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.     

Risk Factors Proximate to Suicide and Suicide Risk Assessment in the Context of Denied Suicide Ideation

Health care providers have significant opportunities to identify individuals at near‐term risk for suicide, but lack empirical data on near‐term risk factors. This study aimed to identify dynamic, state‐related risk factors observed by clinical practitioners within the last 30 days of life of 157 patients who died by suicide and to compare these near‐term risk factors among patients who denied versus responded positively to having suicide ideation (SI ) when last asked by a clinical practitioner prior to their death. Risk factors charted for the majority of all decedents were a history of prior suicide ideation and/or suicide attempt, current anxiety/agitation and sleep problems, current interpersonal problems or job/financial strain, current comorbid diagnoses, current social isolation/withdrawal, and a family history of mental disorder. Two‐thirds of patients denied having SI when last asked and one‐half of these patients were dead by suicide within 2 days. Decedents who denied having SI were quite similar in charted diagnoses, symptoms, behaviors, and environmental circumstances to decedents who responded affirmatively to having SI . Reliance on verbalized or reported SI as a gateway to a suicide risk assessment is questioned and the need for better understanding near‐term risk for suicide, particularly in the absence of stated SI , is highlighted.     

Resilience Factors and Suicide Risk for a Sample of Transgender Clients

This study explored how individual- and community-based resilience factors operated together in order to reduce risk of suicide for a sample of transgender therapy clients. We collected cross-sectional survey data from 106 transgender therapy clients at a local community center, including demographic information, experiences of relational support, participants' emotional stability, and risk for suicide. Results from our mediation analysis indicated that high levels of perceived relational support are related to reduced risk for suicide and that this happens by way of a person's emotional stability. Clinical implications for family therapists are discussed based on the significant indirect effect found in this study.     

Suicide Risk Factors In Alcohol Abuse

ABSTRACT: The “clinical model” approach to estimating suicide risk assumes that persons sharing specific attributes will also share certain indicators of vulnerability to suicide. This would warrant an empirically derived risk assessment scale applicable only to persons with those attributes. Nine hundred seventy eight persons at risk for suicide who met our criteria for alcohol abuse were interviewed at length and followed for two years, during which 53 (5.5 percent) committed suicide. Eleven variables which best differentiated those who suicided from those who did not in an index set were then applied to an independent validation set. Clinical implications of the findings are discussed.     

Evaluation of the Recognizing and Responding to Suicide Risk Training

Changes in attitudes, confidence, and practice behaviors were assessed among 452 clinicians who completed the training, Recognizing and Responding to Suicide Risk, and who work with clients at risk for suicide. Data were collected at three time points. Scores on measures of attitudes toward suicide prevention and confidence to work with clients at risk for suicide improved over time. Clinical practice behaviors improved for assessing and formulating suicide risk, developing suicide prevention treatment plans, and responding to vignettes. Results suggest training can improve clinicians’ attitudes toward suicide, confidence to work with clients at risk for suicide, and, most importantly, clinical practice skills.     

Assessing Legal Strains and Risk of Suicide Using Archived Court Data

Relatively little is known about legal entanglements and suicide risk. This matched case–control study estimated the risk of suicide associated with legal strains using online court archives, a novel source of exposure data. Court records linked to suicide deaths (N = 315), controls (N = 630), and unintentional injury and poisoning deaths (N = 630) for an urban county from 2000 to 2005 revealed that nearly a third of suicide victims had recent court involvement, twice the proportion among controls. Misdemeanors, car accidents, and foreclosures were each associated with a threefold risk of suicide. Implications for suicide prevention and research are discussed.     

Gender and Suicide Risk Among Artists: A Multivariate Analysis

Research on mental disorders among male artists has suggested that artists are at risk of suicide. However, given that men are higher in suicide risk than women, the presumed suicide risk of artists may be an artifact of sampling bias. A logistic regression analysis of data from 21 states finds that artists have a 270% higher risk of suicide than nonartists. However, after controlling for gender and sociodemographic variables, this risk level is reduced to 125%. The findings are related to both psychiatric and work-related stress factors that may place artists at risk of suicide as an occupational group.     

Hope as a Predictor of Interpersonal Suicide Risk

The current study hypothesized that (1) hope would negatively predict burdensomeness, thwarted belongingness, and acquired capability to enact lethal injury; (2) hope would negatively predict suicidal ideation; and (3) the interpersonal suicide risk factors would predict suicidal ideation. Results indicated that hope negatively predicted burdensomeness and thwarted belongingness, but positively predicted acquired capability to enact suicide. Contrary to our second hypothesis, hope did not predict suicidal ideation, but interpersonal risk factors for suicide predicted suicidal ideation. Results are discussed in terms of implications for hope theory and Joiner's (2005) interpersonal risk factors for suicide, and for clinical practice.     

Family Factors Predicting Categories of Suicide Risk

We compared family risk and protective factors among potential high school dropouts with and without suicide-risk behaviors (SRB) and examined the extent to which these factors predict categories of SRB. Subjects were randomly selected from among potential dropouts in 14 high schools. Based upon suicide-risk status, 1,083 potential high school dropouts were defined as belonging to one of four groups; 573 non-suicide risk, 242 low suicide risk, 137 moderate suicide risk and 131 high suicide risk. Results showed significant group differences in all youth self-reported family risk and protective factors. Increased levels of suicide risk were associated with perceived conflict with parents, unmet family goals, and family depression; decreased levels of risk were associated with perceived parental involvement and family support for school. Perceived conflict with parents, family depression, family support satisfaction, and availability of family support for school were the strongest predictors of adolescent SRB. Our findings suggest that suicide vulnerable youth differ from their non-suicidal peers along the dimensions of family risk and protective factors.     

Assisted Suicide,Euthanasia, and Suicide Prevention: The Implications of the Dutch Experience

What impact would legalization of assisted suicide and euthanasia have on our ability to treat suicidal patients and to prevent suicide? Information from a study of the Dutch experience illustrates how legal sanction promotes a culture that transforms suicide into assisted suicide and euthanasia and encourages patients and doctors to see choosing death as a preferred way of dealing with serious or terminal illness. The extension of the right to euthanasia to those who are not physically ill further complicates the problem. So too does the tendency of doctors in such a culture to begin to feel that they can make decisions about ending the life of competent terminally ill patients without consulting the patient. “Normalizing” suicide as a medical option lays the groundwork for a society that turns euthanasia into a “cure” for suicidal depression.     

Risk Factors for Attempting Suicide in Heroin Addicts

In order to examine risk factors for attempting suicide in heroin dependent patients, a group of 527 abstinent opiate dependent patients had a psychiatric interview and completed the Childhood Trauma Questionnaire. Patients who had or had never attempted suicide were compared on putative suicide risk factors. It was found that 207 of the 527 heroin abusers (39.3%) had attempted suicide. Attempters were younger; more were female, reported childhood trauma, a family history of suicidal behavior, a history of aggression, treatment with antidepressant medication, and alcohol and cocaine dependence. Logistic regression revealed that a family history of suicidal behavior, alcohol dependence, cocaine dependence, and treatment with antidepressant medication were significant predictors of attempting suicide. These results suggest that attempting suicide is common among opiate dependent patients and that both distal and proximal risk factors may play a role.     

CSF 5-HIAA Predicts Suicide Risk After Attempted Suicide

Suicide risk after attempted suicide, as predicted by cerebrospinal fluid (CSF) monoamine metabolite concentrations, was studied in a sample of 92 psychiatric mood disorder inpatients admitted shortly after attempting suicide. The potential of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the CSF to predict suicide risk within the first year after attempted suicide was studied by means of survival analysis after median split sub-grouping. Eleven patients (12%) committed suicide within 1 year after attempted suicide. Eight of these belonged to the below-the-median (< 87 nM) CSF 5-HIAA subgroup, that is, the suicide risk was 17% as compared with 7% among those with above-the-median CSF 5-HIAA. The cumulative number of survived patient-months during the first year after attempted suicide was significantly lower in the low CSF 5-HIAA subgroup. It was concluded that low CSF 5-HIAA predicts short-range suicide risk after attempted suicide in mood disorder psychiatric inpatients. These findings lend further support to the serotonin hypothesis of suicide risk.     

A Preliminary Validation Study of Two Ultra‐Brief Measures of Suicide Risk: The Suicide and Perceived Burdensomeness Visual Analog Scales

The advent of rapid‐acting suicide‐focused interventions and longitudinal research designs employing high‐frequency, repeated measurement of suicide risk has resulted in a need to quantify suicide risk during very brief windows of time (e.g., minutes, hours, days). This has rapidly outpaced traditional methods for assessing suicide risk, which often focus on measuring indicators of suicide risk during much broader intervals of time (e.g., weeks to months). Valid and practical methods for rapidly assessing suicide risk during small time intervals are therefore needed. This study reports a preliminary examination of the Suicide Visual Analog Scale (S‐VAS) and the Perceived Burdensomeness Visual Analog Scale (PB‐VAS) in a clinical sample of suicidal adults. Results support the convergent validity, predictive validity, responsiveness, and clinical utility of both scales, suggesting the S‐VAS and PB‐VAS are valid methods for rapidly quantifying two dimensions of suicide risk.     

A School-Based Suicide Risk Assessment Protocol

Suicide remains the third leading cause of death among young people in the United States. Considering that youth who contemplate suicide generally exhibit warning signs before engaging in lethal self-harm, school-based mental health professionals can play a vital role in identifying students who are at risk for suicidal behavior. Nevertheless, the assessment of vulnerable children and adolescents is a challenging undertaking, with many variables considered relevant to the determination of a student's suicide risk level. This article introduces school-based mental health professionals to the Student Suicide Risk Assessment Protocol, an evaluation tool developed by the author to aid in the determination of student suicide potential, assist with the selection of appropriate interventions, and allow for documentation of school personnel's actions taken to mitigate a student's suicide risk.     

Is Veteran Status and Suicide Risk Assessed in Community Long‐Term Care? A Review of the States' Assessment Instruments

Given recent policy initiatives to address suicide risk among older persons and veterans, community‐based elder serving agencies may serve an important role in identifying and referring individuals at risk for suicide. A review of state‐level long‐term assessment instruments was conducted to determine whether veteran status and suicide are assessed. Data from forty‐three state's Units on Aging instruments were content analyzed. Results indicate that over two thirds of the states in this review included questions about suicide and veterans in their assessments, 69.8% and 67.4% respectively. Suicide risk among elders and veterans must be addressed at local, state, and federal levels so that concerted attention and oversight can be provided for matching elders to the services they need.     

Adolescents' Attitudes About the Role of Mental Illness in Suicide,and Their Association with Suicide Risk

We examined teenagers' attitudes about the role of mental illness in suicidal behavior and the relationship between these attitudes and suicide risk. Serious suicidal ideation or behavior and associated risk factors (gender, depression, substance problems, and first‐hand experience with a suicidal peer) were assessed in 2,419 students at six New York high schools. Less than one fifth of students thought that mental illness was a major contributor to suicide. Suicidal adolescents and those at risk were less likely than their nonsuicidal and low‐risk counterparts to associate suicide with mental illness. Our findings contribute to the debate over whether accepting attitudes toward suicide increase suicide risk.     

Stress,Coping, and Suicide Risk in Psychiatric Inpatients

The present study investigated the relationship between interpersonal problems, coping styles, and suicide risk. Seventy-one adult psychiatric inpatients completed a suicide risk scale, a measure of interpersonal problems, and a coping scale designed to measure eight coping styles. Patients admitted with a history of suicidal attempts were compared with patients admitted for other reasons. Interpersonal problems were found to be significantly and positively related to suicide risk. The coping style of “suppression” (tendency to avoid threatening or uncomfortable situations) was found to be significantly and positively related to suicide risk [F(2, 68) = 4.54, p < .01]. Several other coping styles were found to be significantly related to suicide risk. These findings are congruent with a “two-stage model of countervailing forces” and have both research and clinical implications.     

Temperamental Vulnerability and Suicide Risk After Attempted Suicide

The aim was to extend recent findings of suggested temperamental features in attempted suicide and to explore possible domains of vulnerability to suicide risk after attempted suicide. Fifty-four psychiatric inpatients hospitalized after a suicide attempt underwent lumbar puncture for analysis of CSF 5-HIAA concentration and also completed the Karolinska Scales of Personality (KSP) before discharge from the hospital. Suicide attempters scored high on Somatic Anxiety, Psychic Anxiety, and Muscular Tension, and low on Socialization, findings that support recent findings in suicide attempters followed up after an emergency room visit. Five patients committed early suicide, i.e., within 3 years, and the overall long-term suicide mortality after attempted suicide was 13%. There were significant correlations between survival time among early suicides and CSF 5-HIAA (r = .87;p = .054), and the following KSP scale t scores: Somatic Anxiety (r = ?.96;p < .05), Impulsivity (r = ?.88; p < .05), and Socialization (r = .90; p < .05). KSP Socialization showed correlations with CSF 5-HIAA (r = .89; p = .046) among the early suicides. Features of temperamental vulnerability to suicide risk after attempted suicide might involve anxiety proneness, impulsivity, low socialization, and low CSF 5-HIAA.     

Application of The APA Practice Guidelines on Suicide to Clinical Practice

This article presents charts from The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, part of the Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, and a summary of the assessment information in a format that can be used in routine clinical practice. Four steps in the assessment process are presented: the use of a thorough psychiatric examination to obtain information about the patient's current presentation, history, diagnosis, and to recognize suicide risk factors therein; the necessity of asking very specific questions about suicidal ideation, intent, plans, and attempts; the process of making an estimation of the patient's level of suicide risk is explained; and the use of modifiable risk and protective factors as the basis for treatment planning is demonstrated. Case reports are used to clarify use of each step in this process.