Approach
The assessment of a patient at risk of suicide is complex, and influenced by clinician, patient, and organizational factors. A careful and comprehensive history together with a full mental state exam are essential and should be underpinned by a compassionate approach. It is impossible to predict suicide risk accurately for individual patients and this approach fails both patients and clinicians. Even risk factors associated with the highest odds ratio and a significant statistical correlation may not be clinically useful when assessing a particular individual.[119] In addition, the absence of risk factors does not mean the absence of any risk of suicide, as a patient may be imminently at risk of suicide even though they are not a member of a "high-risk" group. It is also vital to remember that suicidal thoughts, feelings, and impulses (and risk) can vary across a relatively short time period.[119] Instead, clinicians should diligently identify all risk factors and focus on an individualized response with the aim of removing, reducing, or mitigating risk by adding in new protective factors and safety planning.
For children and adolescents with psychiatric problems presenting to the emergency department who report current or recent suicidal ideation and for those who present after clear or suspected intentional self-injury, an evaluation by a clinician experienced in evaluating pediatric mental health conditions is recommended.[88]
History
Conduct an initial, brief assessment of the patient’s emotional state and personal circumstances in order to determine whether a more detailed mental state exam is required. In-depth assessment includes biopsychosocial factors, risk factors, and patient needs, strengths, and assets.
In order to facilitate the disclosure of potentially painful or distressing thoughts and feelings, it is vital to gain the patient’s trust. The most effective way to do this is through a compassionate and therapeutic interaction. The authors of this topic strongly recommend specific suicide mitigation training to develop and practice these skills. One paper reviewing 70 studies of people with suicidal thoughts found that about 60% of people who subsequently died by suicide had previously denied having suicidal thoughts when asked by a psychiatrist or primary care physician.[44] This highlights the need for a compassionate and trusting relationship that enables patients to disclose. Additionally, it confirms how important it is to consider all risk, including the degree of emotional pain. Conduct a comprehensive mental state exam while taking the history and note any risk factors and red flag warning signs.
Factors that differentiate those who have thoughts of suicide from those who will act upon those thoughts and then attempt suicide remain uncertain.[120][121] The strongest risk factors for acting on suicidal thoughts in high-income countries are previous suicidal behavior and a mood disorder, particularly if accompanied by substance abuse and/or stressful life events. While mental health disorders contribute in large part to suicide, in some settings, especially where suicide rates are high, be aware that sociocultural or political-economic influences may be important considerations. The most predictive factors for imminent suicide are the presence of a suicide plan and immediate access to lethal means.[122]
Assessment of a patient at risk of suicide
Be aware of posture and positioning relative to the patient. Where possible, aim for a welcoming, unhurried, genuinely concerned, and nonjudgmental atmosphere. Be sensitive to whether the patient feels comfortable with direct eye-contact. The discussion should have the feel of a gentle conversation, with questions being used as prompts, rather than the more traditional consultation approach that focuses on getting through a tick list of questions. In general, the following points can be helpful.
Use appropriate, nonmedical language and words that the patient uses when describing their symptoms and experiences.
Allow the patient enough time to answer questions, and avoid any assumptions or interruptions if possible.
Ask open questions, and avoid any implicit judgment or bias: for example, “How are you feeling today?”
Gather specific details about the individual’s strengths and supports.
Acknowledge that some topics such as past or present suicidal thoughts and self-harm may be particularly sensitive and difficult. Explain the benefits of gathering this information so you can work together to produce a treatment plan and also a safety plan for them to take away with them. Allow the patient more time to answer these questions.
As well as usual aspects of history-taking and a mental state exam it is also useful to ask such questions as:
What is important to you? What do you find comforting?
Are there any people, places, animals, activities, or achievements that make you feel hopeful?
Is there anything else I should know about you?
Elicit as much information as possible about protective factors, which, in older adults, have been shown to include interpersonal relationships, meaningful activities and interests, community engagement, and involvement of mental health services staff.[123]
When approaching young people who have thoughts of self-harm or have self-harmed, always ask about internet use. The internet can be helpful (reducing social isolation, providing formal and informal support) but it can also harm (including triggering and suicide contagion).[124]
The high prevalence of parental unawareness and adolescent denial of suicidal thoughts found in one large community study assessing parent-adolescent agreement in reports of adolescents’ suicidal thoughts suggests that many adolescents at risk for suicide may go undetected. These findings have important clinical implications for settings dealing with adolescents, including the need for a multi-informant approach to suicide screening and a personalized approach to assessment.[125] Further to this, the American Academy of Pediatrics recommends that adolescents are screened for suicide risk as part of well-child visits from 12 years old, as well as during ay higher-risk situations.[126]
Pediatric patients presenting to the emergency department should be screened for suicide risk as well as substance use disorders, as substance use is often associated with depression and self-treatment and is a risk factor for suicidal thoughts and behaviors.[126] For pediatric psychiatric patients presenting to the emergency department, interviewing patients and caregivers both together and separately is beneficial. Patients frequently minimize the severity of their symptoms or the intention behind their acts. When interviewing adolescents alone, discussing the limits of patient confidentiality may facilitate an open and honest conversation. If there are significant concerns that the patient may be at high risk of harm to themselves or others, the clinician may decide to break doctor-patient confidentiality.[88]
Other issues to consider
Collect information on the patient's psychiatric, medical, psychosocial, and family history as these may provide important context.
Psychiatric history: up to 90% of people who die by suicide have a psychiatric diagnosis, most commonly major depressive disorder or substance misuse.[51][52][53] Suicide is also associated with other mood disorders (e.g., bipolar disorders I and II, schizoaffective disorder), anxiety disorders, anorexia nervosa, and psychotic disorders.[127] Diagnose psychiatric disorders using standard international diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders 5th edition, or International Classification of Diseases).
Medical history: obtain a medical history to identify the presence of current medical diagnoses or physical challenges that may increase both short- and long-term suicide risk, such as terminal illness, cancer, chronic disease, pain, functional impairment, cognitive impairment, loss of sight or hearing, disfigurement, loss of independence, or increased dependency on others.[53][65][66][67][68][69][70][71]
Psychosocial history: this provides insight into the patient's current living situation, level of functioning, acute or chronic stressors, assets such as availability of external social supports, risk-buffering factors, and cultural or religious beliefs relating to death or suicide. Also collect information about history of family conflict, bereavement[85] separation or divorce, legal troubles, substance use, domestic violence, abuse (physical, emotional, or sexual abuse) and neglect.
Family history: a family history of suicide increases that individual’s lifetime risk of suicide, in those with and without a known diagnosis of mental illness.[61]
Examination
Conduct a careful psychiatric mental state exam to be able to consider thoughts and acts of self-harm within the context of any current psychiatric symptoms. Agitation is a worrying feature if present alongside suicidal ideation.[88][128] It is also useful to assess personality strengths and weaknesses. Personality traits or thinking styles affect how emotional or psychological stress is tolerated and what type of coping strategies are used to deal with stressors.[88] Although these factors do not predict suicide, they may contribute to the overall clinical picture through their effect on the patient's ability to cope, and on their available support systems.
Investigations
Suicide risk assessment tools mainly use demographic risk factors (which are nonspecific to the individual) and have been developed largely without a solid evidence base.[129] Demographic risk factors may be associated with an increase in the suicide risk of a whole population across its lifetime, but do not predict suicide in an individual at a single time-point. Furthermore, the usual "known" sociodemographic risk factors associated with suicide may not apply to people who have a concurrent psychiatric diagnosis.[130]
Risk scales can provide false reassurance and should no longer be used to predict suicide following self-harm.[131][132] Risk scales should not replace a comprehensive psychosocial assessment of the patient’s individual situation, risks, and needs, as well as their assets and strengths.[133]
Do not rely wholly on identifying risk factors when assessing individuals. A person may be at an elevated or imminent risk of suicide even though they may not fall into a known "at-risk" group and, conversely, not all members of high-risk groups are at equal risk of suicide.[119][131] For example, in the National Confidential Inquiry into Suicide in the UK, between 2010 and 2020 immediate risk of suicide was judged to be low or not present in 83% of people at the last contact with a healthcare professional before dying from suicide. The case notes of patients known to UK health services who had died by suicide within one week of their last assessment showed that 14% had a recent discharge, 12% were nonadherent with medication and 23% had missed their last appointment.[134]
A patient may not explicitly admit to self-harm thoughts or a history of past self-harm or suicide attempts. This could be due to fear, stigma, shame, fear of being judged, or embarrassment. Usually a compassionate approach will help build trust to facilitate a patient disclosing their true thoughts and feelings. If not, it is safer to err on the side of caution and be alert that this may be a possibility. Family, friends, health professionals, teachers, coworkers, or others may also provide valuable information to support your assessment.
If no collateral information is available and the patient does not answer questions directly, the clinician may need to rely on clinical judgment based on apparent risks; warning signs for hidden suicidal ideation, intent, or plan (e.g., presence of psychosis, despondence, emotional distress, guilt, hopelessness, helplessness, anger, agitation, inability to develop rapport, difficulty making eye contact); and subjective impressions. The clinician may need to review hospital or primary care records for evidence of past self-harm, and pay close attention to signs of self-harm injuries during the physical exam.
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