A suicide assessment is a specific type of psychiatric evaluation aimed at determining a person's suicidal risk and creating a specialized treatment plan. The five domains of suicide assessment include the current presentation of suicidality, psychiatric illness, history, psychosocial situation, individual strengths, and weaknesses.16 These domains are summarized in Table 4.
Table 4: Domains of Suicide Assessment16| Current Presentation of Suicidality | - Suicidal or self-harming thoughts, plans, behaviors, and intent
- Specific methods considered for suicide, including their lethality and the patient's expectation about lethality, as well as whether firearms are accessible
- Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety
- Reasons for living and plans for the future
- Alcohol or other substance use associated with the current presentation
- Thoughts, plans, or intentions of violence toward others
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| Psychiatric Illness | - Current signs and symptoms of psychiatric disorders with particular attention to depressive disorders
- Previous psychiatric diagnoses and treatments, including illness onset and course and psychiatric hospitalizations, as well as treatment for substance use disorders
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| History | - Previous suicide attempts, aborted suicide attempts, or other self-harming behaviors
- Previous or current medical diagnoses and treatments, including surgeries or hospitalizations
- Family history of suicide or suicide attempts or a family history of mental illness, including substance abuse
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| Psychosocial situation | - Acute psychosocial crises and chronic psychosocial stressors, which may include actual or perceived interpersonal losses, financial difficulties or changes in socioeconomic status, family discord, domestic violence, and past or current sexual or physical abuse or neglect
- Employment status, living situation (including whether or not there are infants or children in the home), and presence or absence of external supports
- Family constellation and quality of family relationships
- Cultural or religious beliefs about death or suicide
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| Individual strengths and weaknesses | - Coping skills
- Personality traits
- Past responses to stress
- Capacity for reality testing
- Ability to tolerate psychological pain and satisfy psychological needs
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During a suicide assessment, clinicians should also conduct a thorough psychiatric evaluation. This information should be obtained from either the patient or their family members and friends. The clinician must approach the situation with empathy and compassion. In the context of a suicide assessment, the purpose of the psychiatric evaluation is to16:
- Identify specific psychiatric signs and symptoms
- Assess past suicidal behavior
- Review past treatment history and treatment relationships
- Identify a family history of suicide and mental illness
- Identify the current psychosocial situation and the nature of the crisis
- Evaluate current substance misuse
- Appreciate psychological strengths and vulnerabilities
Clinicians should begin by assessing the current signs and symptoms of psychiatric disorders.16 They should pay close attention to signs of a depressive disorder and note any high-risk characteristics. Clinicians should document previous psychiatric hospitalizations along with prior treatment for substance use disorders.1 Specific psychiatric symptoms that increase a person's risk of suicide include aggression, violence toward others, impulsiveness, hopelessness, agitation, psychic anxiety, anhedonia, global insomnia, and panic attacks.
Clinicians should obtain and document a thorough history of the patient's previous suicide attempts, aborted suicide attempts, and self-harming behaviors.1 Do not forget; a previous suicide attempt is one of the strongest risk factors for another attempt. When possible, clinicians should contact the patient's current primary care or psychiatric provider.16
Clinicians should also inquire about the patient's family history. Family dysfunction is linked to suicide and other self-harming behaviors.1 Clinicians must assess for a family history of suicide or psychiatric disorders. Clinicians should also document a history of familial conflict or separation, parental legal trouble, family substance abuse, domestic violence, and physical or sexual abuse.15
Next, the clinicians should assess the patient's current psychosocial situation.16 What are their current stressors? Have they experienced any recent interpersonal losses, financial difficulties, or changes in socioeconomic status? The clinician should document acute crises, chronic stressors, employment status, living situation, family constellation, and cultural or religious beliefs about suicide.16
Substance abuse may contribute to suicide. When suspecting substance use disorder, please consider:
- Ask first about socially acceptable substances such as caffeine or tobacco products. This helps to establish a level of comfort for the rest of the interview. Always ask "how many" and "how often" – e.g.," You mentioned you drink the occasional latte, how many of those during a week?" "So, you have three, four-shot, Grande lattes, six days a week, is that correct?"
- Next, inquire about alcohol use. Be sure to ask specifically about beer, wine, and spirits, as many cultures do not consider beer to be alcohol.
- Next, inquire about over the counter substances, including diet aids, cough and cold preparations, herbal supplements.
- Ask about the misuse of prescription items such as sleep medications, pain preparations, medications for attention deficit disorder, or weight loss.
- Next, ask about marijuana, which is legal for use in some states or settings. Be sure to quantify how much, how often.
- Next, ask about illicit drugs. Be sure to be consistently non-judgmental and focus on the information needed for accurate health assistance. Street drugs such as heroin, cocaine, hallucinogens, methamphetamine, and inhalants should be asked about.
- Remember to ask how much, how often, length of use pattern, and the last time each substance was used. Route of administration is also essential, and be sure to ask whether the person has shared substances, especially injected drugs and needles.
- If prior substance use disorders are mentioned, ask about participation in Alcoholics Anonymous (A.A.), Narcotics Anonymous (N.A.), other twelve-step programs, addiction treatments, detoxifications, or periods of abstinence from the substance. Of particular interest is the length of the longest period without the substance without using other illicit substances or alcohol to help maintain.
- Ask the person what benefits they obtain from their substance of choice. This will be beneficial information when treatment for their substance use disorder begins.
- Ask what negative consequences have arisen from their substance use. Should they need coaching look for items in each of these three key areas:
- Physical risks or illnesses – sickness, accidents, fractures, burns, car wrecks?
- Psychiatric problems – focusing problems, anxiety, depression, suicidal thoughts, psychosis?
- Relationship problems – work, social relationships, legal difficulties, financial worries?
Finally, clinicians must appreciate the patient's psychological strengths and weaknesses. These may include coping skills, personality traits, thinking style, and development needs. Patients at an increased risk of exhibit polarized thinking, closed-mindedness, perfectionism, and excessively high self-expectations.16
Healthcare providers must directly ask patients about suicidal thoughts, plans, and behaviors; however, cultural and religious beliefs about death and suicide may present a patient from speaking openly about his or her thoughts. In this case, clinicians must seek collateral sources such as spouses, friends, family members, clergy, or other healthcare providers.16
Table 5 includes a list of questions that clinicians can use when inquiring about different aspects of suicide. Clinicians should follow these steps16:
- Elicit the presence or absence of suicidal ideation
- Elicit the presence or absence of a suicide plan
- Assess the degree of suicidality including intent and lethality
Table 5: Questions during a suicide assessment16| Opening questions | - Have you ever felt that life was not worth living?
- Did you ever wish you could go to sleep and just not wake up?
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| Follow-up questions | - Is death something you have thought about recently?
- Have things ever reached the point that you have thought of harming yourself?
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| Thoughts of self-harm and suicide | - When did you first notice such thoughts?
- What led to thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)?
- How often have those thoughts occurred (including frequency, obsessional quality, controllability)?
- How close have you come to acting on those thoughts?
- How likely do you think it is that you will act on them in the future?
- Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of the bridge but not jumping)?
- What do you envision happening if you killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)?
- Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?)
- Do you have guns or other weapons available to you?
- Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)?
- Have you spoken to anyone about your plans?
- How does the future look to you?
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| Previous suicide attempts | - Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, the seriousness of injury)?
- What thoughts were you having beforehand that led up to the attempt?
- What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction from a particular person)?
- Were other people present at the time?
- Did you seek help afterward yourself, or did someone get help for you?
- Had you planned to be discovered, or were you found accidentally?
- How did you feel afterward (e.g., relief versus regret at being alive)?
- Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)?
- Has your view of things changed, or is anything different for you since the attempt?
- Are there other times in the past when you have tried to harm (or kill) yourself?
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| Repeated suicidal thoughts and attempts | - About how often have you tried to harm (or kill) yourself?
- When was the most recent time?
- Can you describe your thoughts at the time that you were thinking most seriously about suicide?
- When was your most serious attempt at harming or killing yourself?
- What let up to it, and what happened afterward?
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| Psychosis | - Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus non-recognizable)?
- What do the voices say (e.g., positive remarks versus negative remarks versus threats)?
- If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples?
- How do you cope with (or respond to) the voices?
- Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?)
- Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?)
- Are you worried about having a serious illness or that your body is rotting?
- Are you concerned about your financial situation even when others tell you there is nothing to worry about?
- Are there things that you have been feeling guilty about or blaming yourself for?
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| Harm to others | - Are there others you think may be responsible for what you are experiencing (e.g., persecutory ideas, passivity experiences)?
- Are you having any thoughts of harming them?
- Are there other people you would want to die with you?
- Are there others whom you think would be unable to go on without you?
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During and after conducting a suicide screen or assessment, the clinician should develop a strategy for treatment and management of potential suicidal behaviors. In their publication Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, the American Psychiatric Association defines six critical components of the management of suicidal behavior15:
- Therapeutic Alliance
- Patient Safety
- Determine Treatment Setting
- Treatment Plan
- Care Coordination
- Patient & Family Education
First, the healthcare provider must focus on developing a strong therapeutic alliance with the patient.16 The clinicians should begin by building trust and establishing mutual respect. Only within a trusting relationship will patients feel comfortable discussing and addressing their suicidal ideation and behaviors. The ultimate goal of the patient-provider relationship is reducing the risk of suicide.16
Next, the clinician must attend to the patient's safety.16 Throughout the suicide assessment, the clinician may need to intervene directly to prevent the patient from harming him or herself. For example, the clinician may need to search the patient's belongings for weapons, lighters, matches, medications, or other toxic substances. The healthcare provider may also determine that the patient needs constant observation by another clinician or closed-circuit television.16
After developing a therapeutic alliance and attending to the patient's safety, the clinician must select the most appropriate treatment setting. Patients should always be treated in the least restrictive yet safest, most effective setting.1 Table 6 provides the guidelines for determining when a patient needs inpatient psychiatric treatment.16
Admission to an inpatient psychiatric hospital is usually indicated after a suicide attempt or an aborted suicide attempt.16 Admission may be necessary if the patient expresses suicidal ideation, has previous attempts, and has a diagnosed psychiatric disorder. Outpatient treatment is most beneficial for those with chronic suicidal ideation or who have a stable, supportive living situation.16
Next, clinicians must develop a plan of treatment.16 The treatment plan begins by ensuring the patient's safety and selecting the appropriate treatment setting. After acute treatment, the patient should be referred to a psychiatric specialist such as a psychiatrist or a psychiatric nurse practitioner. These specialized clinicians will continue the patient's care and ensure timely diagnosis and management of any underlying mental health conditions.
In the early phases of treatment, specialists will closely monitor the patient and prescribe specific treatments for symptoms such as anxiety, insomnia, and hopelessness. During the early stages of recovering from a suicide attempt, patients will be encouraged to undergo education and supportive psychotherapy.
Psychiatric specialists and primary care providers must coordinate their care to offer the best treatment to patients with suicidal behaviors. These patients are often complex, requiring an interdisciplinary team of healthcare professionals such as social workers, case managers, and psychiatric nurses.
When the patient agrees, education should be provided to his or her involved family members. Family members need to understand that psychiatric disorders are real and difficult illnesses that require special treatment. Friends and family should also learn about the role of psychological and social stressors that can precipitate or worsen suicidal behaviors.
