Suicide often begins with suicidal thoughts and a wish to die followed by an intention to act, then a plan to end one’s life. These steps can occur over minutes or years. Often, the first opportunity to assess an individual’s suicide risk occurs because of warning signs are identified by a caregiver, gatekeeper, or loved one. However, often a patient’s risk is identified after a suicide attempt is made.
Mental health has traditionally been within the purview of psychiatrists and specifically trained mental health practitioners. But over the last 2-3 decades, family practice physicians, nurse practitioners, allied health professionals, pharmacists, and other healthcare providers have become increasingly responsible for identifying and managing chronic mental health problems—including suicidal ideation and behaviors.
Now it is not uncommon for a variety of healthcare providers to find themselves at the front lines of identifying serious mental health issues that require screening and referral. Because of these changes, all healthcare providers need to be knowledgeable about suicide risk factors and warning signs, suicide screening tools, and know when, where, and how to refer a client who is at risk for self-harm. A good clinical assessment can be the start of suicide prevention efforts.
Did You Know. . .
Beginning July 1, 2019, healthcare professionals are required by the Joint Commission to use a validated tool to assess suicidal risk for all patients whose primary reason for seeking healthcare is the treatment or evaluation of a behavioral health condition.
Harmer et al., 2022
Determining who is at risk for suicide, using either tests or clinical judgment, is extremely difficult, primarily because suicide is a relatively rare event. Nevertheless, screening and assessment can be valuable because they can ensure that those requiring more services get the help they need (CSAT, 2017).
A suicide risk assessment should first evaluate suicidal thoughts, intent, and behavior (including warning signs that may increase the patient’s acuity). Then consider risk and protective factors that may increase or decrease the patient’s risk of suicide. Whether a patient has a mental disorder or not, those identified as having suicidal ideation should receive a complete suicide risk assessment (VA/DOD, 2019).
Unfortunately, most screening tools do not accurately predict risk of suicide. These tools tend to yield an unacceptably high false-positive prediction rate—many of those determined to be “at risk” never experience clinically significant suicidal thoughts or behavior. This is coupled with an unacceptably low degree of accuracy when identifying true cases—a substantial portion of those individuals who die by suicide were not identified by the screening tools (VA/DOD, 2019).
Did You Know. . .
Fifty-eight percent of service members who died by suicide in 2016 had contact with the healthcare delivery system in the 90 days prior to their death; roughly a third of those encounters were with outpatient or inpatient behavioral health (VA/DOD, 2019).
Several studies support the use of the Patient Health Questionnaire-9 (PHQ9). Item 9 is a universal screening instrument to identify suicide risk:
Item 9: “Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?”
Possible Responses: “Not at all,” “Several days,” “More than half the days,” or “Nearly every day.” (VA/DOD, 2019).
The U.S. Preventive Services Task Force (USPSTF) concluded in 2014 that screening is appropriate for high-risk individuals with known mental illnesses or substance use disorders. However, there is insufficient evidence to assess the benefits and harms of screening the general population for suicide risk in a primary care setting.
In a 2022 update, the USPSTF found no eligible studies that reported on benefits or harms directly arising from screening when compared with usual care or no screening. The evidence for screening for suicide risk, anxiety, and depression in children and adolescents relied on indirect evidence on the accuracy of screening and the benefits and harms of treatment (USPSTF, 2022).
Some screening instruments are reasonably accurate for anxiety and depression, but the evidence is limited for suicide risk screening instruments. Additionally, both pharmacotherapy and psychotherapy have benefit for depression and anxiety, but the evidence is limited for suicide risk interventions. Evidence gaps persist in children younger than age 11 years for test accuracy, depression, and suicide risk interventions, and for screening and treatment differences by sex, race/ethnicity, sexual orientation, and gender identity (USPSTF, 2022).
Within military organizations, screening for suicide risk is reportedly controversial and has received mixed support. There is no evidence that universal screening in general military populations is beneficial, but it can be useful when combined with screening for substance use, depression, or PTSD (VA/DOD, 2019).
Despite weak evidence for suicide screening, the Veterans Administration has identified screening as a key part of their Community-Based Intervention for Suicide Prevention program. Although aimed at service members and veterans, the program can be modified for the civilian populations. The program has 3 components: (1) identifying Service members, veterans, and their families and screening for suicide risk; (2) promoting connectedness and improving care transitions; and (3) increasing lethal means safety and safety planning (USDVA, 2021, September).
Structuring the Interview
Assessing suicide risk in clinical practice depends on the skills and philosophical approach of the individual clinician. Nevertheless, any healthcare provider—in any setting—may be called upon to ask a patient about suicidal ideation and behaviors. Understanding when a referral is needed is a critical part of the assessment; anyone thought to be at risk for suicide should be referred.
Because asking about suicide is not easy, providers are encouraged to practice their interview skills at home or with a co-worker. Develop and practice questions until you are comfortable leading a patient through an assessment. Asking a difficult question does not plant the idea of suicide.
There are guidelines on what to assess—life history, previous suicide attempts, and mental state—along with frameworks for how to assess risk. There is less guidance on how to interview patients about suicidal ideation (ie, thinking about, considering, or planning suicide). This is important because the way questions are asked—the words and phrasing used by a clinician—can influence the patient’s response (McCabe et al., 2017).
Importance of Secondary Suicide Risk Screening
In a study of more than 1,300 emergency department patients with recent suicide attempts or ideation, an intervention consisting of secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls resulted in a 5% absolute decrease in the proportion of patients subsequently attempting suicide and a 30% decrease in the total number of suicide attempts over a 52-week followup period.
Source: Coyne, 2017.
When considering a suicidal patient’s experience, safety is related to more than the absence of suicide risk and the need for physical protection. To be safe, patients must feel a connection with healthcare professionals, be protected against their own suicidal impulses, and have a sense of control over their lives (Berg et al., 2017).
Asking About Safety—A Nurse Practitioner’s Perspective
Asking about safety should start with a general, open-ended question such as, “Has something happened recently that has affected your well-being?” A person might respond by saying, for example, “My mother just died—she was my whole life.” If there is no answer or a pause, ask a more direct question. For example, you might ask “Now that your mother has died, what else in your life will bring you joy?” This might be followed by a question of concern such as: “I wonder—has the thought of hurting yourself entered your mind?”
If a person is depressed, they may have trouble organizing their thoughts, leading to a delayed response. Note the amount of time needed to respond, be patient, and give time for an answer. Develop a series of questions that help you determine the level of care needed for patient safety to be preserved.
Although yes/no questions are common in healthcare interactions, they can communicate an expectation in favor of either a yes or no response. For example, “Are you feeling low?” invites agreement to “feeling low.” Conversely, “Not feeling low?” invites agreement to “not feeling low.” Specific positive or negative words can reinforce bias. Words such as “any,” “ever,” or “at all” reinforce negative bias (eg, “Any negative thoughts?”) while words such as “some” reinforce positive bias (eg, “Do you have some pain here?”) (McCabe et al., 2017).
If a patient indicates an intention to harm themself, a healthcare provider’s next act is to refer the patient to someone who is licensed to decide about an involuntary hold. In larger healthcare organizations, psychiatric services are directly available. Patients who agree to be hospitalized must be placed in the least restrictive environment. Depending on the level of risk, patients can be held against their wishes. Determining whether a patient is safe (and whether they can be held against their will) is left to providers who are legally licensed to make that determination.
Asking About Safety: Margo
Margo is a 27-year-old woman who presented in your office for treatment following a suicide attempt. She had slit her wrists 2 weeks before and was recently discharged from the hospital psych ward.
When Margo is asked if she ever tried to harm herself in the past—how many times and in what ways—she replied: “The first time I thought about suicide, I took a bottle of aspirin. The second time I was 17 and I slit my wrists, but I screamed when I saw the blood. Two weeks ago, I was upset when my boyfriend broke up with me and I slit my wrists in a warm bathtub.”
When assessing a person for suicidal ideation and behaviors, start by asking broad questions and get more specific as the interview proceeds. Avoid yes/no questions, which can communicate an expectation in favor of either a yes or no response.
At this point in your assessment, it may be unclear whether Margo has a clear intention of taking her life or if she requires higher levels of protection than someone with less inclination toward dying. An instrument such as the Beck Suicide Intention Scale may be helpful in assessing Margo’s intent.
The key point about Margo is that her attempts have accelerated and become more sophisticated. Keep in mind that the more times a person attempts suicide, the more likely they are to complete the event. In Margo’s case, this should increase your concerns about future risk. Understanding the level of risk will guide your decision about safety, which is the first priority.
What Actions Should You Take?
Margo has just been released from protective custody. What do you think is the most effective care she should receive?
- A follow-up phone call every month from her doctor.
- Monitoring, outreach, therapy, and case management.
- Threatening her with protective custody if she is unable to handle the stresses in her life.
- Encouraging her to move back home with her parents so they can closely monitor her behavior.
Correct answer: b
Because previous suicide attempts are known to be a strong predictor of future attempts and deaths by suicide, continuity of care is critical. For Margo, who has survived a suicide attempt, effective clinical care should focus on community and family support, therapy, and lethal means restriction.
Assessment of Lethality
Once safety has been discussed, ask about lethality, which focuses on the method used, the circumstances surrounding the attempt, and the chance of rescue. Lethality is related to the severity of physical consequences as well as the amount of medical intervention needed following an attempt (Kar et al., 2014).
Safety and Lethality—A Nurse Practitioner’s Perspective
Nonsuicidal self-injury often involves people with borderline personality disorders; self-harm can be an antidote to psychological numbing. This doesn’t let providers off the hook in terms of assessing safety and lethality, but this sort of situation requires a different kind of assessment.
A clinician must decide what direction the self-harm is heading—from superficial and visible self-harm to deeper and less visible self-injury. People with certain types of mental illness are more likely to be associated with escalating self-harm, with an ever-greater likelihood of a completed suicide.
When assessing lethality, try to determine how well thought out the plan is and whether the person has access to the means to complete the plan. Note any additional circumstances and try to evaluate the “risk tipping point.” Determine if it is necessary to take an action that deprives a patient of his or her rights vs. not taking an action that might result in suicide.
The lethality of suicidal behavior can be considered to have five levels: subliminal, low, moderate, high, and extremely high (Kar et al., 2014).
Five Levels of Lethality
- Subliminal—the lowest level. Death is impossible to highly improbable.
- Low. Death is improbable and is not the usual outcome but may be possible as a secondary complication of factors other than the suicidal behavior.
- Moderate. Probability of death is in the middle order.
- High. Chance of death is high and is the usual or likely outcome of the suicidal act.
- Extremely high. Chance of survival is minimal, and death is considered almost certain. (Kar et al., 2014)
There is often a mismatch between the intent of the suicidal act and the lethality of the method chosen. Clients who genuinely want to die (and expect to die) may survive because their method was not foolproof or because they were interrupted or rescued. However potentially lethal the chosen method is, a prior suicide attempt is a highly potent risk factor for eventually dying by suicide. Any suicide attempt must be taken seriously, including those that involve little risk of death, and any suicidal thoughts must be carefully considered in relation to the client’s history and current presentation (CSAT, 2017).
Intentions are self-instructions that guide engagement in a behavior or lead to an outcome. Measures of intention provide a numerical score that reflect how hard a person is willing to try or the likelihood a person will perform—or try to perform—a particular behavior (Williams, 2016). Patients who have a clear intention of taking their life require higher levels of protection than those with less inclination toward dying.
The ability to perceive intentionality appears to be automatic and by adulthood most individuals share a common understanding of the concept of intentionality. Given the importance of inferring the intentions of others, it is not surprising that most adults are keenly attuned to intentionality cues (Brotherton & French, 2015).
Suicidal behaviors can be predictive of suicide. Assessing a person’s intent to die during a risk assessment is an important indicator of current and future risk. Many instruments, such as the Suicidal Behaviors Questionnaire-Revised and the Suicide Intent Scale, include items on communication of suicide ideation and behavior (Harris et al., 2015).
A person’s intent may be inferred from how they describe a “wish to live” or a “wish to die.” These terms have proven useful in assessing suicide ideation and behavior and are included in Beck’s Scale of Suicidal Ideation and the Suicide Status Form. Overall, there is strong evidence that suicidal affects can be valid indicators of current and future risk (Harris et al., 2015).
Beck Suicide Intention Scale
The Beck Suicide Intention Scale (SIS) examines subjective and objective aspects of the suicide attempt, the circumstances at the time of the attempt, and the patient’s thoughts and feelings during the attempt. It is based on a clinical interview using an instrument with 15 items referring to the patient’s precautions and beliefs of the act. Each item is scored on a scale from 0 to 2, with a possible total score of 30 indicating the highest intention of suicide and a wish to die.
The Beck SIS questionnaire covers precautions, planning, communication, and expectations regarding medication load, the degree of planning, and wish to die or live. It is divided into two sections: the first eight items constitute the “circumstances” (part 1) and are concerned with the objective circumstances of the act of self-harm; the remaining seven items, the “self-report” (part 2), are based on the patients’ own reconstruction of their feelings and thoughts at the time of the act.
Source: Grimholt et al., 2017.
In the two-and-a-half years since my son’s death I have learned that his story is, sadly, not uncommon. I have become oddly close with other mystified parents of seemingly successful, engaged, social young men and women who took their lives. They are my partners in grief, and in understanding why suicide is the number two killer of youth in Washington State, just behind accidents.
My son retrieved a gun that was unlocked because it had not been fired in many years and we didn’t think there was any ammunition in the house. Although we have learned that he was showing some warning signs, I will never know what he was thinking, because that gun left him with no chance of survival.
My son was a trained marksman who had attended gun camp every summer. He had also taken the hunter safety class, and was, as his hunting mentor said, “safer with a gun than any adult I know.” I have great respect for the people who trained my son, but not once did any of the safety materials include warnings for parents of youth that 79% of firearm deaths in Washington State are suicides. I had not dreamed that my son was suicidal, much less that he would consider using a gun to take his life. I sincerely hope that other parents safely store firearms and ammunition out of the reach of children.
Kathleen Gilligan, whose son Palmerston Burk died from suicide by firearm in King County
Source: WSDOH, 2016.
Talking About Lethal Means
Lethal means assessment is critically important because certain lethal means such as firearms, hanging/suffocation, or jumping from heights provide little opportunity for rescue and have high fatality rates (Stone et al., 2017). Implementing lethal means safety, including firearm restrictions, reducing access to poisons and medications associated with overdose, and barriers to jumping from lethal heights, is a means to reduce population-level suicide rates (DVA, DOD, 2019).
Providers can educate patients and families about safe firearm storage and access, as well as the appropriate storage of alcoholic beverages, prescription drugs, over-the-counter medications, and poisons. Providers should talk to patients and caregivers about reducing the stock of medicine to a nonlethal quantity and locking medicines—such as prescription painkillers and benzodiazepines—that are commonly abused. This approach can be useful in helping to prevent suicide, as well as unintentional overdoses and substance abuse (HHS, 2012, latest available).
Despite the importance of discussing lethal means, a study of 800 emergency department charts of patients who screened positive for suicidal ideation and suicide risk revealed that only 18% had any documentation of an assessment of lethal means. For the small group who were asked about lethal means, only 8% had documentation that a healthcare professional discussed a safety/action plan to reduce access to lethal means. The most common discussion involved changing home storage or moving objects out of the home (Harmer et al., 2022).
A study of 800 emergency department charts of patients who screened positive for suicidal ideation and suicide risk revealed that only 18% had any documented lethal means assessment (Harmer, et al., 2022).
These findings show the need to document lethal means assessments for all individuals who have a positive screen for suicidal ideation, plus the need to have discussions about the removal of lethal means. This may require adding prompts for these assessments to the electronic documentation system (Harmer et al., 2022).
A successful program developed at a large children’s hospital called the Emergency Department Counseling on Access to Lethal Means (ED CALM) trained psychiatric emergency clinicians to provide lethal means counseling and safe storage boxes to parents of patients under age 18 receiving care for suicidal behavior. In a pre/post quality improvement project, researchers found that, at posttest, 76% reported that all medications in the home were locked up as compared to fewer than 10% at the time of the initial ED visit. Among parents who indicated the presence of guns in the home at pretest (67%), all (100%) reported guns were currently locked up at posttest (Stone et al., 2017).
Talking about Lethal Means—A Nurse Practitioner’s Guidance
If you have identified that your patient is at risk for self-harm, try to identify any lethal means that your patient might be able to access once he or she leaves your office. Ask direct questions: “While you’re in this dangerous period, may I call your partner or family member and ask them to remove the guns or poisons from the house?”
Ask permission and show concern in a non-judgmental manner—this is more likely to elicit accurate information. You can continue by saying “I want to let you know that I appreciate and am honored that you’ve shared your thoughts with me. I’m just concerned that you may go again to a place of despair when you leave and I’m thinking of your safety.”
Try to establish and maintain trust with your patient—if you think the person is at risk, there is no reason to cover your concern or to lie. Make sure you document the results of your discussion.