Suicide Assessment
Richard Niolon, Ph.D.
12/99

Helpful Links:
 PsychPage links on Therapy

Defenses

The DSM IV


Suicide Assessment

This article lays out helpful information on suicidal patients and interviewing them.

First, remember to do three things:
1) consult - this allows for another opinion, better care, and protects you
2) document, document, document! Everything you do, everyone you talk to, every question you ask the client should be documented
3) evaluate the client's risk

Risk Factors
a)
mental diagnosis, especially depression and substance abuse, or Borderline Personality Disorder which increase risk
h)
hospitalized and discharged with improvement; this may seem counterintuitive, but many suicidal people feel better once they have made the decision to kill themselves, and have the energy to wrap up loose ends, see others and say goodbye…
b)
over 45 years old are higher risk
c)
sex (men try more lethal means, women try more often)
i)
Caucasian - ethnic minorities have a lower suicide risk
d)
marital status (unmarried are lowest risk, never married, divorced, widowed, recently sep are highest risk)
j)
previous attempts - this is one of the best predictors
e)
recent job loss increases risk
k)
gay/lesbian youth - may be at 3 to 5 times the risk for suicide as heterosexual Caucasian youth
f)
chronic illness is higher risk
l)
extensive and detailed plans, or plans using a highly lethal means
g)
recent loss of loved one increases risk, as does the anniversary of the loss and fantasies of reuniting with the deceased
m)
history of suicide in their family
n)
history of impulsive or reckless behavior


Questions to Ask
Do you have thoughts of suicide?
Are they related to current stressors going on in your life, or have you had such thoughts before?
Do you have a plan? Tell me.
Ask if they have access to the components of their plan, like a gun, pills, etc…

Signs of depression
sleep, energy, weight, or appetite changes
decreased interest in sex and other pleasurable activities
feelings of helplessness and hopelessness
social isolation and withdrawal from others

Level of Risk
none - no suicidal ideation
mild - some ideation, no plan
mod - ideation, vague plan, low on lethality, wouldn't do it
severe - ideation, plan specific and lethal, wouldn't do it
extreme - ideation, plan specific and lethal, will do it

Highest risk group has suicidal ideation (thoughts of killing self), a plan (any plan so long as it is definite and detailed is high risk), high lethality (guns and walking in front of busses are more serious than overdosing on Tylenol and slashing wrists), few inhibitors (few reasons not to kill self), low self-control (especially drinking or using drugs - can decide not to kill self but fail to act to reverse events and accidentally kill themselves)


4) Empathize with the client
They are experiencing crises and stress, hopelessness, and helplessness. Offer that there is a part of them that wants to live, since they were cooperative with you. Offer too that services and referrals, as well as social support could be helpful to use now too.

Make a No-Suicide Contract
This is best when the client has support, is low risk, and can give clear reasons why they would not kill themselves; the client agrees they won't hurt themselves, and if they feel they can't stop themselves, they will call 911, an ER, a crises line, a therapist, or another designated special person, and will return for help on next appointment. Make the patient sign it and get a witness.

Family Intervention
This is best is there is high support and low impulsiveness in the client. The clients agree with you to contact their family. They stay with the family member until the suicidal thoughts have been addressed in treatment, and the family is briefed on who to contact for help in an emergency. The family also takes an active role to remove drugs, guns, or other means of suicide from the home, and promises 24 hour supervision.

Hospitalization
This is best if there is little family support, or mental illness, substance use or impulsiveness. Try voluntary admission, but use involuntary if needed.