On assessment of acute suicide risk, the following factors were considered:
Nature of suicidal ideation:[checkbox name="variable_30" value=" current suicidal ideation|current plan for suicide|current suicidal plan with high lethality|current suicidal intent|access to firearms or other lethal means|persistent suicidal ideation or thoughts|command hallucinations to hurt self|not able to control impulses|recent suicide attempt|recent suicide preparatory behaviors or communication|recent interrupted/aborted suicide attempt|suicidal fantasies|evidence of suicidal behavior/warning signs in the context of denial of ideation (e.g.contemplation of plan with denial of thoughts or ideation| "].
Associated signs/symptoms:[checkbox name="variable_15" value=" hopelessness|psychic pain related to grief/loss|sense of isolation or alienation (being alone and misunderstood| severe or unremitting anxiety|panic attacks|feelings of shame or humiliation|psychological turmoil|decreased self-esteem|negative ruminations, self-pity| inactivity and social withdrawal|dysphoria|sleep problems|fatigue|loss of appetite|somatic symptoms|extreme narcissistic vulnerability|subjective impulsivity or report of feeling out of control|objective evidence of impulsive/risky behavior|outwardly directed aggression (verbal, threatening, destruction of property, etc)|auto-aggression (e.g.non-suicidal aggression towards self- cutting/scratching/burning skin, pulls hair out, hitting self, hitting walls, throwing self onto floor, etc)|violence against others|agitation|loss of executive function|thought constriction (tunnel vision)|polarized thinking|closed-mindedness| active psychosis|currently meets criteria for depressive or mixed episode|currently meets criteria for alcohol use d/o|currently meets criteria for substance use d/o|current substance intoxication (in the absence of a formal substance use disorder diagnosis)|current substance withdrawal (alcohol, opiates, cocaine, amphetamines)| "].
Factors associated with increased risk include: [checkbox name="variable_99" value=" past history of suicidal ideation/plan|past history of suicide attempt (including aborted or interrupted attempts)|past history of suicidal plan or attempt with high lethality or high suicidal intent|Major depressive disorder dx|Bipolar disorder dx, (greater risk with depressive or mixed episodes)|Schizophrenia dx|Eating disorder dx|Cluster B personality disorder dx or traits (particularly borderline personality disorder)|comorbid psychiatric and/or personality disorders| NONE"].
Factors associated with increased risk include: [checkbox name="variable_11" value=" Neurological disease|Multiple sclerosis|Huntington’s disease|Brain injury|Spinal cord injury|Seizure disorder|Malignant neoplasms|HIV/AIDS|Peptic ulcer disease|Chronic obstructive pulmonary disease, especially in men|Chronic hemodialysis-treated renal failure|Systemic lupus erythematosus|hx of Traumatic Brain Injury (TBI)|terminal disease|new diagnosis of major illness|worsening of chronic illness|use of prescribed medication w/ warning for increased risk of suicide| chronic, severe headache pain|NONE|pain syndrome"].
Factors associated with increased risk include:[checkbox name="variable_12" value=" (+) history of suicide (particularly in first-degree relatives)|(+)history of mental illness|(+)history of substance use disorders|NONE|INDETERMINATE|"].
Factors associated with increased risk include:[checkbox name="variable_13" value="male gender|widowed/divorced/single marital status (particularly for men)| elderly age group (age group with greatest proportionate risk for suicide)| adolescent and young adult age groups (age groups with highest numbers of suicides)|higher risk ethnic or racial group (highest among American Indian, Alaska Native, and white populations|identifying as a sexual minority (referring to sexual orientation) or gender minority (referring to gender identity)|NONE|"].
Factors associated with increased risk include:[checkbox name="variable_14" value=" functional impairment|recent lack of social support (including living alone)| Unemployment|drop in socioeconomic status|poor relationship with family|domestic partner violence|recent stressful life event|childhood traumas (sexual/physical abuse)|unstable or poor therapeutic relationship"].
What Should I Look For (Risk Factors, Warning Signs and Protective Factors)?
Pain-Specific Risk Factors and Warning Signs3,6,8–18
• Pain: severe pain intensity, chronicity (>3 months), and pain location with > risk (headache,
abdominal, low back, generalized); pain-related helplessness and/or losses (e.g. job,
• Precipitants/Stressors/Interpersonal: insomnia/poor sleep quality, catastrophizing behavior,
social withdrawal, perceived burdensomeness, impulsivity, medication misuse, physical and/or
mental impairments affecting normal activities
• Resilience, religious beliefs, higher frustration tolerance, responsibility to family or pets, positive
therapeutic relationships (e.g. longitudinal and positive relationship with health care providers),
social supports, employment
*Protective factors, even if present, may not counteract significant acute risk
Strategies for Working with Patients to Reduce Suicide
Always ask specific questions about suicidal thoughts, plans, behavior and intent
üScreen patients with chronic pain, mental health and substance use disorders by asking about SI
üAssess suicide risk factors, warning signs and protective factors in patients with chronic pain; repeat
assessments with appropriate frequency when increased risk is detected
üRefer as needed for mental health treatment and behavioral management of chronic pain
(e.g., Cognitive Behavioral Therapy) and refer for emergency psychiatric evaluation if evidence of SI,
intent, and/or behavior is present
üConsider high acute risk for suicide attempt and acute psychiatric instability (e.g. severe depression)
to be a contraindication to opioid therapy unless Veteran is closely monitored; discontinue opioids as
(*discontinuing without proper safeguards can increase suicide risk)
, offer patients safer drug and nondrug pain treatments and pr