until any discrepancies between the assessment and the patient’s responses are addressed. 3. Determine intensity : In cases where the patient is having suicidal thoughts, the clinician should ask specific questions about the intensity and frequency of the suicidal thoughts as well as the degree to which the patient is prepared. Does the patient have a suicide plan? If a specific plan is described, the clinician should document that and document whether the patient has self-injurious or lethal plans. Additionally, the clinician should inquire about the method of suicide rehearsals, such as loading a gun, walking on a bridge to assess the height, or tying a noose. Whenever possible, the clinician should confirm findings with a family member or a close friend because patients are more likely to inform close relations of suicidal ideation than they are to tell a healthcare provider. 4. Assessment of protective factors : The clinician should inquire about existing protective factors against suicidal thoughts, such as strong family ties and friendships or the presence of a significant other. Additionally, religious belief, faith, and a sense of belonging can be used as protective factors. It is best to explore the patient’s reasons to die versus reasons to live. The presence of protective factors can help dampen the suicide risk in people with low or moderate suicide risks. Ideally, protective factors can be strengthened and used as part of safety planning in patients with low to moderate suicide risks. 5. Clinical judgment : The provider should use the above information to form and make a clinical decision on the risk of suicide. Clinical decision making is complex given the medical comorbidities, mental health diagnoses, and the contextual and environmental factors affecting patients with
suicidal risk. This decision-making process also includes appropriate documentation of risk and intervention. (Kazim, 2017) Assessment of risk level is based on clinical judgment after completing steps 1-3: 1. High risk level ○ Risk and/or protective factors : Psychiatric disorders with severe symptoms, or acute precipitating event. ○ Suicidality : Potentially lethal suicide attempt or persistent ideation with strong intent or rehearsal. ○ Possible interventions : Admission generally indicated unless a significant change reduces risk; suicide precautions necessary. 2. Moderate risk level ○ Risk and/or protective factors : Multiple risk factors, few protective factors. ○ Suicidality : Suicidal ideation with plan, but no intent or behavior. ○ Possible interventions : Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers. 3. Low risk level ○ Risk and/or protective factors : Modifiable risk factors, strong protective factors. ○ Suicidality : Thoughts of death but no plan, intent, or behavior. ○ Possible interventions : Outpatient referral, symptom reduction, give emergency/crisis numbers. The documentation of the above components in their entirety within the medical record (Kazim, 2017).
Suicide assessment framework option 2: Joiner Assessment Model Joiner and colleagues (1999) developed a suicide risk assessment decision-tree interview based on the interpersonal theory of suicide, which was also recently updated by Chu and colleagues (2015). Consistent with the interpersonal theory, the decision tree addresses suicidal desire and ideation, resolved plans and preparation (i.e., the degree to which plans have been decided upon and preparations for suicide made), and other significant findings such as stressors, hopelessness, impulsivity, and the presence of psychopathology (see Figure 1). However, the main trunk of the decision tree is focused on acquired capability. Joiner suggests determining the presence or absence of two potential presentations of acquired capability. First, clinicians should inquire about previous suicide attempts. Those with multiple suicide attempts would be considered to have acquired capability for death by suicide. Second, individuals without a history of multiple suicide attempts could acquire capability for suicide by the presence of at least three of the
Figure 1: Suicide Assessment Decision Tree
following five symptoms: 1. Single suicide attempt. 2. Aborted suicide attempts. 3. Self-injected drug use. 4. Self-harm (i.e., NSSI).
5. Frequent exposure to, or participation in, physical violence. The Joiner assessment model is comprehensive and organized into four risk categories (low, moderate, severe, extreme). However, these categories are somewhat flexible, and individuals can be classified in between categories (e.g., low-moderate, moderate-severe). As with all risk assessments, Joiner and colleagues note, “suicide risk categories guide clinical decision making and allow clinicians to titrate the level of clinical action insofar that efficiency and efficacy are maximized” (Chu et al., 2015, p. 1187).
Note . Adapted from “Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice,” by T. E. Joiner, Jr., R. L. Walker, M. D. Rudd, and D. A. Jobes, 1999, Professional Psychology: Research and Practice , 30(5), pp. 1-7; and “Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update,” by C. Chu, K. M. Klein, J. M. Buchman- Schmitt, M. A. Horn, C. R. Hagan, and T. E. Joiner, 2015, Journal of Clinical Psychology , 71(12), pp. 1186-1200.
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