Suicide Prevention: Improving Risk Assessment Can Save Lives
Behavioral Health Insights
By Micah Hoffman, MD, DABPN, FAPA, QME, CIME, CHCQM
AllMed Behavioral Health Medical Director
Early detection of risk and timely intervention are key to suicide prevention. But suicide’s complexity makes risk assessment a challenge, particularly for providers without specialized training. Recent studies have found that over 90 percent of people who die by suicide make a healthcare visit in the months prior to death.1 These visits take place in settings ranging from emergency rooms to primary care offices to outpatient facilities. This high rate of utilization by those at risk of suicide shows the opportunity that exists within the current healthcare system to reduce suicide deaths. Maximizing this opportunity calls for improving our ability to assess risk.
In this article, we discuss methods of suicide risk assessment and the need for detailed documentation to clarify decision-making. In our next article, we’ll consider how best to identify the appropriate level of care once a risk level has been determined.
Assessment Goals and Challenges
Suicide risk assessment aims to identify primary risk factors and protective factors to evaluate a person’s current risk of suicide. The assessment guides the determination of the level of care needed and the specific interventions (pharmacologic and non-pharmacologic) that may be helpful in treatment. With suicidality, unlike many other conditions, no clinically practical biomarkers, lab tests, or imaging findings can point the way. Assessing risk systematically requires a physician to identify acute and chronic, modifiable, and treatable risk factors and weigh them against protective factors in the context of the patient’s experience.2
Numerous factors and their interaction contribute to risk. Chronic risk factors may include family history of suicide, living alone, and mental illness, while acute factors may include suicidal ideation, rage, substance use, and personality changes. Among factors generally considered to be protective, interpersonal support, positive coping skills, marriage, and religion/spirituality often top the list.
However, it’s important to note that what holds true at a population level may be very different at the individual level. For example, marriage is widely viewed as a protective factor, but for a given patient, marriage could be a key factor driving suicidal thoughts, the primary reason not to act on suicidal thoughts, or anything in between.3
Given the high number and variability of potential risk factors, a comprehensive assessment of suicide risk requires that a provider obtain collateral information (from family members, friends, clergy, other physicians) for added clarity. Further, thorough documentation of process and feedback is imperative to support evidence-based decision-making, improve patient safety, and mitigate legal risk.
Primary Care: A Crucial Opportunity for Detection
Suicide is the most common psychiatric emergency treated by mental health providers in emergency rooms, but suicide risk factors are more often managed and treated by primary care physicians.4 In recent years, the growing requirements for depression screening in primary care settings have made assessing and managing suicidal ideation a more common element of practice. Even so, many primary care providers feel unprepared to assess suicidal patients appropriately. Whereas assessment and management of suicide risk are considered core competencies for psychiatrists, many primary care providers lack the mental health training and access to subspecialty care that would provide a higher level of confidence.
Using a structured risk assessment model can help mitigate these concerns by making it easier to stratify risk into a high, medium, or low level. Although such tools are imperfect, most experts agree that having a consistent way of assessing and integrating risk and protective factors is more likely to produce consistent risk formulations.5
Evolving Screening and Assessment Tools
The wide variety of standardized screening instruments available as adjuncts to assessment can further complicate an inherently complex task. More commonly used, validated tools include the following:
- Columbia-Suicide Severity Rating Scale (C-SSRS) – a simple set of six questions that can be administered quickly in the field, to individuals of all ages, by responders with no formal mental health training
- Suicide Assessment Five-Step Evaluation and Triage for Clinicians (SAFE-T) Pocket Card – based on data and recommendations from the American Psychiatric Association Practice Guidelines and designed for specialists, because specific training and clinical judgment are necessary to weigh the information obtained6
- Ask Suicide-Screening Questions (ASQ) Toolkit – four screening questions that take 20 seconds to administer, available in youth and adult versions
- Patient Health Questionnaire-9 (PHQ-9) – a 9-question self-report scale used frequently with adults in primary care settings for screening, diagnosing, monitoring, and measuring the severity of depression in the previous two weeks
- Suicide Cognitions Scale – Revised (SCS-R) – a 16-item scale designed to measure negative perceptions and thoughts, such as hopelessness and perceived burdensomeness, that are often cited by suicidal patients
Researchers analyze the effectiveness of these tools on an ongoing basis and reevaluate their fitness for purpose. In one example, a study published in the Journal of Clinical Psychiatry of 509,945 adult outpatients who completed over one million PHQ-9s found response to question #9 (which asks about the frequency of thoughts that you would be better off dead, or of hurting yourself in some way”) to be a strong predictor of suicide attempt or completed suicide over the following two years.7
Similarly, a 2022 study found that SCS-R scores are elevated among patients who attempt suicide within a year of assessment after denying both suicidal ideation and prior attempts.8 Findings such as these offer providers simple, accessible, and low-cost methods for more accurately identifying patients who need immediate clinical intervention. At the same time, these methods help guide more appropriate treatment and use of limited mental health resources.
Expert Clinical Judgment for Improved Outcomes
As suicide rates rise in the U.S., clinicians and researchers are focused on improving outcomes of suicide screening and risk assessment. Physician education programs can make a difference, in part by increasing the subjective competency of primary care providers, so that more are willing to assess and treat suicidal patients.9
For now, meaningful risk assessment remains equal parts art and science, requiring expert clinical judgment in weighing the relevance of evidence-based risk and protective factors. This is where AllMed can help. The board-certified psychiatrists on the AllMed Behavioral Health Review Panel provide insight and experience to support your team’s risk assessment efforts and the treatment decisions that follow.
- Ahmedani, Brian K et al. “Variation in patterns of health care before suicide: A population case-control study.” Preventive medicine 127 (2019): 105796. doi:10.1016/j.ypmed.2019.105796. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6744956/. Accessed May 23, 2023.
- Ryan, Eileen P et al. “Suicide Risk Assessment and Prevention: Challenges and Opportunities.” Psychiatry Online. (2020). https://doi.org/10.1176/appi.focus.20200011. Accessed May 24, 2023.
- Weber, Andrea N et al. “Psychiatric Emergencies: Assessing and Managing Suicidal Ideation.” The Medical clinics of North America 101,3 (2017): 553-571. doi:10.1016/j.mcna.2016.12.006. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5777328/. Accessed May 24, 2023.
- Oquendo, Maria A, and Joel A Bernanke. “Suicide risk assessment: tools and challenges.” World psychiatry : official journal of the World Psychiatric Association (WPA) vol. 16,1 (2017): 28-29. doi:10.1002/wps.20396. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5269494/, Accessed May 24, 2023.
- Ryan, Eileen P et al. “Suicide Risk Assessment and Prevention: Challenges and Opportunities.”
- Simon GE, Coleman KJ, Rossom RC, et al.: Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. J Clin Psychiatry 2016; 77:221–22710.4088/JCP.15m09776. https://www.psychiatrist.com/jcp/depression/suicide/suicide-risk-and-phq-responses/ Accessed June 12, 2023.
- Bryan, Craig J et al. “Scores on the suicide cognitions scale-revised (SCS-R) predict future suicide attempts among primary care patients denying suicide ideation and prior attempts.” Journal of affective disorders vol. 313 (2022): 21-26. doi:10.1016/j.jad.2022.06.070. Accessed May 25, 2023.
- Weber, Andrea N et al. “Psychiatric Emergencies: Assessing and Managing Suicidal Ideation.”