Suicide Risk Assessment

On assessment of ACUTE SUICIDE RISK the following PATIENT factors were considered:

CURRENT PATIENT PRESENTATION
• Nature of suicidal ideation: [checkbox name="variable_30" value=" denies current suicidal ideation|current suicidal ideation|current plan for suicide|current suicidal plan with high lethality|current suicidal intent|questionable or non-viable plan of self-harm (i.e., lacks clear or viable intent, ideation, and/or plan)|access to firearms or other lethal means|suicidal thoughts only, in the past|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)| "].

PSYCHIATRIC HISTORY
• 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|multiple past suicide attempt|Recent discharge from inpatient psychiatric care (elevated risk for suicide
during the first year after hospital discharge; risk is greatest in the first weeks to months post discharge)|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"].

MEDICAL HISTORY
• 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|hx of stroke(stroke survivors have a 73% higher risk for suicide)|hx of COVID-19 (increased risk with severe COVID-19 illness| current status as medical inpatient"].

Pain-Specific Risk Factors and Warning Signs
• Pain: 
[checkbox name="PSF1" value="NONE|severe pain intensity|chronicity (>3 months)|pain location with > risk (headache,abdominal, low back, generalized)|pain-related helplessness and/or losses (e.g. job, relationship, hobbies)|none|"]
• Precipitants/Stressors/Interpersonal: 
[checkbox name="PSF2" value="NA|insomnia/poor sleep quality|catastrophizing behavior|social withdrawal|perceived burdensomeness|impulsivity|medication misuse|physical and/or mental impairments affecting normal activities"]

FAMILY HISTORY
•Family history associated with increased risk include:[checkbox name="variable_12" value=" family history of suicide (particularly in first-degree relatives)|family history of suicide in first-degree relative|family history of mental illness|family history of substance use disorders|NONE|INDETERMINATE|"].

DEMOGRAPHICS
• Demographic 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"].

PSYCHOSOCIAL
• Psychosocia 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)|early parental death or separation|military veteran|unstable or poor therapeutic relationship|access to high lethality means|firearm in home| quantity of pharmaceutical products"].

On assessment of PROTECTIVE FACTORS the following patient factors were considered:

INTERNAL Protective Factors:
• Religious/spiritual beliefs-[select name="ipf8" value="YES|NO|unclear"]
• Religious/cultural/spiritual beliefs against harming self/others-[select name="ipf1" value="YES|NO|unclear|"]
• History of successfully solving problems, resolving conflict and handling disputes-[select name="ipf2" value="YES|NO|unclear|YES, but"] 
• Hopeful-[select name="ipf3" value="YES|NO|YES, but"]
• Future planning-[select name="ipf4" value="YES|NO|YES, but"]

Identifies reasons for living-[select name="ipf5" value="YES|NO"]
• Sense of responsibility to family, children, and/or pets-[select name="ipf6" value="YES|NO"]
• Frustration tolerance-[select name="ipf7" value="YES|NO|YES, but"]
• Ability to cope with stress-[select name="ipf9" value="YES|NO|Yes, but"]
• Optimistic outlook-[select name="ipf10" value="YES|NO"]
• Positive coping skills-[select name="ipf11" value="YES|NO"]
• Fear of death or the actual act of killing one-[select name="ipf12" value="YES|NO"]

EXTERNAL Protective Factors:
• Engaged in treatment for psychiatric, physical and substance use disorders-[select name="epf1" value="YES|NO"]
• Willing to access treatment and support-[select name="epf2" value="YES|NO"]
• Positive therapeutic relationships (e.g. longitudinal and positive relationship with health care providers)-[select name="epf3" value="YES|NO"]
• Supportive community, social network, family and friend supports-[select name="epf4" value="YES|NO"]
• Presence of pets for whom individual has a strong affinity-[select name="epf5" value="YES|NO"]
• Can readily identify supports (family, personal connections, other relationships)-[select name="epf6" value="YES|NO"]
• Able to participate in crisis/safety planning to protect against suicide/homicide-[select name="epf7" value="YES|NO"]
• Engaged in work or school-[select name="epf8" value="YES|NO"]

OBJECTIVE SIGNS indicating LOWER ACUTE RISK:[checkbox name="OLRF" value="NONE|somnolent|sleepy|sleeping|calm |hungry, eating|self-directed actions (eg “I want…”)|future directed actions|manipulative or dyadic (eg “If you don’t… I will kill myself…”)"]


On comprehensive assessment of suicide risk and protective factors, at the time of current evaluation the patient is determined to be:

[checkbox name="lowRisk" value="LOW RISK. Patient does not pose imminent danger to self due to no/limited/insufficient/questionable evidence of suicide potential. Low risk indicators include:"] [checkbox name="lIndicators" value="past thoughts only| no previous attempts| no plan| no access to weapons or means| no recent losses| support system in place| no alcohol/substance abuse| positive coping skills|strong protective factors"]

[checkbox name="mRisk" value="MODERATE RISK. Thought patient presents with a questionable or non-viable plan of self-harm (i.e., lacks clear or viable intent, ideation, and/or plan), they are at elevated risk of harm to self due to current stressors, personal and/or environmental variables, and/or lack of protective factors"]

[checkbox name="hRisk" value="HIGH RISK. Patient poses imminent danger to self with a viable plan to do harm."]

Currently, patient [select name="doesDoesNot" value="|DOES|DOES NOT|"] meet criteria for 6404 Emergency Psychiatric Hospitalization based upon the following factors:
[checkbox name="variable_z" value="current statement denying specific imminent intention, plan, method, involuntary compulsion, or irresistible command hallucinations to harm self|candid, credible, full disclosure of recent events, sx and bx|absence of any evidence from any source of any actual recent dangerous bx|stated willingness to accept voluntary tx recommendations to:___________________________________|general competence|orientation|composure|coherence|sobriety|adequate judgment|apparent awareness of the nature and quality of own actions; and absence of gross, overt psychotic sx|no evidence of grossly diminished/impaired cognitive/judgment or decisional capacity|does NOT appear so incoherent, disoriented, disorganized, incompetent, psychotic, altered, preoccupied/distracted, disabled/impaired, or
bizarre in general bx as to possibly constitute an inadvertent serious endangerment to self or others|NO currently observed severe mental status defects (intoxication; delirium, dementia, retardation; gross, severe, acute psychosis; or grossly altered impaired cognition-mentation) which render patient grossly disabled|current stated willingness to participate in mutual safety plan|convincingly states and-or has demonstrated willingness to utilize 24-7 crises resources if needed, including calling 911 or going to ED|current sobriety|awareness of grave risks of intoxication; understanding and acceptance of need for recovery program|participation, presence and stated willingness of responsible competent-appearing friend or family, who is willing to supervise patient and is advised and aware of: potential risks and crises resource options, including emphasized fact that not meeting criteria at present moment does not guarantee that patient will remain safe over an indefinite future period of time|demonstrates future orientation and planning|no family, friends or others and agencies can’t provide immediate support needed|some support might be mobilized but its effectiveness will be limited|support system potentially available but significant difficulties exist in mobilizing it|interested family or others but questions exist of ability or willingness to help|current unpredictable, impulsive or violent behavior|recent history of violence or impulsivity|unable to cooperate or actively refuses treatment and-or safety planning|shows little interest in or comprehension of efforts to be made in own behalf|only passively accepts intervention maneuvers|expresses desire to get help but is ambivalent or motivation is not strong|recent suicide attempt or aborted attempt|recent violent, near-lethal, or premeditated suicide attempt|patient took precautions to avoid rescue or discovery|active psychosis|continues to have suicide plan and intent|increased distress after attempt|regrets surviving|patient is male, older than age 45 years and has new onset of psychiatric illness or suicidal thinking|patient has limited family and-or social support, including lack of stable living situation|current impulsive behavior|current severe agitation|poor judgment|refusal of help is evident|current suicidal ideation with: specific plan with high lethality|high intent|active psychosis|unstable major psychiatric disorder|history of past attempts|history of past medically serious attempts|contributing medical condition (eg, acute neurological disorder, cancer, infection)|lack of response to or inability to cooperate with partial hospital or outpatient treatment|need for supervised setting for medication trial or ECT|need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting|limited family and-or social support, including lack of stable living situation|lack of an ongoing clinician-patient relationship or lack of access to timely outpatient follow-up|evidence of putting one's affairs in order (eg, giving away possessions, writing a will)|denies suicide ideation/plan/intent or recent attempt but evidence from the psychiatric
evaluation and-or history from others suggests a high level of suicide risk and a recent acute increase in risk|suicidal ideation or attempt was reaction to precipitating events (eg, exam failure, relationship difficulties) and patient's view of situation has changed since coming to hospital|suicidal plan, method and intent have low lethality|patient has stable and supportive living situation|patient is able to cooperate with recommendations for follow-up and contact has been with follow-up provider|patient is able to cooperate with recommendations for follow-up|outpatient treatment likely more beneficial than hospitalization|patient has chronic suicidal ideation and-or self-injury without prior medically serious attempts and available safe and supportive living situation along with ongoing outpatient psychiatric careatient has chronic suicidal ideation and-or self-injury without prior medically serious attempts, if a safe and
supportive living situation is available and outpatient psychiatric care is ongoing"]

Management of Suicide Risk
Stabilize medical conditions 
Safe containment – Physical or chemical restraint – Supervision (1: 1 patient safety monitor) – Remove dangerous objects § Repeated observation / assessment § 
Consider initiation of treatment 
Address modifiable risk factors 
– Treat psychiatric disorder 
– Manage insomnia and other symptoms 
– Address availability of social support 
– Address occupational, and housing concerns 
– Provide psychotherapy (supportive) 
– Communicate with consultants and other providers about treatment
n-Hospital Prevention § 
Treat agitation, anxiety and depression immediately and aggressively § Communication with psychiatric and other treatment providers – Inpatient – Outpatient § 
Encourage family support and involvement 
Encourage staff communication 
Treat pain aggressively 
“Safety-proof” patient rooms 
– Trained 1: 1 sitter or patient safety monitor 

Risk factors that can be modified through treatment & intervention to reduce suicide risk.
• Specific psychiatric symptoms: can be treated with medications and psychotherapy.
• Environmental: 
access to firearms and other lethal means of suicide can be restricted. Individuals can be observed. 
Medications secured/monitored; 
firearms removed, car keys removed, etc.
• Inadequate/lack of social supports: family members and close
friends can be educated about illness and resources to provide
more social support.



Disposition 
– Home with outpatient follow up 
– Admission to medical unit 
– Voluntary admission to inpatient psychiatric unit 
– Involuntary admission to inpatient psychiatric unit


Borderlines
High-risk, static or stable factors might include:
Childhood history, e.g. sexual abuse
History of suicide attempts
Biological and genetic factors
Suicide in the family
Family history of mental illness
History of violence
Young age at first violent incident
Terminal prognosis
Chronic alcoholism

High-risk dynamic factors might include:
Misuse of alcohol: prescribed and/or unprescribed drugs
Social situation, e.g. unemployment
Other people's attitudes to them
Mood disorders
Self-harm (sometimes)
Changes or problems in relationships
Recent clear plans for suicide
Unresponsiveness/non-compliance to treatment
Destabilisers, e.g. stress/poor coping skills
Attitude, e.g. pro-offending, hostile, negative

Static or stable protective factors might include:
Capacity to reflect on own feelings and thoughts
History of at least some good relationships
Capacity to actively share feelings with others
Capacity to feel empathy with others' feelings
Resilience

Dynamic protective factors might include:
Good relationship(s) in the present
Communicative (talking, writing, drawing)
Able to reflect emotionally
Able to ask for and use help
Clear plans or wishes for the future
Previous plans not carried out (but care must be taken not to assume this means they won't this time)

Engaged in effective health and/or mental healthcare
 Feels well connected to others (family, school, friends)
 Positive problem solving skills
 Positive coping skills and resiliency
 Restricted access to means to kill self
 Stable living environment
 Willing to access support/help
 Positive self esteem
 High frustration tolerance
 Emotional regulation
 Cultural and/or religious beliefs that discourage suicide
 Does well in school
 Has responsibility for others