In the United States, about 33% of people who take their life have been in contact with mental health services the year before death and nearly half of people who took their life were seen in primary care the month before death (McCabe et al., 2017). Despite the seriousness and universality of this problem, instruments that evaluate and predict suicide ideation and behavior are lacking (Harris et al., 2015).
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, suicide risk screening and assessment are valuable clinical tools because they can ensure that those requiring more services get the help that they need. In other words, it is not necessary to have a crystal ball if the assessment information shows that a client fits the profile of an individual at significant risk (CSAT, 2015).
Suicide risk measures typically have two goals: (1) to assess current suicide ideation and (2) to assess the potential for future suicidal behaviors (Harris et al., 2015). A good clinical assessment can in itself be the start of suicide prevention efforts. However, several recent reviews have examined the predictive validity of suicide assessment instruments, demonstrating poor performance in the prediction of subsequent suicide attempt and suicide. Nevertheless, guidelines have been developed to aid clinicians in this challenging endeavor, and assessment instruments can supplement the clinical evaluation (Runeson et al., 2017).
Although the U.S. Preventive Services Task Force concluded in 2013 that current evidence is insufficient to assess the benefits and harms of screening the general population for suicide risk in a primary care setting, it concluded that screening is appropriate for high-risk individuals with known mental illnesses or substance use disorders (DVA/DOD, 2013).
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. Therefore, to screen for suicide-related behavior, it is essential that all veterans receive screening for substance use, depression, and PTSD, because this will give “red flags” that these veterans need future followup (NREPP, 2015).
Structuring the Interview
Any healthcare provider in any setting may be called upon to ask a patient about suicidal ideation and behavior. Because this is not easy, providers are encouraged to practice their interview skills at home by developing and practicing questions until they are comfortable leading a patient through an assessment. Understanding when a referral is needed is a critical part of the assessment; anyone thought to be at risk for suicide should be referred.
Assessing risk in clinical practice depends on the skills and philosophical approach of the individual clinician. 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—influences the patient’s response (McCabe et al., 2017).
Asking About Safety
Begin your interview by asking about your patient’s safety. This should start with a general, open-ended question. An example of a general question might be “Has something happened recently that has affected your well-being?” A person might respond by saying, for example, “My dog 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 dog 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 someone is depressed, they may have trouble organizing their thoughts, causing a delayed response. Be patient and give time for an answer. Note the amount of time needed to respond. Develop a series of questions you are comfortable with in order to make a determination about the level of care needed for patient safety to be preserved.
Healthcare providers must take responsibility for asking uncomfortable questions. If you don’t practice and are not fluent with questions about suicide ideation and behaviors, things can get awkward. Asking a difficult question does not plant the idea of suicide.
Although yes/no questions are prevalent in medical 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 words with positive or negative polarity further 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).
Three Components of Safety
Safety can be thought of as having three components: connection, protection, and control. 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.
Source: Berg et al., 2017.
If a patient’s response indicates an intention to harm the self, 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.
Margo has just been released from protective custody. What do you think is the most effective care she should receive?
- A followup 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 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.
Understanding the level of risk for suicide guides your decision about safety, which is the first priority. Patients who have a clear intention of taking their life require higher levels of protection than those with less inclination toward dying. High-risk patients may require inpatient care, which offers an increased level of supervision and higher intensity of care. Those at intermediate and low acute risk may be referred to an outpatient care setting. With appropriate support and safety plans, lower risk patients may be able to be followed up in the community (DVA/DOD, 2013).
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).
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, remember that a prior suicide attempt is a highly potent risk factor for eventually dying by suicide. Also remember that 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, 2015).
Understanding Warning Signs
Warning signs are indications of suicidal ideation and behavior that are observed by or reported to another, and indicate risk for suicide within minutes, hours, or days. About 80% of people who attempt suicide show some sort of warning sign. Knowing and recognizing these signs can help family and friends take action before suicidal thinking turns into action (WSDOH, 2016).
Warning signs can be acute and urgent or simply red flags for concern. Widely accepted general suicide signs include:
- Anxiety, agitation, sleeplessness, or mood swings
- Feeling that there is no reason to live; purposelessness
- Rage, anger, or aggression
- Recklessness, engaging in risky activities without thinking
- Increasing alcohol or drug abuse
- Withdrawing from family and friends
- Feeling trapped (USDVA, 2016a)
Recognizing warning signs, knowing how and where to get help, and making timely referrals can save a life. In one study, researchers tested the ability of common signs of suicide to differentiate between suicidal ideation, non-ideation, and suicide attempts. Although all signs of suicide differentiated suicidal ideation and non-ideation, only anger/aggression was predictive of suicide attempts (Hunt et al., 2017).
Recognition of warning signs is the key to creating an opportunity for early assessment and intervention. Three warning signs require immediate attention. Presence of one or more of these behaviors is a strong indication that further assessment is needed:
- Communicating suicidal thought verbally or in writing, especially if this is unusual or related to a personal crisis or loss
- Seeking access to lethal means such as firearms or medications
- Demonstrating preparatory behaviors such as putting affairs in order (USDVA, 2016a)
Substance Abuse and Suicide Risk
Suicide is a leading cause of death among people who abuse alcohol and drugs. Compared with the general population, individuals treated for alcohol abuse or dependence are at about 10 times greater risk for suicide; people who inject drugs are at about 14 times greater risk for suicide. Depression—a common co-occurring diagnosis among people who abuse substances—also confers risk for suicidal behavior. People with substance use disorders often seek treatment at times when their substance use difficulties are at their peak—a vulnerable period that may be accompanied by suicidal thoughts and behaviors (CSAT, 2015).
According to the Drug Abuse Warning Network (DAWN), from 2005 to 2011, drug-related emergency department visits involving suicide attempts:
- Increased 51% in among individuals aged 12 or older
- Increased 58% among patients aged 18 to 29
- More than doubled for patients aged 45 to 64 doubled (104% increase)
Substance Use Disorders
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no longer uses the terms substance abuse and substance dependence, rather it refers to substance use disorders, which are defined as mild, moderate, or severe to indicate the level of severity, which is determined by the number of diagnostic criteria met by an individual.
Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacologic criteria.
The most common substance use disorders in the United States include:
- Alcohol Use Disorder (AUD)
- Tobacco Use Disorder
- Cannabis Use Disorder
- Stimulant Use Disorder
- Hallucinogen Use Disorder
- Opioid Use Disorder
Source: SAMSHA, 2015.
Even when someone with a substance use disorder is in treatment, the prevalence of suicidal ideation and suicide attempts remains high. There is also a significant prevalence of suicide among those who have at one time been in substance abuse treatment. Because of this, substance abuse treatment providers must routinely assess and refer clients at risk for suicidal behavior. Suicidal thoughts and behaviors are also a significant indicator of other co-occurring disorders (eg, major depression, bipolar disorder, PTSD, schizophrenia, and some personality disorders) that must be explored, diagnosed, and addressed (CSAT, 2015).
Clients in substance abuse treatment should be screened for suicidal thoughts and behaviors routinely during intake and at specific points during the course of treatment. For this approach to be effective, providers must:
- Implement a treatment plan and coordinate the plan with other providers
- Check that referral appointments are kept
- Monitor clients by coordinating with mental health providers, other practitioners, and family members
- Understand suicide warning signs, risk factors, and protective factors.
- Be empathic and nonjudgmental
- Understand how their own attitudes and experiences impact their clients
- Understand ethical and legal principles as well as potential areas of conflict (CSAT, 2015)
Abstinence should be a primary goal of any client with a substance use disorder and suicidal thoughts or behaviors. For most clients abstinence reduces risk, although some individuals remain at risk even after achieving this goal. These can include: