Final - Suicide Risk Assessment Guidebook PDF
Final - Suicide Risk Assessment Guidebook PDF
Final - Suicide Risk Assessment Guidebook PDF
Disclaimer
The Suicide Risk Assessment Guide: A Resource for Health Care Organizations, was
prepared by the Ontario Hospital Association (OHA) in partnership with the
Canadian Patient Safety Institute (CPSI) as a general guide to help health care
organizations with understanding and standardizing the practice of highquality suicide risk assessment.
The research findings, tools and other materials in this resource guide are
for general information only and should be utilized by each health care
organization in a manner that is tailored to its circumstances. This resource
reflects the interpretations and recommendations regarded as valid at the
time of publication based on available research, and is not intended as, nor
should it be construed as, clinical or professional advice or opinion. Health
care organizations and individuals concerned about the applicability of
the materials are advised to seek legal or professional counsel. Neither the
OHA nor CPSI will be held responsible or liable for any harm, damage, or
other losses resulting from reliance on, or the use or misuse of the general
information contained in this resource guide.
ISBN # 978-0-88621-335-0
Publication Number: #332
Acknowledgements
Glenna Raymond (Chair), President and CEO, Ontario Shores Centre for
Mental Health Sciences, Ontario
Dr. Linda Courey, Director, Mental Health and Addiction Services, Cape
Breton District Health Authority, Nova Scotia
Margaret Doma, Director of Risk, Legal, and Medical Affairs, St. Josephs
Health Care Hamilton, Ontario
Denice Klavano, Member, Patients for Patient Safety Canada, Nova Scotia
Ann Pottinger, Advanced Practice Nurse, Centre for Addiction and Mental
Health (CAMH), Ontario
Dr. Michael Trew, Senior Medical Director, Addictions and Mental Health,
Alberta Health Services, Alberta
Dr. Tristin Wayte, Manager, Risk and Evaluation, BC Mental Health and
Addiction Services, British Columbia
Table of Contents
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
This Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii
The Appraisal of Underlying Factors that Indicate Suicide Risk: Warning Signs,
Technical Considerations for the Selection of Suicide Risk Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
Evaluating and Using Risk Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Summary of Assessment Tools and Implications for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Use of Suicide Risk Assessment Tools within the Risk Assessment Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Considerations of Care Settings When Choosing Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
. . . . . . . . . . . . . . . . . . . . . . . . . 81
Appendix J: References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Executive Summary
Executive Summary
BACKGROUND
Suicide is a tragic and distressing phenomenon. The negative effects on
families, friends and communities following a suicide reinforce the urgency
for a better understanding and prevention of suicide. In Canada, Statistics
Canada reported that 3,500 people died by suicide in 2006. Globally, the
World Health Organization (WHO) has reported that the rate of suicide has
risen since 1950, as much as 268% among men aged 15 to 24 (WHO, 2003).
In addition to the rise in rates of persons who have died by suicide, even more
persons have been hospitalized due to attempted suicide, as many as 23,000
hospitalizations in Canada in 2001 (Canadian Institute for Health Information
[CIHI], 2004).
For these reasons, suicide risk assessment has been identified in Canada, and
internationally, as a fundamental safety issue among health care organizations.
A lack of information on and documentation of suicide risk has been
identified as a common issue in reviews of cases where persons have died by
suicide in inpatient mental health settings (Mills, Neily, Luan, Osborne, &
Howard, 2006). In a review of national suicide prevention strategies among 11
countries, including Canada, Martin and Page (2009) found that standardized
suicide risk assessment was not a major component in any of the strategies.
A joint Ontario Hospital Association (OHA) and Canadian Patient Safety
Institute (CPSI) report identified the need for risk assessment tools related
to patient safety including suicide (Brickell, Nicholls, Procyshyn, McLean,
Dempster, Lavoie, et al., 2009). Focusing on suicide risk assessment is a first
step in improving suicide prevention.
risk assessment tools related to patient safety. As a result, the OHA and CPSI
commissioned the development of a resource guide related to suicide risk
assessment and prevention for use in Canadian health care organizations.
It is important to acknowledge that, similar to other medical conditions such
as heart attacks, not all suicides are entirely preventable. However, suicide in
health care settings is a serious adverse event. Public health and the health
system should promote safety and quality of care through high-quality risk
assessment, intervention, and documentation. National quality assurance
and accreditation organizations have recognized the need for consistent
assessment and documentation of suicide risk by integrating these processes
into their evaluation frameworks.
THIS GUIDE
This resource guide was developed based on an environmental scan of
peer-reviewed, best practice, and policy literature on suicide risk assessment
processes, principles, and tools. The methodological approach that informed
this resource guide can be found in Appendix A. Interviews were also
performed with 21 expert stakeholders representing different cultural, ethnic,
geographic, demographic, health sector, and professional backgrounds.
The interviews complemented the environmental scan and added specific
contextual considerations for guiding risk assessment in different situations
and with persons from varied backgrounds.
Executive Summary
The fourth and last section provides resources for hospitals including
key concepts, tips and diagrams which may be reproduced and posted
in the organization. Additionally, more detail on the project methodology
is given as well as references to cited works.
Section I
Overview of Suicide Risk Assessment Principles, Processes, and Considerations
The goal of a suicide assessment is not to predict suicide, but rather to...appreciate the basis for
suicidality, and to allow for a more informed intervention
- (Jacobs, Brewer, & Klein-Benheim, 1999, p. 6).
In this section:
Identifying and evaluating warnings signs as well as risk and protective factors
Explaining why certain demographics like age and sex are excluded as risk factors
Discussing issues such as mental illness and chronic suicidality that compound risk assessment
Primary care
Emergency settings
Mental health settings
Youth
Older adults
Aboriginal communities including First Nations, Inuit, and Mtis
Lesbian, gay, bisexual, transgender, queer communities
Military personnel
It is recommended that readers consult the cited works for a more in-depth overview of each of the concepts presented.
A list of all references can be found in Appendix J.
Definition
Potentiating risk factors are
associated with a person
contemplating suicide at one point
in time over the long term.
Warning signs are factors that
may set into motion the process
of suicide in the short term (i.e.,
minutes and days)
WARNING SIGNS:
Threatening to harm or end ones life
Seeking or access to means: seeking pills, weapons,
or other means
Evidence or expression of a suicide plan
Expressing (writing or talking) ideation about suicide,
wish to die or death
Hopelessness
Rage, anger, seeking revenge
Expressing feelings of being trapped with no way out
Increasing or excessive substance use
Withdrawing from family, friends, society
Anxiety, agitation, abnormal sleep (too much or
too little)
Dramatic changes in mood
Expresses no reason for living, no sense of purpose in life
Unemployed or recent
financial difficulties
Divorced, separated, widowed
Social Isolation
Low Risk:
recommend counseling and
monitor for development of
warning signs.
Figure 1. Illustration of the Accumulation of Potentiating Risk Factors and Warning Signs
on Risk of Suicide (Warning Signs adapted from Rudd et al., 2006).
In essence, identified potentiating risk factors may become focal points for
targeting interventions once risk is abated. For example, experiences such
as prior traumatic events, chronic illness and disability, social isolation and
extreme loss (i.e., financial, personal, social) are important for understanding
the origins of risk. Potentiating risk factors in the absence of warning signs
may represent a less immediate risk of suicide. And by focusing treatment
interventions on these kinds of potentiating factors, care providers may
actually avert a persons future progression into warning signs. Therefore,
though warning signs indicate the persons level of risk, the potentiating risk
factors present areas of focus for interventions.
Fact: The determination of suicide
risk should not rest on demographic
characteristics such as age or sex. Instead,
these characteristics should be considered
Age
Interviews with experts have indicated that age alone should not be included
as a potentiating risk factor as it tells nothing about risk of suicide without the
presence of other potentiating risk factors (e.g., see Figure 1 (p.5)). Instead,
age may be related to suicide through an interaction with other factors such
as impulsivity or life circumstances. For instance, older adults may develop
suicide risk as a result of a long-standing physical illness or pain. Age is still
an important factor to consider in the risk assessment process, but not as a
risk factor. See page 29 where specific considerations related to lifespan and
traumatic life experience are discussed.
Sex
With respect to sex, differences in the rates of suicide between men and
women have been consistently observed in Canada and worldwide. Typically,
rates of suicide among men are higher than rates among females, though
some report that the rate of attempted suicide is higher among females
(Murphy, 1998). It is believed that such attempts may be used as a call for
help by women, whereas men are less inclined to openly discuss distress or
vulnerability (Murphy, 1998; Pearson et al., 1997). Therapeutic interventions
among men and women in distress therefore require early and increased
vigilance to verbal and behavioural cues for warning signs.
Persons who abuse alcohol or other substances may also be at increased risk
of suicide, particularly as inhibitory control is reduced and impulsivity
is increased (Wilcox, Conner, & Caine, 2004). Several interviewees also
indicated that life circumstances and onset of depression following
Definition
Predicament suicide refers to
suicide that occurs when the
individual without mental disorder
is in unacceptable circumstances
from which they cannot find an
acceptable alternative means of
escape. (Pridmore, 2009, p 113)
Protective factors
Protective factors are those that may mitigate risk of suicide (Nelson,
Johnston, & Shrivastava, 2010; Sanchez, 2001); see Box 1 below.
Box 1. Examples of Protective Factors (Sanchez, 2001; United States Public Health
Service, 1999)
The mere absence of warning signs and potentiating risk factors can also be
thought of as a protective factor
It is important to recognize that the absence of these factors can be strengths
which may assist in coping with other risk factors or warning signs. In fact,
several experts interviewed emphasized the use and leverage of protective
factors in a strengths-based approach to assessing and monitoring risk of
suicide, particularly for persons receiving community-based care (See Reason
for Living Inventory in Section II for an example of a tool that can help gather
information on protective factors). Further, it is important to discuss both
the available internal (e.g., persons skills, coping mechanisms) and external
(e.g., strong family or community supports, cultural or religions networks;
Grotberg, 2002) supports. Asking the person to identify with positively worded
statements (e.g., I can take care of myself, I have people
I can talk to, etc.) might also help to shift the focus from the persons distress
and suicidal ideation to areas of strength and support.
Box 2. Successful strategies for building the therapeutic rapport (Heaton, 1998)
Take the time to consider the persons story so that he or she does not
feel dismissed. It is helpful for clinicians to remember that the person in
crisis is more than a cluster of behaviours; consequently he or she should
be seen as a person first, and as a person in crisis second; and
Help the person to see his or her strengths (e.g., reinforce that the choice
to seek help was a good one), validate his or her feelings, and help him or
her to regain control.
protective factors);
behaviours;
Psychiatric history;
Previous treatments;
Plans for treatment and
preventive care;
and protective factors) and plans for treatment and preventive care. Chart
notes should be augmented with structured assessments, including relevant
risk assessments, previous psychiatric history, previous treatment received,
and concerns expressed by family or friends. In settings where behaviours
can be easily observed (e.g., hospital), documentation should also include
information about the persons specific thoughts and behaviours to further
help appraise risk.
Documentation should include information about current and historical
suicidal and purposeful self-harming behaviour. Even if the behaviour
occurred several years previously, it is necessary to explore the circumstances
around that incident and the persons reaction to it, in case a similar situation
arises. For both current and historical suicidal behaviour, details about timing,
method, level of intent, and consequences of the behaviour should
be documented.
A pull out reference is available in Appendix E.
Documentation should include:
1. The overall level of suicide risk
The level of risk should be clearly documented along with information to
support this assertion. This can include information about:
The length of time since previous suicide attempt(s) or self-harming
behavior(s);
The rationale for not being admitted to a more intensive
environment or discharged to a less restrictive environment, and what
safety plans were put into place; and
A thorough suicide risk assessment is essential when considering the timing of discharge.
If the crisis has not been addressed, the person has not fully de-escalated,
or the person cannot (or will not) agree to formulate a safety plan, try to
negotiate a safety plan with the person. Suicidal ideation, low mood or
hopelessness should not be present at time of discharge. Offer concrete
choices (e.g., Do you think staying in hospital would be helpful, or would
returning home with a family member feel safer?) to provide autonomy to
the person to choose the treatment/discharge option that feels most safe
for him or her. Relying on how the person has previously managed in the
community (or while in hospital) is not a fail-safe indicator of how he or she
will respond when back in the community. The person will need preparation
for reintegrating, crisis contact numbers, and a timely appointment with a
professional to address these items. Persons who self-discharge following
a suicide crisis should be red-flagged for close monitoring. Follow-up
appointments should incorporate the same suicide risk management
practices as those used for discharge planning (Bergmans et al., 2007; Hunt
et al., 2009).
Persons in hospital or the emergency department for suicidality should be
discharged with a specific safety plan on how to stay safe once he or she
returns to the community. Strategies for staying safe, early warning signs,
grounding techniques, coping strategies and crisis contact numbers that were
discussed during the intervention should be included in the safety plan.
Writing this plan on paper with the person will help them avoid returning
into crisis once they leave the safety of the hospital (Bergmans et al., 2007)
and also provides something tangible to review if feelings of distress begin to
mount. Support persons, such as family or friends, should also be involved
in the details of the safety plan with clear documentation of who needs to be
contacted if a crisis seems imminent. Sharing the safety plan with the persons
care team will also increase collaboration and continuity of care in the event
of a re-admission.
Table 1. Guiding Principles for Suicide Risk Assessment (adapted from Granello, 2010).
Suicide Risk Assessment:
Explanation
4. Is an Ongoing Process
Explanation
Assessment tools help inform decisions but never provide exact answers.
Assessment requires a combination of experience and training taking
into account all sources of information, including the use of risk
assessment tools.
Threats and warning signs may represent a cry for help and must always
be recognized as potential risks to a persons safety.
Therapeutic rapport is essential for distinguishing between ideation and
behaviours consistent with chronic suicidality and warning signs
representing acute risk.
Rather than using indirect words (e.g., not around anymore) use
direct language specifically referring to suicide or death to avoid
miscommunication.
Communicate that it is okay to talk about suicidal thoughts and behaviours.
Open-ended questions also allow for persons to express their thoughts
about their intentions or behaviours, particularly if their main intentions are
not to die.
Multiple questions may be more effective than one question that simply asks
Have you ever felt suicidal?
12. Is Documented
CARE SETTINGS
In this section, special considerations for primary care, emergency, mental
health, and long term care settings are highlighted, as are general concerns
related to the care environment.
Primary care
As the first point of contact with the health system for most people, primary
care settings (e.g., family physicians, nurse practitioners or clinicians, and
private practice counselling) have the potential to identify, reduce, and
prevent the risk of suicide. However, screening for suicide risk is not a
routine practice among most primary care physicians (Fenkenfield, Keyl,
Gielen, Wissow, Werthamer, & Baker, 2000), and a number of barriers exist
that hinder the professionals ability to recognize and adequately address
suicidality. In particular, time constraints during appointments mean that
persons have very little time in which to discuss their mental health concerns.
When feeling rushed, persons may not feel comfortable or encouraged
to disclose thoughts of suicide (Cole & Raju, 1996; Denneson, Basham,
Dickinson, Crutchfield, Millet, Shen, & Dobscha, 2010). Unless the persons
are questioned directly on the state of their emotional health, it is common
for them to withhold information on psychological distress (Mellor, Davison,
McCabe, et al., 2008). Clinicians in primary care settings can encourage
disclosure of mental health issues through effective communication and a
supportive patient-centered environment.
Education
24 I Suicide Risk Assesment Guide
Emergency settings
Assessment of the risk of suicide in emergency settings is a time sensitive
process that involves evaluating the degree of risk of harm to self, mitigating
acute risk, and determining the appropriate level of care for the person
(Dawe, 2008). Persons who may be at risk of suicide in an emergency
department setting may present immediately following an attempt to commit
suicide, at a point where an attempt was imminent; or they may present for
reasons other than suicidal thoughts or behaviours but still be at risk. In order
to establish risk and triaging for next steps for care, the assessment of suicide
risk in emergency settings involves:
1) Determining the persons actual level of intent, (i.e., whether or not the
person actually wants to die).
2) Evaluating whether the person is telling the truth, either about wanting or
not wanting to die by suicide.
In these situations a brief assessment tool that may not entirely focus
on suicide intentions but asks about plans to attempt suicide in the
future combined with other symptoms such as depression or
hopelessness may be helpful (for example, the Beck Depression
Inventory; Beck, Ward, Mendelson, 1961). Observational tools may
also be useful for providing an indication of risk to the clinician based
on combinations of prior history, current symptom severity, current
ideations and behaviours expressed by the person. See Section II for
more information on tools.
persons weight;
secure unit.
Hanging and jumping from a window or roof were the most common methods
used in inpatient suicide in the U.S., with most hangings occurring in the
bathroom (Tishler & Reiss, 2009). Among veterans mental health hospitals in
the United States, a study on environmental risks in care settings identified up
to 64 hazards per hospital, with an average of 3 hazards per bed (Mills, 2010).
The most common hazard was anchor points on walls that could support the
weight of a person attempting to hang him or herself, followed by material
that could be used as weapons, and issues regarding potential elopement
from secured units. Following an assessment, 90% of the hazards were abated.
Doors and wardrobe cabinets that accounted for almost half of all anchor
points were removed or altered. The study also found that drawers, cords,
mouldings, tiles, flatware, and other small objects could be used as weapons
and were also accessible. Less common, but potentially more lethal were
suffocation risks such as plastic trash can liners and poisons found in cleaners
accessible through unlocked storage closets were identified on secure units.
Clearly, cost is always a consideration when improving the safety of an
environment. However, most of the hazards identified, with the exception
of changes to structures such as doors and walls, were abated simply with
removal, improved education of staff, and changes to the use or availability
of certain materials in care units.
The care setting also needs to maintain a comforting and therapeutic
environment rather than an authoritarian style (Bostwick, 2009). In this sense,
sensitivity should be used when removing personal items from patients that
could pose a risk to safety (Lieberman et al., 2004). Rather than simply taking
items from the person, explain that the items are being removed for the
persons safety and will be kept in a safe and secure storage area.
Youth
Suicide risk assessment among youth needs to consider specific approaches
for conducting the risk assessment interview to help them feel comfortable
and open to discussion.
When asking questions about wanting to die, it is also important to normalize
the youths thoughts or feelings to further encourage disclosure. This can be
done by explaining how other youth have expressed certain feelings (e.g.,
sadness, hopelessness) and tried to die, followed by asking the youth if this is
how he or she feels.
For example, I know that some kids might feel lonely or hurt and want
to try to hurt themselves. Is this how you feel?
of suicidal deaths (Sudak & Sudak, 2005). The evidence regarding the
influence this has on suicide among susceptible youth is also mixed,
although the concern for contagion still exists (CDC, 1998). If a suicide
cluster is suspected in a community, the Centers for Disease Control and
Prevention recommends a community response plan for the prevention and
containment of suicide clusters (see http://www.cdc.gov/mmwr/preview/
mmwrhtml/00001755.htm).
As some evidence exists that an increase in suicidal behaviour by family
members is associated with an increase in deaths by suicide among youth (Ali,
Dwyer & Rizzo, 2011), clinicians should consider:
In terms of specific risk factors and warning signs among youth, awareness
of heightened impulsivity is important to consider, particularly when other
risk factors or warning signs are present (e.g., prior abuse, family or caregiver
conflict, hopelessness) (Kutcher & Chehil, 2007). Suicide ideation in youth
is also related to victimization through bullying, as well as the ability to
communicate feelings, negative attachment to parents or guardians, and
presence of deviant peers (Peter, Roberts, & Buzdugan, 2008). It is also
important to ask the youth and his or her family if there are lethal means
in the home environment, such as hunting weapons, anchor points, or
toxic substances.
Fact: Globally, men and women over 74
years of age have the highest rates of death
by suicide (WHO, 2005); however, men
over 84 years have the highest rate of suicide
across all age groups (Canadian Coalition for
Seniors Mental Health [CCSMH], 2006).
Compared to younger persons, older adults
with suicidal ideation are much less likely
Older adults
Older adults who do see a physician prior to their suicide tend to report
somatic symptoms (e.g., insomnia, weight loss, etc.) or despair, and generally
do not volunteer thoughts of suicide unless directly questioned. Waern and
colleagues (1999) reported that three quarters of older adults who had
died by suicide had spoken to relatives or friends about ideation in the year
preceding the act, though only one-third had discussed such thoughts with a
health care professional.
The Canadian Coalition for Seniors Mental Health (CCSMH) has developed a
guideline on the Assessment of Suicide Risk and Prevention of Suicide that
outlines specific issues to consider among older adults (Heisel et al., 2006).
Again, these guidelines emphasize that older adults may downplay or underreport risk factors or thoughts related to suicide, and that they often present
with somatic symptoms (e.g., pain that is not relieved, difficulty sleeping).
Continual monitoring is recommended due to variations in the expression
and severity of thoughts related to suicide among older adults.
Aboriginal communities
Fact: The Government of Canada (2006)
A common misperception is that all suicide rates are uniformly higher across
all Aboriginal communities. Based on aggregate statistics, the rate of suicide
in Canada is higher among Aboriginal communities compared to the rest of
the population. The Government of Canada (2006) has reported that the rate
of suicide among Aboriginal peoples in Canada was 24 per 100,000 in the year
2000, while the rate among the general population was 12 per 100,000. Inuit
communities in Nunavut have experienced a drastic increase in the rate of
suicide over the last 25 years, from about 35 per 100,000 in 1981 to almost 120
per 100,000 in 2007 (Nunavut Suicide Prevention Strategy Working Group SPSWG, 2010). However, while some Aboriginal communities experience very high
rates of suicide, it is important to recognize that suicide is not a uniform phenomenon
across all communities (Bagley, Wood, & Khumar, 1990; Bohn, 2003). In British
Columbia, for instance, Chandler & Lalonde (1998) reported suicide rates
as high as 800 times the national average among youth in some First Nations
communities. In contrast, in other First Nations communities, rates were
closer to 0. Therefore, suicide cannot be considered uniformly across all
Aboriginal communities. Instead, it is important to understand specific
community and cultural factors in addition to person-level factors during the
risk assessment process.
Fact:
Hatzenbuelher (2011) reported that
Lesbian, gay, and bi-sexual (LGB) youth
(i.e., over 31,000 grade 11 students)
were significantly more likely to attempt
suicide compared to heterosexual youth
(21.5% vs. 4.2%);
Among LGB youth, the risk of
attempting suicide was 20% greater in
unsupportive environments compared
to supportive environments.
ODonnell, Meyer, and Schwartz (2011)
found that the risk of suicide was even
higher among ethnic, minority LGB youth
compared to Caucasian LGB youths.
Military personnel
Persons with experience serving as military personnel may have experienced
traumatic events or have developed other mental health conditions that may
contribute to risk of suicide. The lifetime prevalence of suicide attempt among
active Canadian military has been estimated at 2.2% for men and 5.6% for
women (Belik, Stein, Asmundson, & Sareen, 2009). Recent findings have
indicated that there were no differences between suicide ideation over the
year prior to the study between military personnel and civilians; and that the
prevalence of suicide attempt was lower among military personnel compared
to civilians (Belik, Stein, Asmundson, & Sareen, 2010).
However, there may be specific risk factors and warning signs that should be
considered for military personnel. After controlling for mental illness and
socio-demographic factors, interpersonal trauma (e.g., rape, sexual assault,
physical and emotional abuse) has been found to be significantly related to
suicide attempt among military personnel (Belik et al., 2009).
While many of the risk factors and warning signs may be similar to civilians,
specific occupational risk factors for active military personnel include:
Timing of assigned duty/shift (i.e., morning duty, late evening duty); and
Section II
Inventory of Suicide Risk Assessment Tools
Risk assessment tools are only one aspect of the risk assessment process. They should be used
to inform, not replace, clinical judgment. These tools should be incorporated into the clinical
interview and administered once a therapeutic rapport has been established.
In this section:
Critical review of 15 suicide risk assessment tools identified in the literature review and interviews
A quick reference table with tool characteristics (Table 2, page 58)
Authorship and copyright information for each of the suicide risk assessment scales presented
(See Table 3, page 59)
Definition
Psychometric properties refer to
the statistical properties that
describe how well a tool has been
constructed.
Box 4. Psychometric and Technical Considerations for Evaluating Suicide Risk Assessment Tools
Correlation
The extent of an association between variables (e.g., tool scores), such that when values in one
variable changes, so does the other. A correlation can range from -1.0 to 1.0. The closer the score is to
-1.0 or 1.0, the stronger the relationship between variables. Negative correlations indicate that as the
value in one variable increases the value in the second variable decreases. Correlation is often used
in the validation process when examining how well a tools score relates to other indicators or suicide
risk or distress.
Reliability
The degree to which a risk assessment tool will produce consistent results (e.g., internal consistency)
at a different period (e.g., test-retest), or when completed by different assessors (e.g., inter-rater). A
common statistic reported for internal consistency is the Cronbachs alpha (or ). This statistic, like a
correlation, ranges from 0 to 1.0. A higher score means the items consistently measure the construct
of interest. Typically, a score of 0.7 or higher indicates good reliability.
Validity
The degree to which a risk assessment tool will measure what it is intended to measure or forecast
into the future. Convergent, concurrent, and construct validity may be established by looking at the
correlation between a tools score and scores of other instruments, measures, or factors already know
to measure or indicate the construct of interest (e.g., suicide risk assessment tool should correlate
with other gold standard instruments for measuring suicide risk or factors related to suicide risk
such as severe depression). Face validity can be established when the content of the instrument is in
agreement with the accepted theory or clinical dimensions of the construct of interest. Predictive
validity refers to how well a score on a suicide risk tool can predict future behaviour.
Sensitivity
A component of validity, sensitivity of a risk assessment tool is the ability of the instrument to identify
correctly persons who are at risk.
Specificity
A component of validity, specificity of a risk assessment tool is the ability of the instrument to identify
correctly those who are not at risk.
Factor
Analysis
A statistical approach that can be used to analyze interrelationships among a large number of items
on a tool and to explain these relationships in terms of their common underlying dimensions
(factors). Usually, this analysis is done to determine how items in an instrument measure a
similar factor.
Threshold
Scores
A threshold score is the minimum score that denotes a level of risk on an assessment instrument.
Falling within a high range of points, for example, may suggest higher risk for suicide. Note that not
all threshold scores are validated across populations/settings and their use may result in increased
false negatives (i.e., incorrectly labeling a person not at risk of suicide). To adopt a threshold score for
identifying high risk of suicide, evidence of strong sensitivity and specificity, as described above,
is required.
Modes of
Administration
Several approaches to risk assessment exist, such as a clinical interview or through a self-report
questionnaire. Advantages of self report include the opportunity for screening prior to a visit,
particularly in primary care or use as a break in the clinical interview and an opportunity for
corroboration. Disadvantages include the potential for perceived disconnect between the assessor and
person and the impersonal nature of completing the form.
Suicide Risk Assesment Guide I 37
Although not an exhaustive list of suicide risk assessment tools, the list is based
on recommendations from the literature and interviews with experts. A pull
out summary reference of the assessment tools is provided in Appendix H.
TRAINING IN THE USE OF EACH SUICIDE RISK ASSESSMENT TOOL
IS ADVISED.
The Scales
Beck Hopelessness Scale
What it Measures:
The Beck Hopelessness Scale (BHS; Beck & Steer, 1988) was designed to measure negative attitudes about ones future and
perceived inability to avert negative life occurrences.
Format:
Twenty true/false questions measure three aspects of hopelessness:
Each of the 20 statements is scored 0 or 1. A total score is calculated by summing the pessimistic responses for
each of the 20 items, with higher scores indicating greater hopelessness. The published cut-off score for the BHS is
greater than 9 (Beck, Steer et al., 1985).
Potential setting/Population:
The BHS can be used with psychiatric and non-psychiatric (general population) samples, as well with older
adults (Neufeld et al., 2010). It may be used in a forensic setting, where a cut-off score of greater than 5 has been
identified for suicide risk (McMillan et al., 2007).
Psychometric properties:
The BHS has been found to produce reliable scores with reported internal consistency scores ranging from
a Chronbachs alpha score of = .82 to = .93 among samples of persons with mental illness (Beck & Steer,
1988) and = .88 in a non-psychiatric sample (Steed, 2001). When comparing BHS scores and clinical ratings of
hopelessness, moderate correlations have been found between BHS responses and ratings of hopelessness in a
general practice sample (r = .74) and in a suicide-attempt sample (r = .62) (Beck et al., 1974).
Other considerations:
It has been suggested that the BHS would make a good initial screener to identify people who are in need of a
more intensive clinical risk assessment (McMillan et al., 2007). The BHS is not supported for use in identifying
individuals at high risk of repetitive, non-suicidal self-injury, nor is it supported for use in emergency settings
(Cochrane-Brink
et al., 2000).
The Lifetime/Recent version gathers lifetime history of suicidality, as well as recent suicide-related ideation and/
or behaviour. This version is appropriate for use as part of the persons first interview.
The Since Last Visit version prospectively monitors suicide-related behaviour since the persons last visit, or the
last time the C-SSRS was administered.
The Risk Assessment version is intended for use in acute care settings as it establishes a persons immediate
risk of suicide. Suicide-related ideation and behaviour is assessed over the past week and lifetime through
a checklist of protective and risk factors for suicidality. Mundt et al. (2010) tested and validated a computerautomated version of the C-SSRS and found it well correlated to the Beck Scale for Suicide Ideation (r = .61).
Other considerations:
Information about the reliability and validity of the C-SSRS was not available at the time of publication of this guide.
Potential setting/Population:
Older Adults.
Psychometric properties:
Test-retest reliability of responses by a sample of 32 nursing home residents was r = .86 (one to two months
between points of measurement), and r = .77 for a sample of 13 nursing home residents (1 to 1.5 years between
points of measurement; Heisel & Flett, 2006). Cronbachs alpha for responses to the GSIS ( = .90) and its
subscales (.74 .86) suggest acceptable to good internal consistency (Heisel & Flett, 2006). Responses to the
GSIS have exhibited strong concurrent validity vis--vis the Beck Scale for Suicide Ideation (r = 0.62) and the
Geriatric Depression Scale (r = 0.77; Heisel, Flett, Duberstein, & Lyness, 2005). Further positive features include
its sensitivity to suicide-related ideation across a range of functioning and subscales that focus on maladaptive and
protective factors.
ratings of risk where the SOS scores matched clinician ratings 85% of the time. Further, 98% of patients with
a score of 0 on the SOS were rated as minimal or mild risk by clinicians while 80% with an SOS score of 6 were
rated as moderate to very severe/imminent risk.
Other considerations:
In Ontario and other jurisdictions (e.g., Finland, Iceland), the interRAI MH is used to assess all persons admitted
to an inpatient mental health bed.
The SOS Scale is also used as a basis for the Suicidality and Purposeful Self-harm Clinical Assessment Protocol
(CAP). Once the full interRAI MH, CMH, or ESP is completed, the clinical team is alerted to persons at minimal
to mild (0 to 2), moderate to severe (3 to 4), and very severe risk of harm to self (5 to 6). The CAP provides a list
of initial considerations, guidelines, and interventions that the clinical team can use in care planning to address
immediate and long-term safety issues to prevent future self-harm and suicide. Thus, the interRAI assessment
instruments combine risk assessment with guidelines to support care planning. In jurisdictions such as Ontario,
the SOS Scale is administered for every person admitted to an inpatient mental health bed allowing for embedded
screening and an opportunity to identify persons in need of more in-depth assessment of suicide risk using a
clinical interview.
Other considerations:
While the SAD PERSONS does include a number of factors considered risk and warning factors (e.g., substance
abuse, loss of rational thinking, and presence of a suicide plan) it also includes a number of epidemiologic factors
that may be more distal in terms of risk. More importantly, the risk factors are not organized in any hierarchical
manner suggested by literature on warning signs (Rudd, 2008). For instance, a 40 year old single male with
diabetes would score higher than a 40 year old female with depression and an organized plan for suicide. Thus,
clinicians may be faced with high numbers of false positives.
SAD PERSONAS
A modified version of the SAD PERSONS, the SAD PERSONAS (Hockberger & Rothstein, 1998) was developed to
incorporate a weighting system and modify several items:
S = Sex (male) 1-point
A = Age (<19 or >45 years) 1-point
D = Depression or hopelessness 2-point
P = Previous suicide attempts or psychiatric care 1-point
E = Excessive alcohol or drug use 1-point
R = Rational thinking loss 2-point
S = Separated, divorced or widowed 1-point
O = Organized or serious attempt 2-point
N = No social supports 1-point
A = Availability of lethal means 2-point
S = Stated future intent 2-point
Potential setting/Population:
All health care settings with all populations.
Psychometric properties:
Hockberger & Rothstein (1998) found 31% sensitivity and 94% specificity for the modified version of the SAD
PERSONAS in predicting hospitalization among persons in an emergency department. Cochrane-Brink et al.
(2000) found the modified SAD PERSONAS was not as effective in predicting hospitalizations due to risk of harm
to self compared to other measures of risk including the Suicide Probability Scale.
Other considerations:
While the modified scale makes improvement in weighting risk factors that are consistent with more specific
warning signs for acute suicide, there is still a lack of predictive validity for clinical decision-making. The
assessment does provide an easy to remember checklist of potential risk factors to guide initial screening,
particularly among those not as experienced in clinical risk assessment.
1999). Other studies have found inconsistent results for the predictive validity of the SIS for subsequent nonfatal
suicide attempts. Beck, Morris, & Beck, 1974 found that the SIS was related to subsequent attempted suicide while
Tejedor, Diaz, Castillon & Pericay (1999) did not find a relationship between the SIS score and subsequent suicide
attempt.
Other considerations:
The SIS has been translated into a number of languages and has shown to be reliable in different cultures (Gau et
al., 2009). The SIS might best serve as a research tool or brief screening tool to help understand, retrospectively, the reasons why
a person attempted suicide (Harriss & Hawton, 2005; Sisask et al., 2009). The first section on objective ratings could
even be completed through medical chart review by researchers following a persons death (Freedenthal, 2008).
However, given the inconsistencies and lack of predictive power, the SIS is not a useful screening tool to assess for
future risk of suicide.
Using the suicide probability score (range = 0 to 100) cut off scores have been created representing persons in
inpatient facilities (e.g., high risk = 50 to 100), persons in outpatient clinics (e.g., intermediate risk = 25 to 49), and
persons in the general population (e.g., low risk = 0 to 24). The total weighted score ranges from 30 to 147 with a
weighted score of 78 published as the cut-off for high risk.
The SPS is based on six factors:
Hopelessness,
Suicidal Ideation,
Negative Self-Evaluation (combining positive outlook and interpersonal
closeness), and
Hostility (including angry impulsivity).
continued...
The existence of these different dimensions allows clinicians to identify specific factors that may be contributing
to a persons risk of suicide.
Potential setting/Population:
The SPS has been used in adolescent and adult samples of men and women. Normative scores have been
developed based on samples from the general population, persons receiving inpatient mental health services,
and persons who have attempted suicide (Cull & Gill, 1988). Each of these samples included persons of White,
Hispanic, and African-American racial backgrounds. The SPS has also been applied to adult prison inmate
populations where the higher total probability scores were found to have low to moderate sensitivity and
specificity in discriminating among inmates who would later engage in suicidal behaviour (Naud & Daigle, 2010).
The SPS has also shown to be reliable among university students, adolescents, and male prison inmates (Labelle
et al., 1998).
Psychometric properties:
Among adult populations, the SPS has shown strong reliability with Cronbachs alphas of = .93, and ranging
from = .62 to =.93 for the four clinical subscales (Cull & Gill, 1988, Bisconer & Gross, 2007). The SPS has
also demonstrated good convergent validity correlating well with other measures of suicide risk, hopelessness,
and depression. Test-retest reliability with a correlation of r = .92 has been established over a three-week period.
Predictive validity of the SPS has not been extensively studied in adult populations. In a small sample of adult
inpatients admitted as either a danger to self (high risk group) or danger to others (low risk group) the total
suicide probability score cut off of 50 on the SPS was able to correctly identify persons in the high risk group
(sensitivity) 52% of the time, while correct identification of those not in the high risk group (specificity) occurred
in 78% of cases. These results warrant further investigation before recommendations of the use of a cut-off score
can be made.
Other considerations:
The SPS is reliable and valid for use among adolescent psychiatric inpatients, although the original factorstructure identified in adults was not consistently identified among adolescents (Eltz et al., 2006). Among
hospitalized adolescents, the total weighted SPS score strongly predicts suicide attempts post discharge (HuthBocks et al., 2007). In the same study, the sensitivity of the cut-off score of 78 was moderate at 65%, as was the
specificity at 64%. Lowering the cut-off to 61 greatly improved the sensitivity to 90% but drastically reduced the
specificity to 38%, indicating that a high number of false positives would be expected.
x
26
36
15
x
Predictive
Validity
Reliability
Global
Assessment
Screening
Potential Utility
In
Out ER
Psychiatric
NonPsychiatric
Population Setting
Adults
Children
& Youth
Older
Adults
Population Specific ^
*The interRAI SOS scale is embedded in a larger mental health assessment system based on three different instruments. The number of items in each
instrument varies as does the time to complete the entire assessment.
Note. BSS = Beck Scale for Suicide Ideation; BHS = Beck Hopelessness Scale; C-SSRS = Columbia-Suicide Severity Rating Scale; GSIS = Geriatric Scale
for Suicide Intent; RAI-MH SOS = interRAI Mental Health Severity of Self-harm Scale; MHECC = Mental Health Environment of Care Checklist;
NGASR = Nurses Global Assessment of Suicide Risk; RFL = Reasons for Living Inventory; SIS-MAP = Scale for Impact of Suicidality Management,
Assessment and Planning of Care; SSI-M = Modified Scale for Suicide Ideation; SBQ = Suicidal Behaviours Questionnaire; SIS = Suicide Intent Scale;
SPS = Suicide Probability Scale; TASR = Tool for the Assessment of Suicide Risk.
TASR
SPS
SIS
34
18
SSI-M
108
SIS-MAP
SBQ
10
48
15
114
varies*
SAD
PERSONAS
RFL
NGASR
MHECC
interRAISOS
GSIS
31
C-SSRS
x
20
BHS
21
BSS
# of
Items
Interview/
Observation
Administration
SelfReport
Scale
Table 3. Authorship and copyright information for suicide risk assessment scales.
Scale
Main Author
Contact Info
Copyright
Fee
Aaron T. Beck,
University of Pennsylvania
Gregory K. Brown Department of Psychiatry
& Robert A. Steer Room 2032
3535 Market Street
Philadelphia, PA 19104-3309
abeck@mail.med.upenn.edu
Yes
$115 (Pearson)
www.pearsonassessments.com
Beck
Hopelessness
Scale (BHS)
University of Pennsylvania
Department of Psychiatry
Room 2032 - 3535 Market Street
Philadelphia, PA 19104-3309
abeck@mail.med.upenn.edu
Yes
$115 (Pearson)
www.pearsonassessments.com
Columbia
Suicide
Severity Rating
Scale (C-SSRS)
Kelly Posner
No
Contact author for permission
to use
The Geriatric
Suicide Ideation
Scale (GSIS)
Yes
No
Contact author for permission
to use
InterRAI
Mental Health
Assessment
Tools: Severity of
Self-harm Scale
(interRAI SOS)
Yes
No
Contact interRAI for licensing
Scale
Main Author
Contact Info
Copyright
Fee
The Mental
Health
Environment of
Care Checklist
(MHECC)
Peter Mills
No
No
Modified Scale
for Suicide
Ideation (SSI-M)
Ivan W. Miller,
William H.
Norman, Stephen
B. Bishop &
Michael G. Dow
Ivan W. Miller
Box G-RI
Brown University
Providence, RI 02912-G-RI
Yes
Nurses Global
Assessment of
Suicide Risk
(NGASR)
John Cutcliffe
University of Northern British
Columbia
3333 University Way
Prince George, BC Canada V4N
4Z9
Cutclifi@unbc.ca
Yes
No
Reasons for
Living Inventory
(RLS)
Marsha M.
Linehan
Yes
No
Contact author for permission
to use
SAD PERSONS
Scale
William M.
Patterson, Henry
H. Dohn, Julian
Bird & Gary A.
Patterson
No
No
Scale
Main Author
Contact Info
Copyright
Fee
Amresh Srivastava
& Charles Nelson
Yes
No
Contact author for permission
to use
Suicidal
Behaviors
Questionnaire
(SBQ)
Marsha M.
Linehan
Yes
No
Contact author for permission
to use
Suicide Intent
Scale (SIS)
Aaron T. Beck,
D. Schuyler &
Herman
University of Pennsylvania
Department of Psychiatry
Room 2032 - 3535 Market Street
Philadelphia, PA 19104-3309
abeck@mail.med.upenn.edu
Yes
No
Contact author for details
Suicide
Probability Scale
(SPS)
Yes
Department of Psychiatry
Dalhousie University
5909 Veterans Memorial Lane, 8th
floor
Abbie J. Lane Memorial Building
QEII Health Sciences Centre
Halifax, NS CANADA B3H 2E2
Tel: (902) 473-2470
Fax: (902) 473-4887
Stan.kutcher@dal.ca
Yes
No
The ability to predict suicide based on the score (or scores) on a risk
assessment tool is low. Ideally, the selection of the risk assessment tool
would be based on its predictive ability i.e., based on how someone
responds to the questions in an assessment, how likely is it that he or she
will actually attempt suicide?
The difficulty in answering this question lies in the fact that suicide,
while catastrophic, is a relatively uncommon outcome in most
health care settings. With so few instances where a person dies by
suicide, it is difficult to evaluate its predictive value.
Instead, research on the predictive value suicide risk assessment tools
is forced rely on proxy outcome measures such as increase in risk
factors or warning signs of suicide.
The fact that suicide risk assessment tools can never be 100% accurate
underscores the importance of using clinical judgement and collaboration in
conjunction with suicide risk assessment tools.
For example, in some instances a person may not disclose indicators
of risk in a clinical interview but may report indicators on a
self-report tool.
The inclusion of risk assessment tools may be a way to improve the overall
quality of the suicide risk assessment process. Risk assessment tools are
particularly useful for persons with less experience in risk assessment. In this
sense, the risk assessment tool presents an opportunity for standardizing the
use and process of risk assessment.
Section III
A Framework for Suicide Risk Assessment and Quality Monitoring
Section III: A Framework for Suicide Risk Assessment and Quality Monitoring
Suicide risk assessment needs to be thorough, person-centred, and simple. It needs to incorporate
multiple approaches to ascertain a persons level of distress and risk of suicide.
In this section:
Document all findings (See Section I, page 16 for further discussion); and
Section III: A Framework for Suicide Risk Assessment and Quality Monitoring
Below is a framework for suicide risk assessment adapted from Barker and
Barker (2005) that is expanded to include five dimensions (Box 6). This five
dimensional framework presented in this guide is distinct from the Tidal
model in two respects. First, it is applicable to care settings beyond mental
health. Secondly, it can be used with persons who may come into contact with
mental health and non-mental health care settings for reasons other than risk
of harm to self or have yet to be assessed for suicide risk.
his or her strengths and supports available that may moderate risk.
Section III: A Framework for Suicide Risk Assessment and Quality Monitoring
For persons not already in mental health treatment environments, the level
of restriction in the care environment will increase with the severity of risk
identified. For persons found to have potentiating risk factors where no
warning signs are present, the restriction in the care environment may be less
than persons exhibiting warning signs suggestive of high risk. Recommended
care for this population may include follow-up counselling and further mental
health assessment to attend to the persons distress and prevent escalation of
suicide risk. When warning signs are present, immediate intervention includes
engaging professional mental health services, crisis supports, and/or seeking
emergency mental health services.
When developing a care plan, it is also important to keep in mind the issues
of chronic suicidality and mental illness and their impact on care planning as
discussed in Section I, starting on page 7.
Suicide risk assessment tools, as discussed in Section II, are one source of
information that can be used to determine a persons risk of suicide. They do
not replace clinical judgement (Barker and Barker, 2005). The use of tools
within the stages of the risk assessment framework should remain personfocused and be incorporated using empathetic, warm, and
objective assessment.
The inclusion of risk assessment tools may be a way to improve the overall
quality of the suicide risk assessment process since their use helps add further
summary evidence to inform and communicate risk. Many of the persons
interviewed indicated that risk assessment tools are useful for informing
the overall risk assessment, particularly for persons with less experience
conducting a risk assessment. In this sense, risk assessment tools present
an opportunity for standardizing the use and process of risk assessment.
Among persons who may have difficulty disclosing feelings or emotions (e.g.,
adolescent males), risk assessment tools may also help provide them ways to
express and describe their feelings and distress.
Section III: A Framework for Suicide Risk Assessment and Quality Monitoring
protective factors. Tools that may be useful include the SAD PERSONS, (page
49) and TASR, (page 57) because they are subtle scales that can be completed
by the practitioner during a general clinical interview to get a general
summary of potential risk and can be used to aid in the referral process.
Among persons caring for older adults (e.g., in-home care services), the GSIS,
(page 42) may be useful.
The same tool (GSIS) can be used to monitor persons who may not be at high
risk but have the potential to develop risk on an ongoing basis (e.g., presence
of potentiating risk factor with no warning signs). If risk is determined in
screening, typically persons may be referred to specialized levels of care for
more in-depth suicide risk assessment and intervention.
Emergency rooms
Main goal: Identify the level of risk and level of intent to decide whether a
person can safely leave the hospital setting or must be referred to a more
restrictive level of care for personal safety.
Role of risk assessment tool: Screening
Brief screening, as well as a clinical interview and consultation are important
for this decision-making process. Tools such as the SOS scale embedded in
the interRAI Emergency Screener for Psychiatry might help with this process
since it provides questions of the recency of suicide ideation or attempts,
intent, and other information about risk of harm to others and self care.
This tool will provide a brief indicator of risk that should be accompanied
by a full clinical interview and/or focused assessment of risk, particularly if
any indication of risk is identified through initial screening on the SOS or
other screening methods applied. Global risk assessment tools may help the
emergency room clinical team gauge the persons level of intent and identify
specific areas of distress in order to inform the persons next level of care
(either admission to hospital or discharge to community care setting).
Section III: A Framework for Suicide Risk Assessment and Quality Monitoring
Box 7. Indicators for ROP monitored by Accreditation Canada (2010) for all
mental health services, within hospital and in the community
Section III: A Framework for Suicide Risk Assessment and Quality Monitoring
Quality and the need to develop specific quality indicators for suicide
risk assessments
The relative unavailability and inability to easily collect data related to
suicide risk assessment present challenges to the development and ongoing
monitoring of quality indicators associated with suicide risk assessment. As one
example of this problem, Mahal et al. (2009) had to use a manual chart review
for scoring 19 process quality indicators among 141 persons who received
services at one emergency mental health setting. Requiring that organizations
undergo this kind of data collection exercise for all persons under care would
be onerous and the potential cost, high. While the accreditation process
involves site visits and random chart review to audit these practices, this
process is carried out at broad intervals.
Mork, Mehlum, Fadum, and Rossow, (2010) suggest that evaluating the quality
of ones suicide risk assessment can be done by referring to clearly defined
standards written in organizational guidelines and policies. Without systematic
ways to efficiently track the completion of risk assessment (e.g. electronic
medical records), organizations wanting to monitor the quality of their
risk assessment process, may have to rely on their demonstrated adherence
to suicide risk assessment-related policies. These policies may include the
principles for high-quality risk assessment outlined in this and other guides,
as well as policies for the timing of risk assessments and the processes for
following up on risk identification.
While future research is needed on their validity and effectiveness, other
indicators of high quality organizational suicide risk assessment processes may
include policies that:
More broadly, in terms of outcome, the rate of suicide has been examined as
an indicator of mental health service quality. Desai, Dausey, and Rosenheck
(2005) examined the use of suicide rates as a quality measure for mental
health services delivered through Veterans Affairs hospitals in the United
States. In a sample of over 120,000 persons who received services, 481 suicides
occurred. While suicide rates did vary across facilities, no association was
found between the differences in suicide rates and other quality of care
measures such as length of stay, continuity of care, timeliness of outpatient
visits, rehospitalization, or hospital funding.
Desai and colleagues recommend against the use of suicide rates as a quality
measure because:
Further, the rate of suicide does not
directly reflect the quality of the risk
assessment process itself. It may be
It is clear that designing process indicators (i.e., indicators about the how
the risk assessment was completed) to specifically identify poor suicide risk
assessment is a challenge due to the qualitative nature of risk assessment
processes. Outcome quality indicators measuring the incidence of suicide
ideation, plans, or behaviours while a person is receiving care from a service
Section III: A Framework for Suicide Risk Assessment and Quality Monitoring
Section III: A Framework for Suicide Risk Assessment and Quality Monitoring
2.
3.
The Future
It should be noted that the scope of suicide risk is extremely broad.
This guide focused only on the process of risk assessment within the
context of health care organizations. It does not focus on risk assessment
in non-health care contexts, and also excludes a discussion of the feasibility
of integrating technology into the risk assessment process (e.g., telepsychiatry
and telemedicine), interventions for mitigating risk in different care
environments, or prevention strategies.
Recommendations for future investigation include:
This resource guide represents a first step in the standardization of the suicide
risk and prevention process. Development of these added resources can
provide the foundation for a national strategy on suicide prevention. Such
a strategy can also help generate public awareness about suicide, including
factors contributing to risk, and instil a culture of understanding, acceptance,
and prevention among Canadians.
Section IV
References and Resources
Other (15)
If the person indicated a specific specialty (e.g., youth mental health), then
the person was asked the questions in the context of his or her specialty (e.g.,
what are the key factors to consider in suicide risk assessment of youth?).
Name
Name
Organization
Linda Bender
Associate Professor,
Psychiatry & Behavioural Neurosciences
Coleen Cawdeary
Program Coordinator
Denice Klavano
Member
Name
Name
Organization
Jill Mitchell
Dena Moitoso
Tana Nash
Coordinator
Crystal Norman
Kathy Payette
Clinical Psychologist
Lee Whittmann
WARNING SIGNS:
Threatening to harm or end ones life
Seeking or access to means: seeking pills, weapons,
or other means
Evidence or expression of a suicide plan
Expressing (writing or talking) ideation about suicide,
wish to die or death
Hopelessness
Rage, anger, seeking revenge
Expressing feelings of being trapped with no way out
Increasing or excessive substance use
Withdrawing from family, friends, society
Anxiety, agitation, abnormal sleep (too much or
too little)
Dramatic changes in mood
Expresses no reason for living, no sense of purpose in life
Unemployed or recent
financial difficulties
Divorced, separated, widowed
Social Isolation
Low Risk:
recommend counseling and
monitor for development of
warning signs.
Examples of Protective Factors (Sanchez, 2001; United States Public Health Service, 1999)
The length of time since previous suicide attempt(s) or self-harming
behavior(s);
The rationale for not being admitted to a more intensive
environment or discharged to a less restrictive environment, and what
safety plans were put into place; and
1.
2.
3.
4.
5.
6.
7.
8.
9.
x
36
15
x
Predictive
Validity
Reliability
Global
Assessment
Screening
Potential Utility
In
Out ER
Psychiatric
NonPsychiatric
Population Setting
Adults
Children
& Youth
Older
Adults
Population Specific ^
*The interRAI SOS scale is embedded in a larger mental health assessment system based on three different instruments. The number of items in each
instrument varies as does the time to complete the entire assessment.
26
x
x
x
x
x
x
x
TASR
Note. BSS = Beck Scale for Suicide Ideation; BHS = Beck Hopelessness Scale; C-SSRS = Columbia-Suicide Severity Rating Scale; GSIS = Geriatric Scale
for Suicide Intent; RAI-MH SOS = interRAI Mental Health Severity of Self-harm Scale; MHECC = Mental Health Environment of Care Checklist;
NGASR = Nurses Global Assessment of Suicide Risk; RFL = Reasons for Living Inventory; SIS-MAP = Scale for Impact of Suicidality Management,
Assessment and Planning of Care; SSI-M = Modified Scale for Suicide Ideation; SBQ = Suicidal Behaviours Questionnaire; SIS = Suicide Intent Scale;
SPS = Suicide Probability Scale; TASR = Tool for the Assessment of Suicide Risk.
SPS
SIS
34
18
SSI-M
108
SIS-MAP
SBQ
10
48
15
114
varies*
SAD
PERSONAS
RFL
NGASR
MHECC
interRAISOS
GSIS
31
C-SSRS
x
20
BHS
21
BSS
# of
Items
Interview/
Observation
Administration
SelfReport
Scale
Appendix J: References
Aboriginal Healing Foundation. (2002). The healing has begun. Ottawa: Author. Retrieved from http://www.ahf.ca/
english-pdf/healing_has_begun.pdf.
Accreditation Canada (2011). Required Organizational Practice Handbook. www.accreditation.ca.
Adams-Fryatt, A. (2010). Acknowledging, recognizing, and treating depression in elderly long term care residents.
Annals of Long Term Care, 18, 30-32.
Alexander, M. J., Haugland, G., Ashenden, P., Knight, E., & Brown, I. (2009). Coping with thoughts of suicide:
Techniques used by consumers of mental health services. Psychiatric Services, 60, 1214-1221.
Ali, M. M., Dwyer, D. S., & Rizzo, J. A. (2011). The social contagion effect of suicidal behavior in adolescents: does it
really exist? Journal of Mental Health Policy and Economics, 14, 3-12.
American Psychiatric Association (APA). (2003). Practice guidelines for the assessment and treatment of patients with
suicidal behaviours. American Journal of Psychiatry, 160(11), 1-60.
Anestis, M. D. (2009). Suicide clusters: Is suicidal behaviour contagious? Psychotherapy Brown Bag. Retrieved
www.psychotherapybrownbag.com/psychotherapy_brown_bag_a/2009/05/suicide-clusters-is-suicidal-behavior
contagious.html.
Ayub, N. (2008). Validation of the Urdu translation of the Beck Scale for Suicide Ideation. Assessment, Retrieved from
http://asm.sagepub.com/content/early/2008/02/01/1073191107312240.
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