicide assessment and management,

recommendations varied in length, depth, and content covered. Guidelines ranged from 15 to
190 pages and while the majority discussed evidence-based treatments for suicidal ideation
and behaviors, few offered recommendations on how to select treatment and less than 60%
included a standardized method of determining risk.33 The published guidelines and
resources that included sections on recommended risk categorizations and/or recommended
interventions are included in Table 2.

How to Assess
Interviews between care providers and suicidal patients need to maintain or enhance the
therapeutic alliance. All assessments should be conducted with curiosity, concern, calmness,
and acceptance of the individual’s current emotional and cognitive state.34 Patients with
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suicidal ideation may feel hopeless, desperate, or cognitively overwhelmed, interfering with
their ability to comprehend and convey these thoughts to others. Clinicians should stay
attuned to their own reactions that may be non-therapeutic, such as hostility, avoidance of
negative feelings, or the blurring of professional roles, possibly as a way to take on a savior
role.34

In adolescent populations, the HEADSS assessment (Home, Education and employment,

Activities, Drugs, Sexuality, and Suicide and safety) was developed in the Australian
primary care setting to assess the psychosocial needs of younger populations and guide
decision-making. The primary goal of any adolescent patient interview is to understand the
developmental perspective of the patient while empowering them to participate in their
healthcare, discuss sensitive topics with minimal discomfort, and to ultimately take any
signs or symptoms of distress seriously.35 In collaboration with general practitioners and the
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Charles Walker Memorial Trust, an interactive, case-based toolkit entitled “The CWMT GP
Toolkit – The Mental Health Consultation (With a Young Person)” is available publicly
and online (http://www.cwmt.org.uk/wp-content/uploads/2014/01/GPToolkit2013.pdf).

Risk Factors
One challenge with suicide risk factor assessment is that many risk factors are static, not
modifiable, and are limited in helping determine who needs higher level of care. In a 1983
study, 30 suicides were documented in 803 veterans considered at high risk based on risk
factors, but another 37 suicides were also completed in those not considered to be high risk
by risk factors.13

In contrast, some risk factors may be more acute or sub-acute in nature, indicating a
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heightened risk for suicide in the near term.36 Some of these more acute risk factors, referred
to as “warning signs,” were identified by a consensus panel formed by the American
Association of Suicidology (AAS) to help clinicians appreciate what the patient is doing or
saying in the present moment that may acutely increase their risk.37 There is concern that
even in the setting of significant protective factors, acute risk factors can significantly elevate
an individual’s risk for suicide.38

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Table 3 includes validated risk factors for suicide, separated by those associated with more
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acute suicide risk. Risk factors with asterisks represent factors that are potentially modifiable
in the immediate clinical setting.

• Prior suicide attempt remains the strongest predictor of future attempts and
completions.39 There is increasing correlation between suicidal ideation and
behaviors, especially for those presenting in an emergency room setting.40,41
Although most individuals who self-harm do not go on to commit suicide,
repeated self-harm even without intention to end life is a predictor of suicide and
is typically present within the 12 months preceding suicide in young people.42,43
It should be noted, though, that over 90% of suicides are completed on the first
or second attempt.44

• Suicidal ideation, in contrast to a history of suicide attempts, may represent an

increase in suicide risk, especially if this ideation has developed into the seeking
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of means to perform the action, increasing discussion about death, and rehearsal
behaviors.37 There is no documented difference between passive or active
suicidal ideation in suicide course or outcome; as such, both should hold weight
in suicide assessment.45,46

• Stressful life events must be considered within the circumstance and age of the
patient. Common adolescent events include bullying (either as victim or
perpetrator), disciplinary actions, legal issues, school difficulties, romantic break-
ups, assaults, or problems relating to home-life.47,48 For adults, financial
difficulties, relationship losses, unemployment, and intimate partner violence all
increase the risk for suicide attempts.23,49–51 These events may ultimately
resolve with time and action, but during a visit with a primary care provider, they
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are unlikely to be modifiable.

• All psychiatric disorders, with the exception of intellectual disability and later
course dementias, are associated with an increased risk of suicidal ideation,
attempts, and completions.39,52,53 This risk is significantly greater during active
periods of illness and correlates with severity of illness.48,54 Hopelessness in the
setting of depression increases the risk for suicide and is typically modifiable
with treatment of the mental health disorder.25,40

• Physical illnesses such as pulmonary disease, cancer, stroke, diabetes, ischemic

heart disease, and spine disorders are all independently associated with suicide
completion.55 Suicide decedents tend to spend more time in the hospital for both
medical and psychiatric reasons in the months prior to their death, endorse lower
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global quality of life assessment scores, and suffer from more physical
impairment.29,53 Similar risk for depression and suicide is also found in
adolescent populations with chronic physical illnesses.56 While some illnesses
cannot be cured, the amount of disability or functioning may be modifiable with
therapy.

• High-risk substance use or use disorders, including alcohol, prescription, and

illicit drugs, are associated with increased suicide risk, both in adult and

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adolescent populations.53,57 Twenty percent of suicides occur while individuals

are intoxicated.58 Increasing substance use despite worsening mood symptoms,
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associated dysfunction, and increasing suicidal ideation may lead to a more acute
suicide risk compared to a previous baseline level of use.37

• Members of the LGBTQ community may be at increased risk for suicide,

especially if they have not found acceptance within their community and main
support system. This risk factor should be considered within the environment of
the patient.59,60

Protective Factors
Similar to risk factors, most individuals have both modifiable and non-modifiable protective
factors that may be enhanced during periods of acute distress to help prevent against suicide.
The following questions can help elicit these factors:36,61
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1. What keeps you going during difficult times?

2. What are your reasons for living?

3. What has kept you from acting on those thoughts?

4. What or who do you rely on for support during times like these?

Established protective factors against suicide are provided in Table 4, separated by

modifiability.

Similar to risk factors, protective factors have to be considered within the context of the
patient. For example, social obligation to a spouse is protective against suicide, but the
presence of high-conflict or violence within the relationship significantly increases suicide
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risk.34,61 Responsibility to children is felt to be protective in suicide, except in cases of post-

partum mood and psychotic disorders, teen pregnancy, and extreme economic hardships.
34,62 Although pregnancy and motherhood has been studied as a protective factor, suicide

remains the leading cause of maternal death in industrialized countries and vigilance in
assessing for ante- and post-partum depression and anxiety cannot be overemphasized.
61,63,64

Suicidal Evaluation
Part of a suicide risk assessment is gaining a very clear understanding of the individual’s
desire to complete suicide, their capability to do so, and their current suicidal intent. Some
questions that can help elicit this information are included below.36,61,65

1. Why do you want to die?

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2. Have you done anything in preparation for your death?

3. On a scale of 1–10, where would you rate your seriousness or wish to die?

4. Have you tried out any particular method or taken steps in rehearsal for suicide?

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Determining Level of Risk

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The overall goal at this point is that the primary care provider has been able to adequately
identify key risk factors, both modifiable and acute, and protective factors in order to rate the
individuals current risk of suicide. This acute, current risk may differ from the patient’s
chronic level of suicide risk, the latter of which is typically based on static demographic
factors that are not modifiable.66 There can be ambiguity around risk factors and what may
define a chronic and hard to manage risk versus an acute risk that must be dealt with
immediately, necessitating clinical judgement. As many assessment and screening tools do,
we propose that overall risk be defined as a manageable three levels (low, medium, or high).
Individuals at the lowest and highest risk may be easiest to identify and those at more
moderate levels of risk may require greater assessment to discern the most appropriate
management strategy.65
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Managing Level of Risk

Table 5 has been modified and adapted from Bryan and Rudd 2006 and the SAFE-T protocol
developed through SAMSHA.33,66 Both were chosen due descriptions of different risk
categorizations and their concise response recommendations based on these categories.
Although neither has been studied to predict or prevent suicide, they offer explicit guidance
for the busy general practitioner.

While most providers may feel the primary purpose of a risk assessment is to determine
disposition (home versus hospital), it should also be used to help guide other interventions,
both pharmacologic and non-pharmacologic, and regardless of setting.

NON-PHARMCOLOGIC INTERVENTIONS
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Brief therapeutic interventions, such as psychotherapy, case management, or supportive

telephone calls and letters, are more effective for long-term suicide prevention when they are
directed towards the symptoms of suicide, rather than indirectly targeting symptoms
associated with suicide, such as depression or hopelessness.20,67,68 These methods address
suicide risk head-on in collaboration with patients in order to prevent suicide. The following
interventions may be used as tools.

Safety Plan
Safety plans are prioritized lists of coping strategies and sources of support used during or
preceding a suicidal crisis.69 Steps in creating a safety plan include:

1. Recognize warning signs

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2. Identify and use internal coping strategies

3. Use interpersonal supports as a means of distraction from unpleasant thoughts or

urges

4. Contact friends or family to help resolve the crisis

5. Contact a mental health provider/agency

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6. Reduce potential use of lethal means

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Ideally, these steps should be detailed, written, kept in a personal spot, and followed in a
step-wise fashion until the crisis resolves.70 Safety plans have been shown to reduce suicide
attempts, completions, depressive symptoms, anxiety, and hopelessness within 3 months
compared to interventions without safety plans.71 Safety plans should not be confused with
so called “no-harm” or contracts for safety, which have not been shown to reduce suicide or
suicidal behavior, offering only false reassurance to the provider.47 An example template for
a safety plan can be found online at http://www.sprc.org/sites/default/files/
Brown_StanleySafetyPlanTemplate.pdf

Means Restriction
Access to lethal means of suicide remains a significant risk factor for all age groups and
interventions that minimize these means remain the most impactful form of primary
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prevention against suicide.47,72 Firearms are of specific importance, as they remain the most
common suicidal method and account for over 50% of suicide-related deaths, following by
suffocation, hanging, poisoning, and overdose.73 If guns remain in the home, they should be
unloaded, locked, and stored separately from ammunition.74 Restricting access to drugs and
alcohol has also been shown to reduce suicide rates, especially when substance abuse is
considered a risk factor or warning sign for the individual.75

Psychotherapy
In a pooled sample of 11 trials, psychotherapy regardless of methodology was shown to
reduce suicide attempts by over 30%.73,76 The most robust literature exists for the ability of
cognitive behavior therapy, dialectical behavioral therapy, and problem-solving therapy to
reduce self-harm, suicide behavior, and suicidal ideation.77–80
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While primary care providers are unlikely to be providing psychotherapy, successful

referrals to qualified individuals may be enhanced by the provider’s knowledge and
confidence in its effectiveness in addition to a therapeutic alliance. The risk of suicide
attempts increases the month before and after starting treatment, regardless if treatment is
medications or psychotherapy, making close follow-up very important.81

Follow-up Care
Intensive management that includes weekly follow-up and assertive outreach by clinic
personal after missed appointments has been shown to significantly reduce suicide rates in
the United Kingdom.82 Other follow-up interventions, such as telephone calls, letters, and
post-cards have shown some benefit for reducing repeat suicide attempts.20,83
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National crisis lines are also effective at reducing an individual’s sense of crisis, confusion,
helplessness, and suicidality. This effect is improved when a standardized suicide risk
assessment algorithm has been implemented.84

Referral to Mental Health Provider

In addition to the suggested interventions for referral given in Table 5, referral can be
considered for any patient at risk of suicide.85 Physicians should refer patients to mental

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health providers when they are past their comfort level, following failed response to
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treatment trials for the psychiatric disorder, if the patient’s suicidal thoughts are persistent, if
there is suspicion for current psychotic symptoms (hallucinations, delusions, disorganized
thinking), or when hospitalization may be warranted.65,85,86

Collaborative care models, which place mental health services within the primary care
setting, also reduce suicidal ideation and depression within primary care populations.87
These models have been shown to be cost-effective and should be advocated for by primary
physicians when possible as they have not been disseminated as widely as evidence would
warrant.

PHARMACOLOGIC INTERVENTION
Because over 90% of patients who complete suicide had a mental health diagnosis at their
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time of death, aggressive, evidence-based treatment of mental health disorders should also
be discussed during treatment planning.88 Despite concerns about increased suicide risk with
antidepressant medications, which primarily reflects acute increases in suicidal ideation and
attempts in trials of pediatric samples,89 multiple studies have found them protective against
suicidal thoughts, behaviors, and attempts in all age groups, most strongly and consistently
in adults, especially older adults, when used to treat mood and anxiety disorders.90–96
Selective serotonin-reuptake inhibitors (SSRIs) are preferred over tricyclic antidepressants
(TCAs) in suicidal patients due to lower risk in overdose. TCAs and other medications with
elevated risk in overdose should be prescribed in limited supplies while acute suicide risk
remains elevated.20 When indicated, there is evidence supporting a reduction in risk of
suicide for those treated with clozapine or lithium.97 As with psychotherapy, there is
evidence that suicide attempts are increased in the month before treatment, the month after
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treatment, after discontinuation of medications, and after any dose change. Close follow-up
and monitoring are warranted during treatment.98

Some pharmacologic interventions may be harmful. After adjusting for mental health
diagnoses, a current prescription for any sedative or hypnotic was associated with a four-fold
increase in suicide risk, especially in patients greater than 65 years old.99,100

DOCUMENTATION
Once a suicide risk assessment and treatment plan have been completed, it is important to
document this plan in detail for the protection of both the patient and the healthcare team.
Documentation should include:34

• Summary of presenting complaints

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• Evaluation of current risk factors, protective factors, and warning signs

• Listing of individuals that participated in the evaluation, including patient’s

family, friends, and any consultants

• Summary of treatment options discussed with the patient, including any

suggestions or recommendation for hospitalization, if applicable

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• Review of treatment plan agreed upon with the patient, including why this plan
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provides the safest treatment in the least restrictive environment. Treatment plan
may include:

a. Starting medications and/or therapy

b. Means restriction (ideally with verification from support system that it

will be completed)

c. Substance use reduction or formal treatment

d. Safety plan creation (make a copy and scan into medical record)

e. Referral to mental health provider

f. Hospitalization
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• Include plan for follow-up (next appointment, any follow-up phone calls or other
planned out-of-clinic contacts)

The goal of documentation is to clarify the clinical reasoning behind the assessment with a
plan that logically follows. From a medicolegal perspective, physicians cannot be expected
to predict suicide outcomes, in which high risk individuals may not act and low risk
individuals complete suicide.13,101 While legal standards of care vary, a documented suicide
risk assessment that captures the clinical decision makings should suffice.102 Given the
aforementioned need to contextualize the risk assessment within the story of a particular
patient, the assessment need not list every risk and protective factor, but can highlight those
key risk and protective factors deemed most relevant for the case. Examples of documented
suicide risk assessment can be found in Box 1.
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EVALUATION AND EDUCATION

Although many primary care providers feel unprepared for assessing and managing suicidal
patients, they are often starting with a strong therapeutic alliance that has been
independently shown to decrease suicidal ideation in the primary care population.103
Physician education programs, both through post-graduate training and continuing medical
education, can achieve clinical outcomes similar to psychiatrists in the treatment of
depression, reduced suicide rates, and increased subjective competency such that providers
are more willing to assess and treat suicidal patients.72,104,105

FUTURE CONSIDERATIONS/SUMMARY
Suicide risk assessment is distinct from assessing risk for other conditions, such as
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cardiovascular risk. There are a multitude of factors that must be considered without a clear
algorithm that exists or can be developed. This can prove daunting for many clinicians
without some template for stratification of risk from which to tailor the appropriate
management, but this process is not unlike the many decisions the clinician must make on a
daily basis for which clinical judgement is paramount. Suicide risk assessment similarly
requires the clinician to exercise their clinical judgement and to weigh the relevance of
evidence-based risk and protective factors for the assessment of a particular patient’s risk.

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Interventions can have a positive impact97 and this review is dedicated to the cadres of
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clinicians willing to make the effort to save the lives of those suffering so profoundly as to
take their own, at times not even knowing which lives were spared.

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KEY POINTS
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1. Screening tools, including but not limited to the Patient Health Questionnaire
-9 (PHQ-9) and the Columbia Suicide Severity Rating Scale (C-SSRS) may
identify individuals at risk and in need of further assessment.

2. The suicide risk assessment involves a clinical judgment based on an

individualized evaluation of various risk and protective factors for suicide.

3. There exist a variety of interventions for which to target risk of suicide that
may be tailored to the individuals risk profile.
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Box 1
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Example documented suicide risk assessments

This 30 year-old married female presents with a major depressive disorder and appears to be a low suicide risk.
She denies suicidal ideation, has no history of attempts, and is responsible for two children. She has recently
started on sertraline and is hopeful about her future. She can be managed safely as an outpatient.

The patient is a 67 year-old married, retired male construction worker who with ischemic cardiomyopathy and
recent increased use of alcohol, placing him at a moderate to high risk of suicide. He has no history of suicide
attempts and a strong support system. He had a recent hospitalization for a myocardial infarction, during which
he developed a depressive syndrome and he appears increasingly hopeless about the future, particularly
surrounding his medical bills and debt. While intoxicated last week, he reported having vague and fleeting
suicidal thoughts though denies any past or current intent of acting on these thoughts. His wife is not aware of
any acute evidence of dangerousness and was willing to secure the patients firearms and excess medications. He
was offered hospitalization, but declined. There is insufficient evidence of acute dangerousness to warrant
involuntary hospitalization. Patient agrees to quit drinking and engage in close follow-up for his depression with
referral to a psychiatrist. He verbalizes intent to seek emergent assistance if feeling unsafe.
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Table 1

Examples of screening questions to identify risk factors for suicide.

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Where do you live and who lives with you?

Home How do you get along with each member?
Who could you go to if you needed help with a problem?

What do you like about school (or work)?

Education/employment What are you good and not good at?
How do you get along with teachers and other students (boss and co-workers)?

What sort of things do you do in your spare time?

Activities Do you belong to any clubs, groups, etc.?
What sort of things do you like to do with friends?

Many young people at your age are starting to experiment with cigarettes or alcohol. Have you tried these or other
Drugs drugs like marijuana, injection drugs, or other substances?
How much are you taking and how often?

Some young people are getting involved in sexual relationships.

Sexuality
Have you had a sexual experience with a guy or a girl or both?

What sort of things do you do if you are feeling sad, angry, or hurt?
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Some people who feel really down often feel like hurting themselves or even killing themselves. Have you ever felt
Suicide/safety this way?
Have you ever tried to hurt yourself?
Do you have access to firearms in your home or the home of a friend or family member?
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Table 2

Published guidelines and resources for suicide risk assessment.

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Name Source(s)

Practice Parameter for Assessment and Treatment of Children and Adolescents with American Academy of Child and Adolescent
Suicidal Behaviors Psychiatry
Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors American Psychiatric Association (APA)
VADOD Clinical Practice Guidelines for Assessment and Management of Patients at Department of Veterans Affairs, Department of
Risk for Suicide Defense
Assessment and Care of Adults at Risk for Suicidal Ideation and Behavior Registered Nurses’ Association of Ontario
Core Competencies for Assessment and Management of Suicide American Association of Suicidology
National Suicide Prevention Lifeline Suicide Risk Assessment Standards Packet National Suicide Prevention Lifeline, SAMSHA
Suicide Assessment Five-step Evaluation and Triage (SAFE-T) SAMSHA
Suicide Prevention: Saving Lives One Community at a Time American Foundation for Suicide Prevention
(AFSP)
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Suicide and the Elderly AFSP

International Association for Suicide Prevention (IASP) Guidelines for Suicide IASP
Suicide Care in Systems Framework National Action Alliance for Suicide Prevention,
Clinical Care and Intervention Task Force
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Table 3

Summary of suicide risk factors.

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Suicide Risk Factors

Chronic Acute

Prior attempts Suicidal ideation

Recent hospitalization Purposelessness
Living alone Insomnia*
Family history of suicide Anxiety, agitation*
LBGTQ population Trapped feeling
Adverse childhood events Non-adherence to care
Stressful life events Withdrawal
Mental illness* Anger, rage, revenge-seeking
Physical illness* Recklessness
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Unemployment Mood and personality changes

Advancing age Substance Use*
Hopelessness*
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Table 4

Protective factors for suicide.

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Suicide Protective Factors

Non-modifiable Potentially Modifiable

Female gender Interpersonal support

Marriage Positive coping skills
Children Life satisfaction
Pregnancy*
Religion/Spirituality
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Table 5

Illustration of levels of suicide risk.

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Characteristics of Level
Acute Risk Level Recommended Response
Protective Factors Acute Risk Factors Suicidal Evaluation

1 Frequent outpatient follow-

up, monitoring for any
change in risk.
Ideation limited in
Easily identifiable, Few risk factors, mild
frequency, intensity, or 2 Further evaluation of mood
Mild multiple protective mood symptoms,
duration. No plan or symptoms.
factors. evidence of self-control
intent
3 Consider psychiatric
referral.

1 Increase frequency/
duration of visits. Repeated
evaluation of need for
hospitalization.
2 Involve family and support
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system.
3 Means restriction.
4 Review emergency
protocols, such as
Baseline chronic risk Frequent suicidal emergency rooms and
factors. Minimal mood ideation, still limited in crisis services.
Some identifiable
Moderate symptoms. Maintained intensity and duration.
protective factors. 5 Control mood symptoms
self-control. Rare acute May have plan, but no
risk factors. intent. with medications and/or
psychotherapy.
6 Frequent follow-up with
phone calls or nursing
visits (if available).
7 Consider psychiatric
referral and/or
hospitalization, especially
if risk increasing with re-
evaluation.
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1 Evaluation for inpatient

hospitalization, either by
on-site psychiatric
professional or through an
emergency room.
Multiple acute risk Frequent, intense, 2 Do not leave patient alone
factors or high acuity persistent suicidal in the office during
Minimal protective risk factor. Poor self- ideation with plans. May assessment.
Severe
factors endorsed. control, either at discuss intent, but has no
baseline or due to gathered means or had 3 Hospitalization may be
substances. rehearsal behaviors indicated even if
involuntarily.
4 Means restriction for acute
period following
hospitalization.
Author Manuscript

Med Clin North Am. Author manuscript; available in PMC 2018 May 01.