Despite advancements in mental health care accessibility and evidence-based treatments for various psychiatric disorders, suicide rates in the United States continue to rise. This concerning trend underscores the critical need for effective suicide risk assessment tools in psychiatric care and behavioral health settings. Currently, the absence of definitive biomarkers or laboratory tests necessitates a reliance on clinical evaluation, making suicide risk assessment a high-stakes and often challenging aspect of psychiatric practice. Effective triage and assessment are paramount to ensure appropriate intervention, avoiding both overly restrictive measures and inadequate responses to genuine risk. This article delves into suicide risk assessment as a crucial initial step in prevention, emphasizing the significance of tools like the Safe-t/c-ssrs Triage Tool For Psychiatric Care/behavioral Health in enhancing clinical practice. While research progresses towards precision treatments and comprehensive prevention strategies, optimizing our assessment methodologies remains a cornerstone of suicide prevention efforts. Suicide risk assessment, when approached with skill and empathy, provides a vital opportunity for therapeutic engagement, aiming to alleviate suffering and ultimately prevent suicide.
In 2017, suicide claimed the lives of over 47,000 Americans aged 10 and older, highlighting its position as a significant public health crisis. It stands as the second leading cause of death for individuals aged 15 to 34, and ranks alarmingly high for younger and older age groups as well. The age-adjusted suicide rate has surged by 33% since 1999, with a notable increase of 53% among women and 26% among men. Interestingly, the most substantial rise in suicide rates is observed in individuals over 45 years old. Several factors have been proposed to explain this increase, including a potential rise in mental illness prevalence and the impact of decreased interpersonal connection in the digital age. However, the complexity of suicide necessitates a thorough understanding of assessment and management strategies, recognizing that assessment is not prediction.
Predicting future behavior, especially suicide, with complete accuracy is inherently impossible. The medical standard of care emphasizes prudence and caution in patient management. While a standard of care exists for suicide risk assessment, there’s no definitive method to predict suicidal acts. Therefore, the purpose of assessment is to utilize available knowledge about the patient, risk factors, and warning signs to promote safety, minimize suicidal behavior risk, and enhance overall well-being. Despite the alarming increase in suicide rates, it remains statistically a low base rate event. Ongoing research into the neurobiology of suicide offers hope for improved understanding and differentiation between individuals who attempt suicide and those who do not.
Suicidal behavior is multifaceted, stemming from a complex interplay of factors rather than a single cause. These factors can be broadly categorized into distal and proximal influences. Distal factors, which are more background or predisposing factors, may include genetics, personality traits like impulsivity and aggression, prenatal conditions, childhood trauma, and neurobiological vulnerabilities. Proximal factors, which are more immediate triggers, can include mental illness, physical health issues, psychosocial crises, substance use, access to lethal means, and exposure to suicidal behavior. The stress-diathesis model posits that suicide arises from the interaction of environmental or internal stressors with pre-existing vulnerabilities. Proximal risk factors can act as triggers when combined with distal risk factors, thus elevating suicide risk.
Neurobiological Insights into Suicide Risk
Recognizing the heterogeneity of suicidal individuals is crucial for developing more precise assessment methods and effective treatments. Research into subgroups of suicidal individuals is shedding light on potential biological underpinnings. For instance, studies have examined the hypothalamic-pituitary-adrenal (HPA) axis, a critical component of the stress response system, and its potential link to impulsivity and aggression in suicidal individuals. While studies measuring cortisol levels, an indicator of HPA axis function, have yielded mixed results, subgroup analysis reveals interesting patterns. Specifically, suicide attempters with high aggression and impulsivity exhibit a more pronounced cortisol response, supporting the idea of a stress-responsive subtype of suicidal behavior. This suggests that treatment approaches may need to be tailored based on these specific neurobiological and behavioral profiles.
Reviews of biological predictors of suicide have identified promising biomarker categories, including indicators of serotonergic function, inflammation, neuronal plasticity, and lipid metabolism. The serotonergic system, crucial for mood regulation, has long been implicated in suicidal predisposition. Studies have shown that reduced serotonin release, indicated by higher serotonin-1A autoreceptor binding, is associated with more severe suicidal ideation and attempts in depressed patients. Abnormalities in serotonergic function and altered stress responses consistently emerge as compelling biological markers for suicide risk.
Emerging research highlights the potential role of metabotropic glutamate receptor type 5 (mGluR5) and lipids in suicidality. Increased mGluR5 levels have been observed in suicidal individuals with posttraumatic stress disorder, suggesting it as a potential biomarker and therapeutic target. Dyslipidemia, or abnormal lipid levels, is also under investigation. While the exact mechanism is unclear, it may involve increased proinflammatory cytokines, which have been linked to suicidal behavior and potentially interact with the HPA axis and serotonin pathways. Elevated C-reactive protein (CRP) levels, indicative of acute inflammation, have also been associated with increased suicide risk, further supporting the role of inflammation in suicidal behavior. However, CRP fluctuations might limit its practicality as a consistent biomarker.
Genetics also plays a significant role in suicidal behavior. Twin studies and genetic research have demonstrated a heritable component. However, the genetic basis is complex and polygenic, involving multiple genes each contributing a small amount to overall risk. Identifying specific genes and genetic variations associated with suicide vulnerability, such as variations in APH1B, AGBL2, SP110, and SUCLA2, is an ongoing area of research. Deciphering the genetic underpinnings of suicide is hoped to lead to more effective risk identification and intervention strategies, though ethical considerations around genetic research in this area need careful attention.
Screening for Suicide Risk: Implementing Tools like SAFE-T and C-SSRS
The array of available instruments for identifying suicidal individuals can be overwhelming. Suicide screening involves using standardized tools to identify individuals who may be at risk. Screening can be universal, applied to everyone in a specific setting, or targeted to specific populations. Universal screening examples include the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE)–Patient Safety Screener administered in hospital emergency departments (EDs). Studies on universal screening in EDs, combined with brief interventions (secondary screening, discharge resources, and follow-up calls), have shown a reduction in post-ED suicidal behavior. These interventions, while having associated costs, have demonstrated effectiveness in suicide prevention compared to treatment as usual alone. Key components of these interventions include safety planning, mental health resource provision, and suicide hotline information. Safety planning itself has proven valuable in reducing suicidal behavior and improving treatment engagement in various clinical settings.
The Joint Commission (TJC) mandates the implementation of National Patient Safety Goal 15.01.01, emphasizing suicide risk reduction in accredited psychiatric and general hospitals. This includes screening all individuals evaluated for mental health concerns for suicidal ideation using validated tools and performing evidence-based suicide risk assessments for those screening positive. While TJC doesn’t specify a single tool, it mentions the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) Pocket Card and the Columbia–Suicide Severity Rating Scale (C-SSRS) as examples of evidence-based assessment tools to be used alongside clinical evaluation. The SAFE-T/C-SSRS triage tool for psychiatric care/behavioral health thus gains significant importance in meeting these standards. TJC also requires risk stratification (high, medium, low), although the evidence supporting this specific stratification is limited.
The SAFE-T tool, based on American Psychiatric Association guidelines, is designed for specialists and requires clinical judgment to interpret the information. It moves beyond single risk factors by considering life events, ideation patterns, and motivations, while also balancing risk with protective factors. The C-SSRS, SAFE-T Pocket Card, and ED-SAFE screening tools are freely available resources. It’s important to acknowledge that screening tools have inherent limitations. They aim to balance sensitivity (correctly identifying those at risk) and specificity (avoiding false positives). Positive predictive value, the proportion of those identified as high-risk who actually engage in suicidal behavior, is also crucial. While numerous screening and assessment tools exist, a systematic review indicates that no single instrument has demonstrated sufficient accuracy to predict suicide with high sensitivity and specificity. Therefore, structured and consistent evaluation of risk and protective factors, whether using specific instruments or not, remains vital for effective risk management. Clinical judgment remains paramount, even when utilizing tools like the SAFE-T/C-SSRS triage tool for psychiatric care/behavioral health.
Clinical Assessment: The Role of the Psychiatrist and Tools like SAFE-T/C-SSRS
In the absence of reliable biomarkers, the clinical evaluation of suicidal patients rests heavily on the expertise of the psychiatrist. This involves integrating clinical judgment with knowledge of validated risk and protective factors. As noted by Shea, assessing suicidality demands “gentle sensitivity and tenacious persistence.” Suicide risk assessment is integral to the broader psychiatric evaluation, given the strong link between mental illness and suicide risk. Disposition decisions (inpatient vs. outpatient) can be complex, particularly when patient autonomy conflicts with safety concerns.
BOX 1. Suicidal risk assessment in the context of the psychiatric evaluation
Establish Chief Complaint and Fully Explore the Presence of Disorders With Special Attention to Those Associated With Suicide
- Mood disorders, anxiety disorders, psychotic features and disorders, substance use disorders, personality disorders
- Self-injury (explore intent)
Explore Psychiatric History
- Psychiatric diagnoses, previous episodes of illness
- Psychiatric hospitalizations and outcome
- Prior treatment (medications, psychotherapies, electroconvulsive therapy, etc.)
- Substance use (current, past, and treatment)
- Trauma history
Suicide Risk—Use Earlier Information as a Segue Into Questioning About Suicidal Ideation
- Explore the continuum of suicidal thinking from passive death wishes to suicide attempts.
- Previous suicide attempts, interrupted and aborted attempts, self-injurious behavior (obtain details to understand lethal intent and current ideation/attempts)
Family History
- Family history of mental illness and substance use
- Family history of suicidal behavior and death by suicide
Psychosocial Stressors and Supports
- Family relationships and quality
- Social supports outside family
- Religious and cultural beliefs about suicide
- Loss of employment, legal/financial problems
- Stressors causing humiliation
- Recent significant losses
Potential Protective Factors
- Reasons for living (family, pets, beliefs)
- Past coping with stress
Systematic suicide risk assessment should identify acute and chronic, modifiable, and treatable risk factors, and weigh them against protective factors to guide management. While risk factors are informative, they have limitations. For example, a history of suicide attempt is a risk factor, but many suicides occur on the first attempt. These first attempts are often associated with specific demographics (male, older, African American) and methods, and may occur outside of known mental health issues. This highlights the challenge in identifying all individuals at risk. However, the rising suicide rate necessitates improved identification and management strategies, rather than resignation. Risk factors are statistically more prevalent in suicide deaths, and warning signs can further indicate immediate risk, often overlapping with risk factors.
BOX 2. Risk factors for suicide
Previous suicide attempt
Family history of suicidal behavior, especially death by suicide
Mental illness, especially mood disorder or schizophrenia
Impulsivity
Agitation
Anxiety disorder
Traumatic brain injury
Recent major stressor or crisis
Abuse trauma history, especially childhood
Male and over age 60 (though female rates are rising)
Alcohol or opioid use/misuse
ADHD with comorbidities
Chronic pain
Access to lethal means
Self-injurious behavior
LGBT identity
BOX 3. Warning signs for suicide
Suicidal thoughts or plans
Talking/writing about suicide
Increased substance use
Clinical depression
Anxiety (with mood disorder)
Hopelessness
Agitation
Withdrawal
Psychotic thinking
Feeling trapped/desperate
Feeling like a burden
No purpose in living
Impulsive/reckless behavior
Rage/anger
Mood changes
Insomnia
Standardized instruments can augment clinical assessment by eliciting specific information about suicidal thinking, planning, and intent. The C-SSRS, for example, has demonstrated clinical utility in assessing suicidal ideation and behavior across various settings and populations. It assesses current and past suicidal behaviors and has shown sensitivity and specificity. Other tools, like the Scale for Suicide Ideation, can also be valuable for repeated assessments. However, the superiority of one tool over another is debated. Reviews suggest that many instruments lack sufficient diagnostic accuracy alone. Therefore, instruments like the SAFE-T/C-SSRS triage tool for psychiatric care/behavioral health should be used as adjuncts to, not replacements for, thorough clinical evaluation.
The Patient Health Questionnaire (PHQ-9), commonly used for depression screening, includes an item (item 9) about suicidal thoughts. While response to item 9 can identify increased risk, it has a high false-negative rate. Studies show it can predict suicide attempts, but many attempts occur in those who deny suicidal thoughts on item 9. Therefore, item 9 alone is insufficient for suicide risk assessment and should be paired with validated tools and clinical assessment. There are no rigid rules for using these instruments, but a consistent, process-oriented framework integrating risk and protective factors, potentially incorporating tools like SAFE-T/C-SSRS, is recommended to aid risk management. Ultimately, diagnostic proficiency and empathic interviewing remain essential for eliciting crucial information and enhancing the data from screening tools.
Assessing patient credibility and overall clinical impression, including nonverbal cues, are critical aspects of suicide assessment. While some psychiatrists worry about relying on “clinical impression,” diagnostic expertise and awareness of risk/warning signs (guided clinical assessment), combined with experience-based judgment, remain central to effective suicide risk assessment.
Obtaining collateral information from family and friends is also crucial, especially in ED or crisis situations. HIPAA privacy rules allow disclosure when there’s a serious and imminent threat and family can mitigate it. Contacting family can be vital in complex cases to inform disposition decisions (hospitalization vs. outpatient care). HIPAA does not prevent clinicians from listening to family information and incorporating it into decision-making. In situations of acute risk and patient refusal to provide collateral contacts, erring on the side of caution and hospitalization is prudent.
Clinicians may feel overwhelmed by the volume and sometimes conflicting information on suicide assessment. For example, CDC data suggests over half of suicide deaths occur in individuals without known mental health conditions, while psychological autopsy studies indicate a much higher rate of underlying mental illness. Joiner et al.’s review of community suicides found evidence of diagnosable mental disorder or significant subclinical symptoms in all decedents, regardless of prior diagnosis.
Research on protective factors is less extensive and findings are sometimes ambiguous. Religious belief, for instance, is often cited as protective, but research suggests religious service attendance may protect against attempts more than ideation. The individual’s interpretation of protective factors is crucial, as their meaning and impact can vary. Reasons for living, mental health care, and social connectedness are potential protective factors, but their significance is dynamic and individual-specific.
Suicide Prevention Strategies: From Treatment to Means Restriction and Safety Planning
Given suicide’s relatively low base rate, prevention studies often require large sample sizes. A comprehensive analysis suggests that restricting lethal means and providing effective depression treatments have the strongest evidence for suicide prevention, but no single strategy is definitively superior.
The zero-suicide model, a core component of the National Strategy for Suicide Prevention, posits that suicide is preventable in healthcare settings. It’s an aspirational goal, not a guarantee of zero suicides. Seven key elements for health systems include: system-wide culture change, workforce training, evidence-based risk identification (including tools like SAFE-T/C-SSRS triage tool for psychiatric care/behavioral health), risk management and safety planning, evidence-based treatments, care transitions, and continuous policy improvement. However, given current knowledge gaps, a more realistic “envision zero suicide” stance may be more appropriate. Postvention resources for survivors and clinicians, alongside ongoing research, are also crucial.
Treating Comorbid Psychiatric Disorders
Effective treatment of mental illness, a major suicide risk factor, is critical for prevention. Accurate diagnosis is essential for guiding appropriate treatment. Pharmacological treatment plays a significant role. While antidepressants have been linked to a slight increase in suicidal ideation in youths, the benefits outweigh the risks for most. Pharmacoepidemiologic studies show a correlation between antidepressant use and lower suicide rates. However, clinicians should educate young patients and families about potential agitation-related side effects.
Lithium and clozapine have demonstrated antisuicidal effects in specific populations (mood disorders and schizophrenia, respectively), though more research is needed. Electroconvulsive therapy and ketamine show promise for rapid reduction of suicidal ideation, especially in treatment-resistant depression. However, concerns exist regarding ketamine’s abuse potential.
Suicide-Specific Treatments and Means Restriction
Despite various suicide-specific treatments, suicide rates continue to rise. Psychosocial treatments like safety planning intervention (SPI), dialectical behavior therapy (DBT), brief cognitive-behavioral therapy (CBT), and the Collaborative Assessment of Management of Suicidality (CAMS) show promise but haven’t yet yielded sustained improvements in overall suicide rates. School-based awareness programs and physician education are also important strategies.
Restricting access to lethal means is a proven suicide prevention strategy. Firearms, despite being used in a minority of attempts, account for half of US suicides due to their lethality. While gun control legislation’s impact is debated, studies suggest that specific laws related to handgun ownership are associated with attenuated suicide rate increases. Restricting access to firearms and other lethal means in at-risk individuals is crucial.
Suicide rates are disproportionately high in rural areas, necessitating targeted interventions. Rural areas often have less mental health access and may be more susceptible to social deprivation factors. Strategies should consider these unique challenges.
Restricting access to other lethal means, such as jumping sites, pesticides, and toxic medications, has also proven effective in reducing suicides. Examples include barriers on bridges and changes in medication packaging. Safety planning, particularly the SPI model, is a best practice for suicide prevention, providing individuals with coping strategies and support resources. However, safety plans must be individualized and thoughtfully implemented, not used as a rote exercise.
On the Horizon: Future Directions in Suicide Prevention
Despite increased attention, suicide rates remain a concern, highlighting the need for improved identification and risk mitigation strategies. Focusing solely on mental illness may limit our understanding, as a significant minority of suicides occur without known psychiatric disorders.
Suicide-specific diagnoses, such as suicide crisis syndrome (SCS) and suicide behavior disorder, have been proposed to enhance research and clinical care. SCS focuses on the acute mental state preceding attempts, characterized by hopelessness, entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. Biological underpinnings of SCS are also being explored. Suicide behavior disorder aims to improve continuity of care for at-risk individuals and facilitate research using large databases.
Machine learning and smartphone technology offer promising avenues for suicide prediction and prevention. Machine learning can analyze vast datasets to identify complex risk patterns. Smartphone apps and sensors may also play a future role, but these areas are still in early stages of development.
Conclusions: The Art and Science of Suicide Prevention
Suicide prevention demands a multifaceted approach, combining scientific advancements with compassionate clinical practice. While neurobiological research continues to advance, clinically practical biomarkers remain elusive. Therefore, current strategies emphasize universal prevention efforts (means restriction, media influence) alongside expert psychiatric evaluation and risk assessment, including the use of tools like the SAFE-T/C-SSRS triage tool for psychiatric care/behavioral health.
Psychiatric evaluation and suicide risk assessment remain both an art and a science. Empathic interviewing, diagnostic expertise, and awareness of risk factors, combined with tools like SAFE-T/C-SSRS, are paramount for identifying and managing suicidal patients. The ultimate goal remains alleviating suffering and preventing the tragic loss of life to suicide.
Footnotes
Dr. Ryan receives royalties from Oxford University Press and honoraria from the American Physicians Institute and Northwestern University (Grand Rounds). Dr. Oquendo receives royalties for the commercial use of the Columbia Suicide Severity Rating Scale and owns shares in Mantra, Inc. Her family owns stock in Bristol-Myers Squibb.
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