Assessing suicide risk

Suicide is a significant cause of death in Australia. It is the leading cause of death in people aged 15 to 44 years, and the third leading cause of death for people aged 45 to 55 years. Suicide is more common in males than females (75% of suicide deaths are in males), in minority groups, and in individuals with poor socioeconomic status (eg unemployed, homeless, economic insecurity).

Self-harm is a risk factor for suicide, but many patients who self-harm do not report having an intention to die. The management of patients who deliberately self-harm is beyond the scope of these guidelines.

Assessing suicide risk is a standard and crucial component of psychiatric assessments and mental health plans, but it is inherently difficult to reliably predict an individual’s risk of suicide. For examples of risk factors associated with suicide, see Risk factors associated with suicide—this is not an exhaustive list of risk factors or a ‘check list’ for assessing suicide risk. Use the risk factors for suicide as a prompt to inform discussions with the patient.

Risk factors for suicide can be:

static—fixed or historic (eg history of self-harm or psychiatric disorder, gender, minority groups, family history of suicide)
dynamic—can fluctuate in duration and intensity (eg psychosocial stress, suicidal thoughts, active psychological symptoms, feelings of hopelessness).

While it is very difficult to predict an individual’s behaviour, the presence of static and dynamic risk factors is associated with suicide or severe self-harm and should raise concern and instigate referral to an acute psychiatric service or acute mental health team. However, the number of risk factors present does not correlate to the level of risk. Evidence suggests it is a change in dynamic risk factors that exposes an individual to imminent risk of suicide (eg a change in dynamic factors in a psychiatric patient with recurrent suicidal thoughts, who has a combination of static risk factors).

Obtain a thorough history from the patient, and where relevant consult with their family, carers or significant others. Key questions to assess suicide risk outlines key questions to ask when assessing suicide risk.

It is important to differentiate patients who are suicidal from patients who have suicidal thoughts—although many patients have thoughts about ending their life, only some patients have an intent to die. There are a range of factors that indicate these thoughts go further than a passing idea of death providing relief from their current suffering, to an actual risk that they may act on these thoughts (eg they have current intent, a specific plan, access to means or have had previous suicide attempts).

Table 1. Risk factors associated with suicide
[NB1]
Risk factors	Static [NB2]	Dynamic [NB2]
individual	male gender (75% of suicide deaths are in males)	poor coping skills poor communication skills
psychiatric	previous suicide attempt—particularly in older adults history of self-harm psychiatric disorder—especially major depression, bipolar disorder, schizophrenia, schizoaffective disorder, substance use disorder, personality disorder history of dangerous behaviour on impulse	current intent definite plan for suicide attempt current psychosis or at risk of psychosis recent discharge from psychiatric admission or emergency department ambivalence towards survival of a suicide attempt
medical	chronic pain or severe illness immobility history of alcohol or other drug problems	alcohol or other drug problems
emotional	history of low self-esteem	low self-esteem little sense of control over life circumstances lack of meaning and purpose in life feeling of hopelessness guilt and shame
family	history of abuse and violence history of family dispute, conflict and dysfunction family history of suicide separation and loss homelessness	abuse and violence active family dispute, conflict and dysfunction exposure to major life stressors (eg grief, homelessness) low likelihood of suicide attempt being detected
socioeconomic	history of peer rejection social isolation/absence of social supports imprisonment social or cultural discrimination (eg minority ethnic group, diverse sexual orientation) neighbourhood violence and crime poverty unemployment lack of support services	peer rejection social isolation/absence of social supports recent release from prison ready access to means of suicide with high potential lethality (eg drugs, firearms, ropes, hosepipes) economic insecurity school failure
Note: NB1: This is not an exhaustive list or ‘check list’ for suicidal risk—the number of risk factors present does not correlate to the level of risk of suicide. The prevalence of risk factors for suicide is high relative to the incidence of suicide. Risk factors for suicide can be used as a prompt to consider discussing with the patient. Early consultation or referral to an acute psychiatric service or acute mental health team is indicated if there is a significant risk of suicide. If the risk of suicide is extremely high, consider involuntary treatment in accordance with the relevant mental health legislation—see the Royal Australian and New Zealand College of Psychiatrists website. NB2: Risks factors can be static (ie fixed or historic) or dynamic (ie can fluctuate in duration and intensity).

Figure 1. Key questions to assess suicide risk

Questions to ask when assessing suicide risk

When people feel like you are/have been feeling, they sometimes think that life is not worth living—have you been thinking like that or have you ever thought like that?
Have you been thinking of harming yourself?
Are you thinking of suicide?
If yes, how often are you having these thoughts?
Have you thought about how you would act on these (is there a plan)? Do you have easy access to a weapon? (Consider whether the plan seems feasible, the methods are available and whether it is likely to be lethal.)
Do you think you would or could act on this plan?
Have you thought about when you might act on this plan?
Are there any things/reasons that stop you from acting on these thoughts?
Have you tried to harm yourself in the past?
If yes, how many times?
When was the most recent time?
Do you know anyone who has recently tried to harm themselves?
Do you feel safe at the moment?

If a suicide attempt has been made

What did you hope would happen as a result of your attempt? (Distinguish whether the intent was to die or to end their pain.)
Do you regret that the attempt was not successful?
Do you still have access to the method used?
Did you use alcohol or drugs before the attempt? What did you use?