Assessment of suicide risk

Suicide risk assessment is a process of estimating the likelihood for a person to attempt or die by suicide. The goal of a thorough risk assessment is to learn about the circumstances of an individual person with regard to suicide, including warning signs, risk factors, and protective factors. Risk for suicide is re evaluated throughout the course of care to assess the patient's response to personal situational changes and clinical interventions. Accurate and defensible risk assessment requires a clinician to integrate a clinical judgment with the latest evidence based practice, although accurate prediction of low base rate events, such as suicide, is inherently difficult and prone to false positives. The assessment process is ethically complex: the concept of "imminent suicide" (implying the foreseeability of an inherently unpredictable act) is a legal construct in a clinical guise, which can be used to justify the rationing of emergency psychiatric resources or intrusion into patients' civil liberties. Some experts recommend abandoning suicide risk assessment as it is so inaccurate. In addition suicide risk assessment is often conflated with assessment of self harm which has little overlap with suicide. Instead, it is suggested that the emotional state which has caused the suicidal thoughts, feelings or behaviour should be the focus of assessment with a view to helping the patient rather than reducing the anxiety of clinician who overestimates the risk of suicide and are fearful of litigation. Given the difficulty of suicide prediction, researchers have attempted to improve the state of the art in both suicide and suicidal behavior prediction using natural language processing and machine learning applied to electronic health records.

There are risks and disadvantages to both over estimation and under estimation of suicide risk. Over sensitivity to risk can have undesirable consequences, including inappropriate deprivation of patients' rights and squandering of scarce clinical resources. On the other hand, underestimating suicidality as a result of a dismissive attitude or lack of clinical skill jeopardizes patient safety and risks clinician liability. Some people may worry that asking about suicidal intentions will make suicide more likely. In reality, regarding that the enquiries are made sympathetically, it does not. Key areas to be assessed include the person's predisposition to suicidal behavior; identifiable precipitant or stressors such as job loss, recent death of a loved one and change of residence; the patient's symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behavior; impulsivity and self control; and protective factors. Suicide risk assessment should distinguish between acute and chronic risk. Acute risk might be raised because of recent changes in the person's circumstances or mental state, while chronic risk is determined by a diagnosis of a mental illness, and social and demographic factors. Bryan and Rudd (2006) suggest a model in which risk is categorized into one of four categories: Baseline, Acute, Chronic high risk, and Chronic high risk with acute exacerbation. The Modified Scale for Suicide Ideation (MSSI) was developed by Miller et al., using 13 items from the SSI and 5 new items. The modifications increased both reliability and validity. The scale was also changed to range from 0 to 3, yielding a total score ranging from 0 to 54. Joiner found two factors, Suicidal Desire and Ideation, and Resolved Plans and Preparation. The MSSI was also shown to have higher discrimination between groups of suicide ideators and attempters than the BDI, BHS, PSI, and SPS.

The Suicide Intent Scale (SIS) was developed in order to assess the severity of suicide attempts. The scale consists of 15 questions which are scaled from 0–2, which take into account both the logistics of the suicide attempt as well as the intent. The scale has high reliability and validity. Suicide ranked higher in the severity of the logistics than attempted suicides (it was impossible to measure intent for suicide), and those with multiple attempts had higher scores than those who only attempted suicide once.

The Suicidal Affect Behavior Cognition Scale (SABCS) is a six item self report measure based on both suicide and psychological theory, developed to assess current suicidality for clinical, screening, and research purposes. Substantial empirical evidence was found, from four independent studies, confirming the importance of assessing suicidal affect, behaviors, and cognition as a single suicidal construct. The SABCS was the first suicide risk measure to be developed through both classical test theory (CTT) and item response theory (IRT) psychometric approaches and to show significant improvements over a highly endorsed comparison measure. The SABCS was shown to have higher internal reliability, and to be a better predictor of both future suicidal behaviors and total suicidality over an existing standard.

The Suicide Behaviors Questionnaire (SBQ) is a self report measure developed by Linehan in 1981. In 1988 it was transformed from a long questionnaire to a short four questions that can be completed in about 5 minutes. Answers are on a Likert scale that ranges in size for each question, based on data from the original questionnaire. It is designed for adults and results tend to correlate with other measures, such as the SSI. It is popular because it is easy to use as a screening tool, but at only four questions, fails to provide detailed information.

The Life Orientation Inventory (LOI) is a self report measure that comes in both a 30 question and 110 question form. Both forms use a 4 point Likert scale to answer items, which are divided into six sub scales on the longer form: self esteem vulnerability, over investment, overdetermined misery, affective domination, alienation, and suicide tenability. This scale has strong reliability and validity, and has been shown to be able to differentiate between control, depressed, possibly suicidal, and highly suicidal individuals. It also contains 3 validity indices, similar to the MMPI. However, while useful, this inventory is now out of print.

The Nurses Global Assessment of Suicide Risk (NGASR) was developed by Cutcliffe and Barker in 2004 to help novice practitioners with assessment of suicide risk, beyond the option of the current lengthy checklists currently available. It is based on 15 items, with some such as "Evidence of a plan to commit suicide" given a weighting of 3, while others, such as "History of psychosis" are weighted with a 1, giving a maximum total score of 25. Scores of 5 or less are considered low level of risk, 6 8 are intermediate level of risk, 9 11 are high level of risk, and 12 or more are very high level of risk. Each item is supported theoretically by studies that have shown a connection between the item and suicide. However, the validity and reliability of the test as a whole have not yet been empirically tested.

Within the United States, the suicide rate is 11.3 suicides per 100,000 people within the general population.

In the United States, the peak age for suicide is early adulthood, with a smaller peak of incidence in the elderly. On the other hand, there is no second peak in suicide in black men or women, and a much more muted and earlier peaking rise in suicide amongst non Hispanic women than their male counterparts. In the United States, suicide is around 4.5 times more common in men than in women. U. S. men are 5 times as likely to die from suicide within the 15 to 19 year old demographic, and 6 times as likely as women to die from suicide within the 20 to 24 year old demographic.

In the United States white persons and Native Americans have the highest suicide rates, Black persons have intermediate rates, and Hispanic persons have the lowest rates of suicide. However, Native American males in the 15 24 age group have a dramatically higher suicide rate than any other group. A link may be identified between depression and stress, and suicide.

There is evidence of elevated risk of suicide among non heterosexual individuals (e. g. homosexual or bisexual individuals),

The literature on this subject consistently shows that a family history of suicide in first degree relatives, adverse childhood experiences (parental loss and emotional, physical and sexual abuse), and adverse life situations (unemployment, isolation and acute psychosocial stressors) are associated with suicide risk. Recent life events can act as precipitants. Significant interpersonal loss and family instability, such as bereavement, poor relationship with family, domestic partner violence, separation, and divorce have all been identified as risk factors. Financial stress, unemployment, and a drop in socioeconomic status can also be triggers for a suicidal crisis. This is also the case for a range of acute and chronic health problems, such as pain syndromes, or diagnoses of conditions like HIV or cancer. Research domain criteria symptom burdens, particularly the positive and negative valence domains, are associated with time varying risk of suicide. Specific psychotic symptoms, such as grandiose delusions, delusions of thought insertion and mind reading are thought to indicate a higher likelihood of suicidal behavior. Another psychiatric illness that is a high risk of suicide is schizophrenia. The risk is particularly higher in younger patients who have insight into the serious effect the illness is likely to have on their lives.

All major mental disorders carry an increased risk of suicide. However, 90% of suicides can be traced to depression, linked either to manic depression (bipolar), major depression (unipolar), schizophrenia or personality disorders, particularly borderline personality disorder. Comorbity of mental disorders increases suicide risk, especially anxiety or panic attacks. Risk factors for suicide among people with schizophrenia include a history of previous suicide attempts, the degree of illness severity, comorbid depression or post psychotic depression, social isolation, and male gender. The risk is higher for the paranoid subtype of schizophrenia, and is highest in the time immediately after discharge from hospital. Antidepressants have been linked with suicide as Healy (2009) stated that people on antidepressant have the tendency to die from suicide after 10–14 days of commencement of antidepressant. People with a diagnosis of a personality disorder, particularly borderline, antisocial or narcissistic personality disorders, are at a high risk of suicide. In this group, elevated suicide risk is associated with younger age, comorbid drug addiction and major mood disorders, a history of childhood sexual abuse, impulsive and antisocial personality traits, and recent reduction of psychiatric care, such as recent discharge from hospital. While some people with personality disorders may make manipulative or contingent suicide threats, the threat is likely to be non contingent when the person is silent, passive, withdrawn, hopeless, and making few demands. A history of excessive alcohol use is common among people who die from suicide, and alcohol intoxication at the time of the suicide attempt is a common pattern.