Assessment of suicide risk

Suicide risk assessment is a process of estimating the likelihood for a person to attempt or die by suicide. The goal of a thorough risk assessment is to learn about the circumstances of an individual person with regard to suicide, including warning signs, risk factors, and protective factors. Risk for suicide is re-evaluated throughout the course of care to assess the patient's response to personal situational changes and clinical interventions. Accurate and defensible risk assessment requires a clinician to integrate a clinical judgment with the latest evidence-based practice, although accurate prediction of low base rate events, such as suicide, is inherently difficult and prone to false positives. Suicide risk assessment is a process of estimating the likelihood for a person to attempt or die by suicide. The goal of a thorough risk assessment is to learn about the circumstances of an individual person with regard to suicide, including warning signs, risk factors, and protective factors. Risk for suicide is re-evaluated throughout the course of care to assess the patient's response to personal situational changes and clinical interventions. Accurate and defensible risk assessment requires a clinician to integrate a clinical judgment with the latest evidence-based practice, although accurate prediction of low base rate events, such as suicide, is inherently difficult and prone to false positives. The assessment process is ethically complex: the concept of 'imminent suicide' (implying the foreseeability of an inherently unpredictable act) is a legal construct in a clinical guise, which can be used to justify the rationing of emergency psychiatric resources or intrusion into patients' civil liberties. Some experts recommend abandoning suicide risk assessment as it is so inaccurate. In addition suicide risk assessment is often conflated with assessment of self-harm which has little overlap with completed suicide. Instead, it is suggested that the emotional state which has caused the suicidal thoughts, feelings or behaviour should be the focus of assessment with a view to helping the patient rather than reducing the anxiety of clinician who overestimates the risk of suicide and are fearful of litigation. In 2017, an example of how to do this in practice was published in the Scientific American. Given the difficulty of suicide prediction, researchers have attempted to improve the state of the art in both suicide and suicidal behavior prediction using natural language processing and machine learning applied to electronic health records. There are risks and disadvantages to both over-estimation and under-estimation of suicide risk. Over-sensitivity to risk can have undesirable consequences, including inappropriate deprivation of patients' rights and squandering of scarce clinical resources. On the other hand, underestimating suicidality as a result of a dismissive attitude or lack of clinical skill jeopardizes patient safety and risks clinician liability. Some people may worry that asking about suicidal intentions will make suicide more likely. In reality, regarding that the enquiries are made sympathetically, it does not. Key areas to be assessed include the person's predisposition to suicidal behavior; identifiable precipitant or stressors such as job loss, recent death of a loved one and change of residence; the patient's symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behavior; impulsivity and self-control; and protective factors. Suicide risk assessment should distinguish between acute and chronic risk. Acute risk might be raised because of recent changes in the person's circumstances or mental state, while chronic risk is determined by a diagnosis of a mental illness, and social and demographic factors. Bryan and Rudd (2006) suggest a model in which risk is categorized into one of four categories: Baseline, Acute, Chronic high risk, and Chronic high risk with acute exacerbation. Risk level can be described semantically (in words) e.g. as Nonexistent, Mild, Moderate, Severe, or Extreme, and the clinical response can be determined accordingly. Others urge use of numbers to describe level of relative or (preferably) absolute risk of completed suicide. The Scale for Suicide Ideation (SSI) was developed in 1979 by Aaron T. Beck, Maria Kovacs, and Arlene Weissman to quantify intensity in suicide ideators. It was developed for use by clinicians during semi-structured interviews. The scale contained 19 items rated on a scale from 0 to 2, allowing scores between 0 and 38. The items could be grouped into three categories: 'Active Suicidal Desire, Preparation, and Passive Suicidal Desire.' Initial findings showed promising reliability and validity. The Modified Scale for Suicide Ideation (MSSI) was developed by Miller et al., using 13 items from the SSI and 5 new items. The modifications increased both reliability and validity. The scale was also changed to range from 0 to 3, yielding a total score ranging from 0 to 54. Joiner found two factors, Suicidal Desire and Ideation, and Resolved Plans and Preparation. The MSSI was also shown to have higher discrimination between groups of suicide ideators and attempters than the BDI, BHS, PSI, and SPS. The Suicide Intent Scale (SIS) was developed in order to assess the severity of suicide attempts. The scale consists of 15 questions which are scaled from 0-2, which take into account both the logistics of the suicide attempt as well as the intent. The scale has high reliability and validity. Completed suicides ranked higher in the severity of the logistics than attempted suicides (it was impossible to measure intent for the completed suicides), and those with multiple attempts had higher scores than those who only attempted suicide once. The Suicidal Affect Behavior Cognition Scale (SABCS) is a six-item self-report measure based on both suicide and psychological theory, developed to assess current suicidality for clinical, screening, and research purposes. Substantial empirical evidence was found, from four independent studies, confirming the importance of assessing suicidal affect, behaviors, and cognition as a single suicidal construct. The SABCS was the first suicide risk measure to be developed through both classical test theory (CTT) and item response theory (IRT) psychometric approaches and to show significant improvements over a highly endorsed comparison measure. The SABCS was shown to have higher internal reliability, and to be a better predictor of both future suicidal behaviors and total suicidality over an existing standard. The Suicide Behaviors Questionnaire (SBQ) is a self-report measure developed by Linnehan in 1981. In 1988 it was transformed from a long questionnaire to a short four questions that can be completed in about 5 minutes. Answers are on a Likert scale that ranges in size for each question, based on data from the original questionnaire. It is designed for adults and results tend to correlate with other measures, such as the SSI. It is popular because it is easy to use as a screening tool, but at only four questions, fails to provide detailed information.