Estimating the risk of suicide

Health professionals are in a key position for identifying people at risk of suicide and preventing suicide. Not all health professionals treat suicidal clients on a regular basis and therefore it can be challenging when a client presents with suicide risk. This tip sheet does not replace specialised training, but may be a helpful guide.

The management of a person at risk of suicide requires the assessment of risk, followed by appropriate interventions to minimise any risk. In estimating the risk, health professionals need to consider those factors that elevate suicide risk and also consider those factors that mitigate suicide risk. These risk and protective factors are also an important consideration in any management decisions.

Identifying and monitoring suicide risk

Sometimes a person will clearly articulate suicidal ideation, other times the cues will be more subtle – a person may describe feelings of hopelessness, depression, insomnia or express a desire for medication change. Health professionals must be alert for the cues, and be ready to ask the patient directly about suicide intent. 

 

Risk factors for suicide

  • Previous suicide attempt/s
  • Lack of support
  • Concurrent mental disorders
  • Increasing substance abuse
  • Low social support/living alone
  • Male gender (three times more likely than females)
  • Expressing feelings of hopelessness 

 

Suicide risk assessment

When a thorough risk assessment is undertaken in a systematic way it is more than a guess or intuition – it is a reasoned and structured clinical judgement.

 

  • Be familiar with the concept of risk and the factors associated with increased risk
  • Establish rapport with the individual
  • Conduct and document a thorough risk assessment
  • Use clearly defined and commonly understood categories for defining levels of risk (For example: non existent, mild, moderate, high and imminent.)
  • Recognise the need for ongoing monitoring of suicide risk, as risk fluctuates as circumstances change.

A comprehensive suicide risk assessment should explore the following elements:

Current suicidal thoughts

  • Are suicidal thoughts present?
  • When did these thoughts begin?
  • How persistent are they?
  • Can they control them?
  • What has stopped the person acting on their thoughts so far?

Access to means

  • Does the person have access to means to carry out their plan? For example, is there a firearm available?
  • How deadly is the method?
  • Type of occupation? For example, police officer, farmer (access to guns), health worker (access to drugs).

Important Note: If a person has developed a potentially fatal or effective plan and has the means and knowledge to carry it out, the chances of dying from suicide are much higher. 

Presence of a suicide plan

  • Has the person made any plans?
  • Is there a specific method and place?
  • How often does the person think about the plan? 

Important note: A suicide plan or preparation for death, such as saying goodbyes and putting affairs in order, indicates serious suicidal intent.

History of suicidal behaviour

  • Has the person felt like this before?
  • Has the person harmed themselves before?
  • What were the details and circumstances of the previous attempts? 
  • Are there similarities in the current circumstances?

Communicating with an emotionally distressed person can be difficult, but it is important to persist and gather the information required to estimate the risk, identify protective factors and determine the appropriate management. 

The approach: some suggestions

  • Establish rapport - adopt an open body language i.e. maintain eye contact, lean forward and use a quiet voice.
  • Use a calm, patient, non-judgemental, and empathic approach. 
  • Begin with supportive statements and open-ended inquiries. For example: “I hear how difficult things are for you at this time. Some of my patients with similar problems/symptoms have told me that they have thought about ending their life. I wonder if you have had similar thoughts?”

Risk Assessment Questions

A hierarchy of screening questions that gently leads to asking about suicidal intent is an accepted method of risk assessment. Ask specific questions about self-harm, suicidal thoughts, plans, attitudes towards suicide, history of suicidal behaviour, thoughts of death, and feelings of hopelessness.

“Are you feeling hopeless about the present or future?”
“Have things been so bad lately that you have thoughts that you would rather not be here?”
“Have you had thoughts about taking your life?”
“When did you have these thoughts and do you have a plan to take your life?”

Protective factors for suicide

In addition to an assessment of the risk, a comprehensive approach to management of suicide focuses on the identification and fostering of protective factors, which reduce the risk of suicide. Protective factors to consider when creating a management plan 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

Managing the risk of suicide

In consultation with the client, decide the next steps to be taken to maintain safety. This could involve contacting the client’s supports, referral to an appropriate mental health service or developing a safety contract. For more information about support options for someone at risk, please refer to Assessing support for clients at risk.

 

This information is available as a downloadable PDF.

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