Factors in the assessment of suicidality in youth

Suicide remains a leading cause of death among youth, and suicide ideation and behavior are relatively common in both normal and clinical populations. Clinicians working with young people must assess for the presence of suicidal ideation, suicidal behavior, and other risk factors, in order to determine the level of risk. This paper provides the clinician with a summary of risk factors for youth suicide, as well as providing standardized terminology to enhance assessment of suicidal ideation and behavior.     

Suicide assessment and evaluation strategies: a primer for counselling psychologists

Suicide is a recognized national health risk in many countries. In order to effectively intervene in suicidal crises, it is important for mental health professionals to understand facts about suicidal behaviour, procedures for assessing an individual's risk of self-harm, and the evaluation of the lethality of a client's suicidal gestures. With updated knowledge and proper training, counselling psychologists can play a vital role in suicide prevention. This paper summarizes for counselling psychologists current statistics about suicide, general and specific risk factors for suicidality, and assessment tools used to evaluate suicidal risk.     

Suicide Risk Assessment and Risk Formulation Part I: A Focus on Suicide Ideation in Assessing Suicide Risk

The main procedure used by clinicians to determine whether an individual may be at risk of suicidal behaviors is the suicide risk assessment (SRA). The purpose of the SRA is to identify risk and protective factors that then provide the data for the formulation of suicide risk. The suicide risk formulation (SRF) assigns a level of suicide risk that ideally leads to triage and treatment deemed appropriate for that level of risk. Some of the problems with the SRA are explored here, with an emphasis on addressing the over reliance on communicated suicide ideation, and recommendations are made for improvements. Part II of this article (Berman & Silverman, 2013, also appears in this issue of STLB) examines the process of an SRF and, similarly, makes recommendations to improve clinical practice toward the desired end of saving lives.     

Do close supportive relationships moderate the effect of depressive symptoms on suicidal ideation?

Depressive symptoms, a lack of close supportive relationships and suicidal ideation are important risk factors for suicidal acts. Previous studies have primarily focused on the additive effects of close relationships and depressive symptoms on suicide risk. Here we explored whether, in addition, close relationships moderated the impact of depressive symptoms on suicidal ideation. An analysis of pre-existing data from 319 attendees at a student counselling service using moderated regression models indicated that when the student has close supportive relationships, the association between depressive symptoms and suicidal ideation is weaker than when he/she feels an absence of close relationships. This confirms the need to include enquiries about the presence of close relationships and depression as part of any suicide risk assessment.     

Determinants and Predictive Value of Clinician Assessment of Short‐Term Suicide Risk

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short‐term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10‐point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire‐Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one‐month follow‐up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow‐up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.     

Using the Linehan Risk Assessment and Management Protocol With a Chronically Suicidal Patient: A Case Report

The Linehan Risk Assessment and Management Protocol (LRAMP) is an empirically supported, comprehensive framework used to assess suicide risk and protective factors, and provide a guide for the therapist to consider reasonable options for intervening on suicidal behavior. This protocol includes a structured checklist for assessing, managing, and documenting suicide risk. It also structures the documentation to clearly describe the presentation, assessment, in-session interventions, decision-making process, and follow-up to other members of the treatment team. This paper describes a case in which the LRAMP was used to guide the assessment, intervention, and documentation of the suicidal behavior of a patient, “Ann,” being treated with outpatient Dialectical Behavioral Therapy in a community mental health clinic. Each section of the LRAMP is discussed as it was used with this complex patient, who had history of high utilization of acute psychiatric services. Application of the LRAMP included the assessment of risk and protective factors, and the use of an individualized crisis plan that engaged the patient, her family, the therapist, and the clinical team, to decrease acute risk, continue outpatient treatment, and avoid inpatient hospitalization. The considerations for documenting clinical decision-making with chronically suicidal patients are discussed.     

Adolescent suicide risk: four psychosocial factors

Suicide is a leading cause of death among adolescents. This study examined the suicidal ideation, behavior, and attempt history of 100 adolescents ages seventeen to nineteen. Four psychosocial factors were found to be important for overall suicide risk: hopelessness, hostility, negative self-concept, and isolation. It is suggested that focusing on these four psychosocial factors would enhance suicide assessment and prevention efforts with adolescents.     

The Internal Suicide Debate Hypothesis: Exploring the Life versus Death Struggle

Researchers and theorists (e.g., Shneidman, Stengel, Kovacs, and Beck) hyothesized that suicidal people engage in an internal debate, or struggle, over whether to live or die, but few studies have tested its tenability. This study introduces direct assessment of a suicidal debate, revealing new aspects of suicidal ideation. Results, from an online survey (N = 1,016), showed nearly all suicide‐risk respondents engaged in the debate. In addition, debate frequency accounted for 54% of the variance in suicidality scores, and showed significant associations with other indicators of suicide risk. Likely factors of the debate, reasons for living and dying, showed significant differences by suicidality, and most suicide‐risk participants reported going online for such purposes, demonstrating a behavioral component of the debate.     

A Standard of Care for the Assessment of Suicide Risk and Associated Treatment: The Florida State University Psychology Clinic as an Example

The Florida State University has established a set of guidelines to be used as a standard of care for suicide. This standard of care guides therapists through a suicide risk assessment that focuses on key variables related to suicidal behavior that are among the best predictors of completed suicide. This standard of care includes necessary components of suicide risk assessment, critical steps to follow to ensure the safety of suicidal patients, treatment recommendations, and guidelines for minimizing the legal risk of the therapist. Though this standard of care was developed in a research and training clinic, these principles may be applied to all clinicians offering psychological services to patients, regardless of the nature of the clinic or setting.     

Risk for Suicidal Ideation and Attempt among a Primary Care Sample of Adolescents Engaging in Nonsuicidal Self‐Injury

One in five adolescents in the United States has engaged in nonsuicidal self‐injury (NSSI), one in eight have had serious thoughts of suicide, and one in 25 have attempted suicide. Research suggests that NSSI may increase risk for suicide attempt, yet little is known about the relationship between NSSI and suicidal ideation or attempts. In a primary care setting, 1,561 youth aged 14–24 years completed a brief, comprehensive, mental health screen as part of a routine well visit to determine which factors were most likely to predict suicidal ideation and attempt among youth engaging in NSSI. Results of recursive partitioning revealed that current depression and history of alcohol use best differentiated youth engaging in NSSI with low versus high risk for suicidal ideation and attempts. This simple algorithm is presented as a clinical screening tool that might aid medical providers in determining which youth would benefit from more intensive assessment and intervention.     

Suicide risk assessment: Clinicians’ confidence in their professional judgment

Suicide risk assessment is a critical component of mental health practice for which the stakes are high and the outcomes uncertain. This research examines the consistency with which clinicians make determinations of suicide risk and factors influencing clinical confidence. Seventy-one social workers interviewed two standardized patients performing in scenarios depicting suicidal ideation, judged whether the patient required hospitalization, and completed standardized suicide risk assessment measures. Self-ratings and qualitative interviews explored participants’ confidence in their judgment of risk. Participants had highly divergent views regarding whether or not the risk of suicide was sufficiently high to require hospitalization. However, regardless of the ultimate decision reached, participants were equally confident when recommending either clinical course of action. The variation in risk assessment appraisals in this study, despite at times high rates of confidence in risk appraisals, speaks to the need for ongoing training, consultation, and increased decision support strategies.     

Racial differences in self-disclosure of suicidal ideation and reasons for living: implications for training

Racial differences in suicidal self-disclosure and reasons for living were investigated in 2 separate studies. In Study 1, a random sample of archival client and therapist intake data from a university counseling center for 1 year was examined, and results indicate that ethnic minority clients do not self-disclose suicidal ideation as readily as their nonethnic minority peers. In addition, a significantly higher number of ethnic minority clients were deemed "hidden ideators" because their suicidal ideation only became evident when a counselor performed a suicide risk assessment. Only 1 of the 36 ethnic minority clients with suicidal ideation in the sample voluntarily self-disclosed this ideation at intake without an assessment by the therapist. Study 2 used the Reasons for Living Inventory (RFL) and compared African American and European American college students from an introductory psychology course. The RFL is a useful instrument to compare potential race differences in reasons people report for choosing not to kill themselves, because it does not require respondents to self-disclose (or to have) current suicidal ideation. The results from Study 2 indicate European Americans report fewer reasons for choosing not to kill themselves than their African American peers and that African Americans scored significantly higher than European Americans on the moral objections and survival and coping beliefs subscales of the RFL. Implications for training counselors in suicide risk assessment, prevention, and treatment with ethnic minorities are discussed.     

Principles of Behavioral Assessment and Management of “Life-Threatening Behavior” in Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) in its initial iteration was developed for the treatment of suicidal and self-injuring adults. As a result, the assessment and management of suicidal and nonsuicidal self-injurious (NSSI) behavior was and is central to the conduct of standard DBT. In this paper the authors describe the DBT approach to suicide risk assessment including discussion of both comprehensive and targeted suicide risk assessment and the associated documentation. In addition, it describes when and when not to conduct such assessment. Finally, this article describes management of both imminent and distant suicide risk and the application of DBT treatment strategies that can be applied in session.     

Suicidal Ideation of Psychiatrically Hospitalized Adolescents has One-Year Predictive Validity for Suicide Attempts in Girls Only

Clinicians commonly incorporate adolescents’ self-reported suicidal ideation into formulations regarding adolescents’ risk for suicide. Data are limited, however, regarding the extent to which adolescent boys’ and girls’ reports of suicidal ideation have clinically significant predictive validity in terms of subsequent suicidal behavior. This study examined psychiatrically hospitalized adolescent boys’ and girls’ self-reported suicidal ideation as a predictor of suicide attempts during the first year following hospitalization. A total of 354 adolescents (97 boys; 257 girls; ages 13–17 years) hospitalized for acute suicide risk were evaluated at the time of hospitalization as well as 3, 6, and 12 months later. Study measures included the Suicidal Ideation Questionnaire-Junior, Multidimensional Anxiety Scale for Children, Children’s Depression Rating Scale-Revised, Beck Hopelessness Scale, Youth Self-Report, and Personal Experiences Screen Questionnaire. The main study outcome was presence and number of suicide attempt(s) in the year after hospitalization, measured by the Diagnostic Interview Schedule for Children. Results indicated a significant interaction between suicidal ideation, assessed during first week of hospitalization, and gender for the prediction of subsequent suicide attempts. Suicidal ideation was a significant predictor of subsequent suicide attempts for girls, but not boys. Baseline history of multiple suicide attempts was a significant predictor of subsequent suicide attempts across genders. Results support the importance of empirically validating suicide risk assessment strategies separately for adolescent boys and girls. Among adolescent boys who have been hospitalized due to acute suicide risk, low levels of self-reported suicidal ideation may not be indicative of low risk for suicidal behavior following hospitalization.     

Empirically informed approaches to topics in suicide risk assessment

The purpose of this article is to approach topics in suicide risk assessment from a scientifically informed standpoint. We summarize and elaborate a general framework for an empirically supported best practice recommendation in evaluating suicide potential and minimizing risk. This risk assessment framework provides a concise heuristic for assessment of suicidal symptoms, points the way to relatively routinized clinical decision-making and activity, and is compatible with best practices relevant to the legalities of suicide risk assessment. Having established a general and scientifically based framework for risk assessment, we go on to address the other questions noted above, with reference to the framework and to our ongoing scientific work. We conclude by summarizing all the work and providing clear and concise clinical recommendations based thereon.     

The Great Black Hope: Hope and Its Relation to Suicide Risk among African Americans

Positive psychology has garnered considerable scholarly interest recently and has been suggested to hold promise in the application to suicide research and prevention; however, empirical research has lagged behind these suggestions. This is the first study to examine the relationship between hope and a specific theory of suicide in African Americans. It was hypothesized that (1) hope would negatively predict the interpersonal suicide risk factors of burdensomeness and thwarted belongingness; and positively predict acquired capability to enact suicide; (2) hope would negatively predict suicidal ideation; and (3) the interpersonal suicide risk factors would predict suicidal ideation. Results were primarily as predicted. Implications for hope theory and Joiner's theory of suicidal behavior are discussed, as well as implications for clinical practice.     

Religion and Suicide

Religion impacts suicidality. One’s degree of religiosity can potentially serve as a protective factor against suicidal behavior. To accurately assess risk of suicide, it is imperative to understand the role of religion in suicidality. PsycINFO and MEDLINE databases were searched for published articles on religion and suicide between 1980 and 2008. Epidemiological data on suicidality across four religions, and the influence of religion on suicidality are presented. Practice guidelines are presented for incorporating religiosity into suicide risk assessment. Suicide rates and risk and protective factors for suicide vary across religions. It is essential to assess for degree of religious commitment and involvement to accurately identify suicide risk.     

Suicidal behavior in schizophrenia and schizoaffective disorder: examining the role of depression

Understanding the relationship between depression and suicidal behavior among individuals with schizophrenia and schizoaffective disorder can aid assessment and treatment. In this study, 86 individuals with schizophrenia and schizoaffective disorder were assessed for past and current suicidal behavior, depression, hopelessness, and reasons for living. Thirty-four percent reported a history of suicide attempts. Suicidal behavior typically occurred 4.5 years after the onset of psychosis and 7.5 years after the onset of the first major depressive episode for those who had a history of major depression. Depression was frequent among both attempters and non-attempters, but only half of the attempters reported a suicide attempt during an episode of major depression. And almost half of those with depression never made a suicide attempt despite a long history of illness. Although depression is a potential stressor for triggering suicidal behavior in a vulnerable subset of individuals with schizophrenia, schizophrenia research must identify other risk factors for suicidal behavior. Clinicians should remember that even without a depressive episode there is still a significant risk for suicidal behavior in schizophrenia.