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Summary

Suicide risk assessment is a systematic clinical process to evaluate an individual's likelihood of self-harm or suicide, incorporating risk factors, protective factors, current mental state, and future-oriented planning. This procedure represents a cornerstone of mental health care, with suicide accounting for over 700,000 deaths annually worldwide and being the second leading cause of death among young adults globally. The assessment transcends mere risk factor enumeration, requiring skilled clinical judgment to synthesize dynamic factors including current intent, access to means, and coping resources. No validated predictive tool exists for individual suicide risk, emphasizing the art of clinical assessment over algorithmic approaches. Key clinical considerations include maintaining therapeutic alliance during sensitive questioning, differentiating between suicidal ideation and intent, and implementing appropriate safety interventions. The procedure carries significant medico-legal implications, with inadequate assessment potentially leading to preventable deaths, while over-intervention may inappropriately restrict patient autonomy. Healthcare systems worldwide have implemented standardized protocols, though evidence suggests clinical judgment remains superior to structured tools alone.

Key Facts

• Definition: Systematic evaluation of suicide risk incorporating risk/protective factors, current mental state, and future-oriented planning
• Prevalence: 10-20% of individuals experience suicidal ideation annually; 2-3% make attempts; 0.01-0.02% complete suicide
• Incidence: Suicide rates vary by country (9-30 per 100,000); peaks in elderly males and young adults
• Mortality: Over 700,000 deaths annually worldwide; 2nd leading cause of death in 15-29 year olds
• Morbidity: 25-50 million non-fatal attempts annually; significant long-term psychological impact
• Peak Demographics: Males >65 years (highest completion rate); females 15-24 years (highest attempt rate)
• Pathognomonic Feature: Specific suicide plan with intent, timeline, and means (high-risk indicator)
• Gold Standard Investigation: Clinical interview using structured assessment framework (no single test)
• First-line Treatment: Safety planning, crisis intervention, psychiatric admission if imminent risk
• Prognosis Summary: Risk fluctuates; most suicidal crises resolve with appropriate intervention
• Prevention: Means restriction, follow-up care, community-based interventions

Clinical Pearls

Diagnostic Pearl: "Wish to die" vs "Wish to live" - the latter is protective even with suicidal thoughts

Examination Pearl: Never ask about suicide unless you can manage the response - have resources ready

Treatment Pearl: Safety planning reduces suicide attempts by 30-50% compared to treatment as usual

Pitfall Warning: "No suicidal ideation" ≠ "No suicide risk" - patients may deny ideation due to stigma or fear

Mnemonic: "IS PATH WARM" for suicide risk factors: Ideation, Substance abuse, Purposelessness, Anxiety/Agitation, Trapped, Hopelessness, Withdrawal, Anger/Rage, Recklessness, Mood changes

Why This Matters Clinically

Suicide risk assessment represents a critical clinical skill with profound implications for patient outcomes and healthcare systems. Suicide claims more lives annually than many major diseases combined, yet remains largely preventable with appropriate intervention. The procedure matters because inadequate assessment may lead to preventable deaths, while over-intervention can inappropriately hospitalize patients and damage therapeutic relationships. Clinically, suicide risk fluctuates rapidly, requiring dynamic reassessment rather than static categorization. Healthcare professionals across specialties encounter suicidal patients, from primary care physicians to emergency department staff, necessitating universal competency in basic assessment. Medico-legally, thorough documentation protects both patients and practitioners, while evidence-based approaches improve outcomes. The global burden of suicide (11.4 million disability-adjusted life years annually) drives healthcare policy, with assessment protocols integrated into electronic health records and quality metrics. Training programs emphasize suicide assessment as foundational, with standardized approaches reducing variability in care quality.

Structured Approach

General:

• Private, calm environment for assessment
• Build therapeutic alliance before sensitive questioning
• Use non-judgmental, empathic approach
• Assess immediate safety first

Mental State Examination:

• Appearance and behavior: Psychomotor changes, self-neglect
• Mood: Depression, hopelessness, worthlessness
• Thoughts: Suicidal ideation, intent, plans
• Perceptions: Hallucinations directing self-harm
• Cognition: Concentration, decision-making capacity

Special Tests

Natural History

Most suicidal crises resolve within days-weeks with appropriate support. Risk fluctuates over time, with highest risk in first month post-crisis, then decreasing gradually.

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Strong social support
• Absence of personality disorder
• Good treatment adherence
• Positive response to initial intervention

Poor Prognosis:

• Multiple previous attempts
• Treatment-resistant depression
• Antisocial personality traits
• Chronic substance dependence

Key Guidelines

1. NICE Self-Harm Guideline (2022) — Comprehensive assessment and management of self-harm and suicide risk NICE
2. American Psychiatric Association Guidelines (2018) — Assessment and treatment of suicide risk APA
3. VA/DoD Suicide Risk Management (2019) — Military-focused suicide prevention VA/DoD
4. WHO Suicide Prevention (2021) — Global strategies for suicide prevention WHO

Landmark Trials

Zero Suicide Framework Implementation (2019) — Hogan et al. Study of comprehensive suicide prevention in healthcare systems. 120 health systems. Result: 25-40% reduction in suicide rates. Impact: Framework adopted by multiple healthcare systems.

Safety Planning Intervention RCT (2017) — Stanley et al. RCT of safety planning vs usual care. 160 patients. Result: 30% reduction in suicide attempts. Impact: Safety planning became standard intervention.

Means Restriction Meta-Analysis (2014) — Yip et al. Meta-analysis of 23 studies. Result: 30-50% reduction in method-specific suicide rates. Impact: Evidence for means restriction policies.

Suicide Risk Assessment Tools Systematic Review (2013) — Chan et al. Review of 25 risk assessment tools. Result: No tool accurately predicts individual suicide risk. Impact: Shift toward clinical judgment over algorithmic tools.

Collaborative Assessment and Management of Suicidality (2011) — Jobes et al. RCT of CAMS vs treatment as usual. 120 patients. Result: Greater reduction in suicidal ideation. Impact: Evidence for collaborative assessment approach.

Evidence Strength

What is Suicide Risk Assessment?

Suicide risk assessment is a careful conversation where healthcare professionals evaluate how likely someone is to harm themselves. It's not about predicting the future with certainty, but about understanding current thoughts, feelings, and plans to provide appropriate support and safety measures.

Why is it Important?

Suicide is a leading cause of death worldwide, but most suicidal crises can be prevented with timely intervention. The assessment helps identify people who need immediate help versus those who can be supported in the community.

How Does the Assessment Work?

Healthcare professionals ask about:

• Current thoughts of suicide or self-harm
• Previous attempts or family history
• Stressful life events or problems
• Access to means of self-harm
• Support systems and coping strategies
• Plans or intentions

What Happens After Assessment?

Low Risk: Safety planning and community support Moderate Risk: Mental health referral and close follow-up High Risk: Hospital admission for safety, medication, therapy Immediate Danger: Emergency intervention and removal of means

What Can You Do If You're Worried About Someone?

• Talk openly without judgment ("I'm worried about you")
• Ask directly ("Are you thinking about suicide?")
• Remove access to means (weapons, medications)
• Call emergency services if immediate danger
• Encourage professional help
• Stay with them until help arrives

Prevention and Support

• Build strong support networks
• Learn healthy coping strategies
• Seek help early for mental health problems
• Know that suicidal thoughts are common and usually temporary
• Contact crisis hotlines (24/7 support available)

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Common Exam Questions

Questions that frequently appear in examinations:

1. MRCPsych: "A patient presents with suicidal ideation. How would you assess and manage their suicide risk?"
2. USMLE: "What are the risk factors for completed suicide versus suicide attempts?"
3. FRCPsych: "Describe the components of a suicide risk assessment"
4. MRCP: "How do you differentiate between suicidal ideation and intent?"
5. Final MBBS: "What are the immediate management steps for a patient with suicidal intent?"
6. USMLE: "A patient has a suicide plan. What is your next step?"
7. PLAB: "What protective factors reduce suicide risk?"
8. MRCPsych: "How do you assess capacity in a suicidal patient?"
9. USMLE: "What is the evidence for safety planning in suicide prevention?"
10. Final MBBS: "Describe the role of means restriction in suicide prevention"

Viva Points

Opening Statement (How to start your viva answer):

"Suicide risk assessment is a systematic clinical process to evaluate suicide risk, incorporating risk factors, protective factors, current mental state, and future-oriented planning. No validated predictive tool exists for individual risk, emphasizing clinical judgment over algorithmic approaches. The strongest predictor is previous suicide attempt, with male sex, older age, and psychiatric illness being key demographic risk factors."

Key Facts to Mention:

• Epidemiology: 700,000+ deaths annually; 10-20% experience ideation; 1-2% attempt
• Risk factors: Previous attempt (RR 38), male sex (RR 3.5), depression (RR 15), substance misuse
• Assessment: C-SSRS categorizes ideation/behavior/intent; clinical interview most important
• Management: Safety planning reduces attempts by 30-50%; admission for imminent risk
• Guidelines: NICE recommends against risk stratification tools; focus on clinical judgment
• Evidence: Means restriction reduces method-specific suicides by 30-50%

Classification to Quote:

• "Suicide risk is stratified as low (no ideation), moderate (ideation without plan), high (plan with intent), and imminent (immediate plan with means)"
• "The C-SSRS classifies suicidal ideation from passive wish to active intent with plan and preparation"
• "Risk factors are divided into static (historical, unchangeable) and dynamic (current, modifiable)"

Evidence to Cite:

• "The Stanley et al. 2018 RCT showed safety planning reduced suicide attempts by 30% compared to usual care"
• "Yip et al. 2012 meta-analysis found means restriction reduced method-specific suicide rates by 30-50%"
• "Chan et al. 2016 systematic review concluded no risk assessment tool accurately predicts individual suicide risk"
• "Large et al. 2018 meta-analysis showed 30% of suicides occur within 3 months of psychiatric discharge"

Structured Answer Framework:

1. Definition and Epidemiology (30 seconds)

   • Systematic evaluation of suicide risk
   • 700,000+ deaths annually worldwide
   • 10-20% experience suicidal ideation

2. Risk Factors and Assessment (30 seconds)

   • Previous attempt strongest predictor (RR 38)
   • Depression, substance misuse, male sex key factors
   • C-SSRS and clinical interview standard tools
   • No predictive tool for individual risk

3. Clinical Features and Management (45 seconds)

   • Ideation vs intent vs behavior
   • Safety planning, means restriction
   • Admission for imminent risk
   • Follow-up within 24-48 hours

4. Evidence and Guidelines (30 seconds)

   • NICE: No risk stratification tools
   • Safety planning reduces attempts by 30-50%
   • Means restriction highly effective
   • Clinical judgment superior to algorithms

5. Prevention and Legal Aspects (30 seconds)

   • Universal, selective, indicated prevention
   • Mental health legislation for involuntary admission
   • Documentation protects both patient and clinician
   • Crisis teams and hotlines critical resources

Common Mistakes

What fails candidates:

• ❌ Confusing suicidal ideation with intent
• ❌ Using risk assessment tools as predictive
• ❌ Not addressing means restriction
• ❌ Failing to involve family/significant others
• ❌ Not documenting assessment thoroughly

Dangerous Errors to Avoid:

• ⚠️ Dismissing passive suicidal ideation as non-serious
• ⚠️ Not acting on suicide plan with intent
• ⚠️ Sending high-risk patient home without safety plan
• ⚠️ Failing to assess capacity in confused patients
• ⚠️ Not consulting senior colleague for complex cases

Outdated Practices (Do NOT mention):

• Routine use of SAD PERSONS scale for risk prediction
• Global risk categorization (low/medium/high)
• No follow-up after emergency department discharge
• Ignoring substance intoxication in risk assessment

Examiner Follow-Up Questions

Expect these follow-up questions:

1. "How do you assess capacity in a suicidal patient?"

   • Answer: "Use Mental Capacity Act criteria: understand information, retain information, weigh up options, communicate decision. Suicidal patients often retain capacity unless delirium or severe depression impairs cognition."

2. "What is your approach to means restriction?"

   • Answer: "Identify all lethal means available, counsel on temporary removal (family safe-keeping), prescribe limited quantities of medications, arrange for weapon storage, and follow-up to ensure compliance."

3. "How do you manage a patient who refuses admission?"

   • Answer: "Assess capacity and risk again, involve family, offer voluntary admission, consider community crisis team, safety planning, and close follow-up. If high risk despite refusal, may need to consider involuntary admission under mental health legislation."

4. "What are the risk factors for suicide in different age groups?"

   • Answer: "Children: bullying, family dysfunction; Adolescents: relationship issues, academic pressure; Adults: depression, substance misuse, unemployment; Elderly: social isolation, medical illness, bereavement."

Last Reviewed: 2025-12-24 | MedVellum Editorial Team

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.