Estimating the risk of suicide

Health professionals play an important part in suicide prevention through their role in assessing people at risk. A suicidal client can be challenging for health professionals, particularly if they do not regularly deal with such cases. This information should not replace specialised training, but may be a helpful resource for professionals dealing with suicidal clients. 

When a person is suicidal, their management first requires an assessment of risk, followed by appropriate intervention to minimise any risk. The risk assessment needs to consider both the factors that increase the risk of suicide as well as those that mitigate the risk. These risk and protective factors should also be considered in any management decisions.

Recognising suicide risk

Sometimes a client may openly express suicidal ideation, but often the cues may be more subtle. They may speak about feeling hopeless, depressed, having trouble sleeping, or perhaps ask for a medication change. It is important that health professionals look out for risk factors or cues, and are ready to question the patient about suicidal intent. 

 

Suicide risk factors:

  • Previous suicide attempt/s
  • Lack of social or professional support
  • Co-existing mental illness
  • Increasing substance abuse
  • Male gender (three times more likely than females)
  • Expressing feelings of hopelessness

 

The risk assessment

Comprehensive, systematic risk assessment is a logical, structured clinical judgement.

 

Tips:

  • Understand the concept of risk and the factors associated with increased risk
  • Establish rapport with the individual
  • Conduct and document a thorough risk assessment
  • Establish and record level of risk using clear, commonly understood categories/definitions (e.g. non-existent, mild, moderate, high and imminent)
  • Acknowledge the need for ongoing monitoring of suicide risk, which may fluctuate under changed circumstances

Thorough suicide risk assessments should explore the following domains

1

Suicidal thoughts

  • Does the client have suicidal thoughts?
  • When did these begin?
  • How persistent are they?
  • Is the client able to control the thoughts?
  • What is stopping the client from acting on the thoughts?

3

Access to means

  • Does the client have access to the means (e.g. weapons, medication) to carry out their plan?
  • How lethal is the method?
  • Does the client have an occupation that may mean they have access to lethal means (e.g., police officer, health worker)

2

Presence of a suicide plan

  • Does the client have a plan?
  • Have they specified a method or place?
  • How often is the client thinking about their plan?

Note: Plans or preparations for suicide (like putting affairs in order, saying goodbyes) indicate serious suicidal intent.

4

Previous suicidal behaviour 

  • Has the client had suicidal feelings before?
  • Do they have a history of self-harm?
  • What were the details/circumstances of previous attempts?
  • Are there similarities in the current situation?

It can be challenging to communicate with a client who is in distress, but it is important to be persistent. Gathering the above information will allow you to estimate the risk of suicide and decide on a management plan. 

Suggestions for communicating with suicidal clients:

  • Build client-practitioner rapport (e.g. by using open body language, maintaining eye contact)
  • Aim to be calm and patient. Use empathy and avoid judgement.
  • Use supportive statements and ask open-ended questions (e.g.'It sounds like you are having a really difficult time at the moment. Some of my patients who have been through similar things have told me they'd thought about ending their life. I wonder if you've ever had similar thoughts?')

Risk Assessment Questions

One accepted method of risk assessment is to work through a hierarchy of screening questions that gently lead to directly asking about suicidal thoughts, feelings, plans or behaviour. These may include: 

'Are you feeling hopeless about the present or future?'
'Have you ever thought that you'd rather not be here?'
'Have you ever thought about hurting yourself?'
'Have you made any plans to take your life?'

Protective factors for suicide

A comprehensive assessment and management plan for suicide risk should also consider the recognition and promotion of protective factors to reduce the client's risk of suicide. These may include: 

Personal

  • Adaptive coping skills
  • Effective problem solving skills
  • Self-understanding
  • Sense of competence
  • Spirituality

Work

  • Supportive work environment
  • Positive relationships with colleagues
  • Professional development opportunities
  • Access to employee assistance programs

Family

  • Relationship to family
  • Sense of responsibility

Community

  • Involvement and opportunities to participate
  • Affordable, accessible supportive services

Suicide risk management

The next step is to decide, in consultation with the client, on how to manage the risk of suicide and maintain safety. This may include referrals to other health professionals or services, contacting the client's family or support network, or the development of a safety contract. For more information about the support options for clients at risk of suicide, refer to Assessing support for clients at risk.

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