SUICIDE SCREENING AND ASSESSMENT

Suicide screening and assessment of risk for suicide are important in any suicide prevention plan; however, it is very difficult to predict who will actually die by suicide.

Suicide prevention screening refers to a quick procedure in which a standardized instrument or tool is used to identify individuals who may be at risk for suicide and in need of assessment. It can be done independently or as part of a more comprehensive health or behavioral health screening. Suicide assessment, as opposed to screening, refers to a more comprehensive evaluation done by a clinician to confirm a suspected suicide risk, to estimate imminent danger, and to decide on a course of treatment.

Suicide Screening

There is debate about the benefits of screening all patients (universal screening) for suicide risk factors and whether screening actually reduces suicide deaths. The general view, however, is that such screening should only be undertaken if there is a strong commitment to provide treatment and follow-up, since there is some evidence that screening improves outcomes when it is associated with such close follow-up and treatment. Instead of universal screening, some recommend that screening be done only for those presenting with known risk factors (selective or targeted screening). Despite this lack of uniform guidance, health systems are implementing suicide screening protocols, and screening tools are already widely used in primary care settings (Durkin, 2019; O’Rourke et al., 2019).

U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS

In 2019, the U.S. Preventive Services Task Force issued a final recommendation statement concluding that current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care and to those who do not have an identified psychiatric disorder.

The recommendations further state that, although evidence to screen asymptomatic populations is inadequate, providers should consider identifying patients with risk factors such as a history of suicide intent or behaviors, especially those with mental health diagnoses, and those who seem to have a high level of emotional distress, and to refer them for further evaluation.

JOINT COMMISSION RECOMMENDATIONS

The majority of people who die by suicide visit a healthcare provider within months of their death, representing an important opportunity to intercede and connect them with mental health resources. However, The Joint Commission indicates that few healthcare settings routinely screen for suicide risk. In 2016, The Joint Commission issued a Sentinel Event Alert recommending that all patients in all medical settings be screened for suicide. For children and adolescents, screening should be done without the parent or guardian present. However, if the parent or guardian refuses to leave the room or the child insists that they stay, the screening should still be conducted.

Patients who are screened and found positive for suicide risk on the screening tool should receive a brief suicide safety assessment conducted by a trained clinician to determine whether a more comprehensive mental health evaluation is required.

The Joint Commission recommended that primary, emergency, and behavioral health clinicians look for suicidal ideation in all patients in both nonacute and acute care settings. The Commission advised:

• Reviewing each patient’s personal and family history for suicide risk factors
• Screening all patients for suicide risk factors using a brief, standardized, evidence-based screening tool, and reviewing screening questionnaires before the patient’s appointment is ended or the patient is discharged
• That research suggests that a brief screening tool is more reliable at identifying patients at risk for suicide than a clinician’s personal judgment or questions about suicidal thoughts that use vague or softened language
  (TJC, 2018)

SCREENING TOOLS

The following are validated, evidence-based screening tools:

Ask Suicide-Screening Questions (ASQ)

A four-item suicide screening tool designed to be used for patients ages 10 to 24 in emergency departments, inpatient units, and primary care facilities. The tool takes two minutes to administer and asks the following four questions:

1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you ever tried to kill yourself? If yes, how?
   (NIMH, 2019)

Columbia-Suicide Severity Rating Scale (C-SSRS) Screening Version

This screening tool is to be used in general healthcare settings for all ages and asks questions that address:

1. Whether and when the patient has thought about suicide
2. What actions they have taken, and when, to prepare for suicide
3. Whether and when they have attempted suicide or began a suicide attempt that was either interrupted by another person or stopped of their own volition
   (TJC, 2018)

Patient Health Questionnaire-9 (PHQ-9)

A nine-item tool used to diagnose and monitor the severity of depression used for ages 12 and older in all primary care and behavioral healthcare settings. Question #9 screens for the presence and duration of suicide ideation (TJC, 2018).

Suicide Behavior Questionnaire-Revised (SBQ-R)

A four-item, self-report questionnaire for use in ages 13 to 18 that asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones and includes a question about lifetime suicidal ideation, plans to die by suicide, and actual attempts (TJC, 2018).

Recognizing Suicide Warning Signs

Besides screening for risk factors for suicide, it is important to be able to recognize behaviors that indicate an individual is at immediate risk for suicide. These are referred to as proximal factors, or warning signs, and are grounds for immediate action. Such warning signs include:

• Talking about or writing about death, dying, or dying by suicide
• Threatening to hurt or kill oneself
• Looking for ways to kill oneself, such as searching online for lethal methods or buying a gun
• Talking about feeling hopeless or having no reason to live
• Talking about feeling trapped, like there is no way out
• Talking about being a burden to others
• Increasing use of alcohol or drugs
• Withdrawing from friends, family, or social activities
• Changing one’s eating and/or sleeping habits
• Showing rage, anger, or talking about seeking revenge
• Acting anxious or agitated
• Displaying significant changes in mood, especially suddenly changing from very sad to very calm or happy
• Taking risks that could lead to death, such as driving extremely fast
• Losing interest in school, work. or hobbies
• Losing interest in personal appearance
• Visiting or calling people to say goodbye
• Giving away important possessions
• Preparing for death by writing a will and making final arrangements
  (APA, 2019b)

Suicide Risk Assessment

The purpose of a suicide risk assessment is to determine a patient’s risk and protective factors with a focus on identification of targets for intervention. There are a number of standardized scales available to evaluate risk of suicide, but none of them is associated with a high predictive value (Schreiber & Culpepper, 2019). The most effective assessment begins with the establishment of a therapeutic relationship with the patient.

ESTABLISHING RAPPORT

The initial contact with a person who is suicidal may occur in many different settings—home, telephone, inpatient unit, outpatient clinic, practitioner’s office, rehabilitation unit, long-term care facility, or hospital emergency department. Being skilled at establishing rapport quickly is essential for all clinicians. It is imperative that the person be given privacy, be shown courtesy and respect, and be made aware that the clinician wants to understand what has happened or is happening to them.

It is important to note that often suicidal persons have recently perceived rejection, and a considerable amount of expertise may be required in order to establish rapport (IASP, 2019).

Basic Attending Skills

Basic attending and listening skills are valuable in establishing rapport and a therapeutic alliance in order to obtain information, set the foundation for the treatment plan, and assist in determining interventions. These skills range from nondirective listening behaviors to more active and complex ones.

Positive attending behaviors are nonverbal and include:

• Eye contact. Cultures vary in what is considered appropriate. Asian and Native Americans, for example, may view eye contact as aggressive. Most patients are comfortable with more eye contact when the interviewer is talking and less when they are talking.
• Body language. Usually leaning slightly toward the patient and maintaining a relaxed but attentive posture is effective. This may also include mirroring, which involves matching the patient’s facial expression and body posture.
• Vocal qualities. These include tone and inflections of the interviewer’s voice. Tonal quality may move toward “pacing,” which is matching the patient’s vocal qualities. Vocal qualities can be used to lead the patient.
• Verbal tracking. This involves using words to demonstrate that the interviewer has an accurate following of what the patient is saying, such as restating or summarizing what the patient has said.

Negative attending behaviors include:

• Overuse of positive attending behaviors, which can become negative or annoying
• Turning away from the patient
• Making infrequent eye contact
• Leaning back from the waist up
• Crossing the legs away from the patient
• Folding the arms across the chest
  (Grieve, n.d.)

Listening Skills and Action Responses

Effective interviewing also requires nondirective and directive listening as well as directive action responses.

Nondirective listening responses:

• Silence is a skill requiring practice to be comfortable with. It is very nondirective, and if used appropriately, it can be very comforting for the patient.
• Paraphrasing, or reflection, is a verbal tracking skill that involves restating or rewording what the patient has said. There are three types of paraphrasing that can be utilized:
  • Simple paraphrasing gives direction but involves rephrasing the core meaning of what the patient has said.
  • Sensory-based paraphrasing involves the interviewer using the patient’s sensory words in the paraphrase (visual, auditory, kinesthetic, etc.).
  • Metaphorical paraphrasing involves making an analogy or metaphor to summarize the patient’s core message.
• Intentionally directive paraphrasing is solution-focused and attempts to lead the patient toward more positive interpretations of reality. It involves selecting positive parts of the patient’s statement and can also include adding to or “twisting” what has been said.
• Summarization is an informal summary of what the patient has said. It should be interactive, encouraging, and supportive, and include positives or strengths that may help the patient cope.
  (Sommers-Flanagan & Sommers-Flanagan, 2016)

Directive listening skills:

• Validating feelings involves acknowledgement and approval of the patient’s emotional state. It can help patients accept their feelings as normal or natural and can enhance rapport.
• Interpretive reflection of feeling, also referred to as advanced empathy, seeks to uncover deeper, underlying feelings, which can bring about strong emotional insights or defensiveness.
• Interpretation is a classic psychoanalytic technique that can produce patient insight or a solution-focused way to help patients view their problems from a new and different perspective, also known as reframing.
• Confrontation involves pointing out discrepancies to help the patient see reality more clearly. It works best when excellent rapport has been established, and it can be either gentle or harsh.
  (Sommers-Flanagan & Sommers-Flanagan, 2016)

When attempting to elicit information from suicidal persons, it should be remembered that challenging or direct questions which could be interpreted as critical will rarely be of benefit. The individual who is suicidal should be encouraged and given the opportunity to express thoughts and feelings and allowed to discharge pent-up and repressed emotions. This can best be achieved by asking open-ended questions such as: “What are your feelings about living and dying?” Such questions allow an expression of the ambivalent feelings most often experienced by persons who are suicidal. Direct questions such as “Do you really want to kill yourself?” do not allow such an expression (IASP, 2019).

OPEN-ENDED QUESTIONING IN RESPONSE TO PERSONS WHO ARE SUICIDAL

Person’s Statement	Appropriate Responses
(Adapted from Videbeck, 2011)
Everyone will be better off without me.	Who would be better off? What would be better for those people? Where are you planning to go?
I just can’t bear it anymore.	What is so hard to bear? What would make your life better? When did you begin to feel this way?
I just want to go to sleep and not deal with it again.	What do you mean by “sleep”? What is it you don’t want to deal with anymore?
I want it to be over.	What is it you want to be over? How can you make it be over?
I won’t be a problem much longer.	How are you a problem? What is going to change in your life so you won’t be a problem any longer? When will you no longer be a problem?
Things will never work out.	What can you do to change that? What, then, do you propose to do?
It is all so meaningless.	What would make life more meaningful? What are some aspects of your life that make it worth living? What is happening in your life that makes it so meaningless?

ASSESSING SUICIDAL INTENT

Once it is determined that suicidal ideations are present, the next step is to determine whether the patient has active (thoughts of taking action) or passive (wish or hope to die) intent. The patient should be asked if the thoughts are new and if there are changes in the frequency or intensity of chronic thoughts. It is also important to inquire about the patient’s ability to control these thoughts.

Suicidal intent can be determined best by considering the degree of planning, the knowledge of the lethality of the intended suicidal act, and the degree of isolation of the person. At this point, specific and direct questions should be asked to gather specific information, such as:

• Do you ever wish you were dead?
• Have you ever felt that life is not worth living?
• Have you been thinking about death recently?
• How long have suicidal feelings been present?
• Did you ever think about suicide?
• Have you ever practiced or attempted suicide?
• Do you have a plan for suicide?
• What is your plan for suicide?
• Do you have your chosen means for suicide available or readily accessible?
• Do you know how to use the method you have chosen?
• Do you have a history of substance use or impulsive behaviors?
• Do you have a plan for others after death, such as leaving a suicide note, changing your will?

Red flags to consider may include a sense of hopelessness, a feeling of entrapment, well-formed plans, a perception of no social support, distressing psychotic phenomena, and significant pain or chronic illness (Harding, 2019; Schreiber & Culpepper, 2019).

Suicide Risk Assessment Tools

Although various suicide risk assessment tools are available, experts have repeatedly come to the conclusion that there is not any one tool that can predict who will die by suicide to any useful degree. There are many tools available to assist healthcare professionals in determining suicidal intent. These assessment tools are used to assess a person’s intent to carry through. They are often used when positive results have been obtained with one of the screening tools mentioned above. The following are validated/evidence-based suicide risk assessment tools:

• Columbia-Suicide Severity Rating Scale (C-SSRS): Risk assessment version provides a checklist of protective risk factors for suicide, used along with the C-SSRS screening tool. It is appropriate in all settings for all ages and special populations in different settings. The tool features a clinician-administered initial evaluation form, a “since last visit” version, and a self-report form (Oquendo & Bernanke, 2017).
• Beck Scale for Suicide Ideation (BSI): A 21-item self-report instrument that can be used in inpatient and outpatient settings for detecting and measuring the current intensity of the patient’s specific attitude, behaviors, and plans to die by suicide during the preceding week. It assesses the wish to die, desire to make an active or passive suicide attempt, duration and frequency of ideation, sense of control over making an attempt, number of deterrents, and the amount of actual preparation for the contemplated attempt (TJC, 2018).
• Scale for Suicide Ideation-Worst (SSI-W): A 19-item interviewer-administered rating scale that takes approximately 10 minutes which measures a patient’s intensity of specific attitudes, behaviors, and plans to die by suicide during the time period that they were most suicidal. Can be used in both inpatient and outpatient settings (TJC, 2018a).

Clinical Interview

The clinical interview is the “gold standard” for suicide assessment and intervention. A clinical interview focuses on three areas—the presenting problem, the psychosocial history, and the current situation and functioning. Rather than focusing on risk factors and suicide prevention, the interview should focus on eight suicide dimensions or drivers:

1. Unbearable emotional or psychological distress
2. Problem-solving impairments
3. Interpersonal disconnection, isolation, or feelings of being a social burden
4. Arousal or agitation
5. Hopelessness
6. Suicide intent and plan
7. Desensitization to physical pain and thoughts of death
8. Access to firearms
   (Sommers-Flanagan, 2019)

Although infrequent, homicide/murder and suicide are a reality. Any question of suicide also must be coupled with an inquiry into the person's potential for homicide. Suicide is considered aggression toward the self, whereas homicide is considered aggression toward others. Because suicide is an aggressive act, consideration of homicide must also be addressed. It has been found among homicide-suicides that most victims were spouse/partners and/or children. Most of the perpetrators are male and most victims are female (Soreff et al., 2019).

ASSESSING THE PLAN, LETHALITY, AND RISK

The evaluation of a suicide plan is extremely important in order to determine the degree of suicidal risk. When assessing lethality of a plan, it is important to learn all the details about the plan, the method chosen, and the availability of means. People with definite plans for a time, place, and means are at high risk for suicide. Someone who is considering suicide without making a plan is at lower risk.

Suicidal deaths are more likely to occur when persons use highly damaging, fast-acting, and irreversible methods—such as jumping from heights or shooting—and do so when rescue is fruitless.

Methods of Suicide and Lethality

The desire for a painless method of suicide often leads individuals to choose a method that tends to be less lethal. This results in attempted suicides that do not end in death. For every 25 attempts, there is one death. For drug overdoses, the ratio is around 40 to 1. The following are methods of suicide and the likelihood that they will result in death:

• Firearms: 82.5%
• Drowning/submersion: 65.9%
• Suffocation/hanging: 61.4%
• Gas poisoning: 41.5%
• Jump: 34.5%
• Drug/poison: 1.5%
• Cut/pierce: 1.2%
• Other: 8.0%
  (HSPH, 2020)

Factors that influence the lethality of a chosen method include:

• Intrinsic deadliness. A gun is intrinsically more lethal than a bottle of pills.
• Ease of use. If a method requires technical knowledge, for example, it is less accessible than one that does not.
• Accessibility. Given the brief duration of some suicidal crises, a gun in the cabinet in the hall is a greater risk than a very high building 10 miles away.
• Ability to abort mid-attempt. More people start and stop mid-attempt than carry through. It is easier to interrupt a hanging or to call 911 after overdosing than if jumping off a bridge or using a gun.
• Acceptability to the individual. Must be a method that does not cause too much pain or suffering. For example, fire is readily accessible, but it is seldom ever used in the United States.
  (HSPH, 2020)

Level of Risk

A clinical judgment that is based on all the information obtained during assessment should help to assign a level of risk for suicide and determine the setting of care.

Patients who are low risk of suicide:

• Have thoughts of death only
• Have no suicide plan
• Have no clear intent
• Have easily identifiable and multiple protective factors
• Have no history of suicidal behaviors
• Have evidence of self-control
• Are willing to talk about stressors or depression
• Have supportive family members or significant others
• Are willing to comply with treatment recommendations
• Have a high degree of ambivalence

Most people who are suicidal do not necessarily want to die; they just do not want to continue living in an intolerable situation or state of mind. This ambivalence is one of the most important tools for working with suicidal persons. Almost everyone who is suicidal is ambivalent about dying, leaning toward suicide at one moment in time, and then leaning toward living the next. The healthcare professional can use this ambivalence to help focus the person on the reasons why they should live.

Patients who are at moderate risk:

• Have suicide ideation
• Have no clear plan for suicide
• Have limited intent to act
• Have some identifiable protective factors
• Exhibit fair/good judgment
• Have no recent suicidal behavior
• Have supportive family or significant others
• Are willing to comply with treatment recommendations
• Have a high degree of ambivalence
• Have no access to lethal means

Patients who are at high/severe/imminent risk:

• Have a specific suicide plan
• Have access to lethal means
• Have minimal protective factors
• Have impaired judgment
• Have poor self-control either at baseline or due to substance use
• Have a poor social support network
• Have severe psychiatric symptoms and/or an acute precipitating event
• Have a history of prior suicide attempt

(Yasgur, 2016; WICHE MHP & SPRC, 2017)

Psychiatric illness is a strong predictor. More than 90% of patients who attempt suicide have a psychiatric disorder, and 95% of patients who successfully die by suicide have a psychiatric diagnosis.

A prior history of attempted suicide is the strongest single factor predictive of suicide. One of every 100 suicide attempt survivors will die by suicide within one year of the initial attempt, a risk approximately 100 times that of the general population. Following a suicide attempt, the risk for dying by suicide is greatest in patients with schizophrenia, unipolar major depression, and bipolar disease (Schreiber & Culpepper, 2019; Yasgur, 2016; WICHE MHP & SPRC, 2017).

Indicators of high risk for suicide following a suicide attempt include:

• Suicide attempt with a highly lethal method
• Suicide attempt that included steps to avoid detection
• Ongoing suicidal ideation or disappointment that a suicide attempt was not successful
• Inability to openly and honestly discuss the suicide attempt and what precipitated it
• Lack of alternatives for adequate monitoring and treatment
• Psychiatric disorders underlying the suicidal ideation and behavior
• Agitation
• Impulsivity
  (Schreiber & Culpepper, 2019)

Impulsiveness and Access to Means

Research has found that when people make a decision to attempt suicide, nearly half will attempt it within 20 minutes (Meinert, 2018). To define impulsivity in relation to suicide, however, is difficult. Some consider the duration from first suicidal ideation to actual attempt, and others define it as an absence of planning or preparation. Regardless of this uncertainty, it is common for suicide attempts to be considered impulsive acts, and there is evidence that strongly links the two.

Studies done among people who have attempted suicide have found that those with impulsive suicidal behavior, when compared to those with nonimpulsive suicidal behavior:

• Have less severe and intensive suicide ideations, suggesting they progress from vague suicide ideation directly to a suicide attempt
• Have significantly lower intent
• Use significantly less lethal methods
• Are relatively younger
• Rarely have significant risk factors such as being older; living alone; or being widowed, divorced, or separated
• Have psychiatric symptoms as the main reason for a suicide attempt

Impulsivity is considered a possible phenotype underlying self-harm and suicidal behaviors, and there is evidence that different facets of impulsivity follow different neurodevelopmental trajectories, with some factors more strongly associated with such behaviors than others. It is unclear, however, whether impulsivity is a useful predictor of self-harm or suicidal behavior in young people, a population already considered to have heightened impulsive behaviors (McHugh et al., 2019; Lim et al., 2016; Chaudhury et al., 2016).

There is substantial support for the idea that ease of access influences the choice of method. Having access to lethal means increases the risk for death by facilitating transition from thought to action. Approximately one half of all suicide deaths in the United States are the result of self-inflicted gunshot wounds, and the next most commonly used method is intentional overdose. The most lethal method, a firearm, is present in at least one third of all households in America (ASS, 2018).

Research in 2019 found that more adolescents were attempting suicide by overdosing on medications readily available in the home. These included over-the-counter medications such as ibuprofen and aspirin, or prescription medications such as antidepressants, antipsychotics, antihistamines, and ADHD medications. These drugs can have very serious medical outcomes and can impact brain function. ADHD medications have the highest risk of a serious medical outcome (Spiller et al., 2019).

Another readily accessible means for suicide are common household chemicals. The use of toxic gases generated by a combination of these chemicals has become more prevalent recently. These are often referred to as “detergent” suicides or chemical suicides involving self-inflicted exposure to toxic gases in a confined space such as a car, bathroom, or closet (USDHHS, 2019b).

It is of utmost importance for clinicians to recognize that these methods, as well as other highly lethal suicide methods, are widely accessible and must be considered when determining the disposition of someone who has suicidal ideations.

Differentiating between Non-Suicidal Self-Injury and Suicide Attempt

Healthcare professionals are increasingly confronted with another problem related to suicide attempts, called non-suicidal self-injury (NSSI). NSSI is distinct from suicide because patients do not intend the acts to be lethal. DSM-5 defines NSSI as the “deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned” (APA, 2013).

The distinction between suicidal and non-suicidal self-injury has been discussed for the past two decades due to the fact that most people engaging in this practice also report suicidal ideation. NSSI co-occurs with a variety of psychiatric disorders, including depression, substance abuse disorders, posttraumatic stress disorder, eating disorders, and other personality disorders. The age of onset is generally between 12 and 16, appears to decline in young adulthood, may be slightly more prevalent in females, and is associated with significant functional impairment.

Patients often injure themselves many times during a single episode and create multiple lesions in the same location, most often in areas that are easily hidden but accessible, such as the upper chest, torso, forearms, or front of thighs.

Self-injurious behaviors can include:

• Cutting, stabbing, or carving the skin with a sharp object, such as a knife, razor blade, or needle
• Scratching or abrading the skin
• Burning the skin (typically with a cigarette)
• Head banging
• Hair pulling
• Self-punching, -pinching, -biting
• Interfering with wound healing
• Swallowing nonedible objects
• Auto-amputation (rarely)
• Eye enucleation
  (Hauber et al., 2019; Klonsky, 2017)

NSSI can be either self-focused or social/other-focused. The motivations are not clear, but there are indications that the functions of these behaviors include:

• Affect regulation or reduction of mental pain to achieve a sense of calm and relief
• Transference of mental pain onto the body
• Self-directed anger or punishment for perceived failings and faults
• Influencing others (to cause reactions, to seek help)
• Anti-dissociation (to avoid feeling disconnected from sense of self or reality)
• Anti-suicide (to stop suicidal urges)
  (Klonsky, 2017)

It has been found that higher impulsivity along with being connected with the suicide or self-harm thoughts of others, as well as the occurrence of physical or sexual abuse, worries about sexual orientation, and trouble with the law independently differentiated adolescents who regularly engage in NSSI from single-time and non-NSSI adolescents (Clayton, 2019; Hauber et al., 2019).

NSSI is a stronger predictor of suicide attempts than other risk factors such as depression, anxiety, and personality disorders. It is theorized that both suicidal wishes and the capability to act on them are necessary for potentially lethal suicide attempts. Among those people with high distress and strong suicidal ideations, the fear of pain, injury, and death may be a barrier to making a suicide attempt. A person who has experience and practice with self-inflicted injury and who has become accustomed to pain and injury may be more capable of overcoming these fears (Klonsky, 2017).

ASSESSMENT OF NSSI PATIENTS

Assessment of the patient who presents with non-suicidal self-injurious behavior includes:

• Determining what type of injury and how many types of injuries the patient has inflicted
• Determining how often non-suicidal self-injury occurs and how long it has been occurring
• Determining the function of NSSI for the patient
• Checking for coexisting psychiatric disorders
• Estimating the risk of suicide attempt
• Determining how willing the patient is to participate in treatment
  (Clayton, 2019)

Signs of NSSI that may be found during the physical examination include:

• Unexplained or clustered scars, fresh cuts, or other signs of bodily damage
• Unexplained use of bandages
• Blood stains on clothing
• Inappropriate dress for the weather (e.g., long-sleeved shirts in the summer)
  (Southard et al., 2017)

Once signs of NSSI are identified, an assessment tool can be used to aid in diagnosing NSSI and differentiating patients who are at increased risk of suicide. These may be either self-administered or clinician-administered. Examples include:

• Self-Harm Behavior Questionnaire (SHBQ) is a self-report instrument that examines the level of self-destructiveness and asks questions about thoughts, gestures, and suicide attempts. Questions are grouped in four sections that examine the range of self-harming suicide behaviors. This scale can be helpful in diagnosing future thoughts and behaviors that can lead to death.
• Suicide Attempt and Self-Injury Interview (SASII) is a clinician-performed instrument that collects details of the physical aspects, intent, medical severity, social context, precipitating and concurrent events, and outcomes of NSSI and suicidal behavior during a specific period of time. Major SASII outcome variables are the frequency of self-injurious and suicidal behaviors, the medical risk of such behaviors, suicide intent, a risk/rescue score, instrumental intent, and impulsiveness.
  (Drzał-Fiałkiewcz et al., 2017)

Documentation of Risk Assessment

Good documentation is basic to clinical practice. Accurate, sufficiently detailed, and concise records of a patient’s treatment allow for quality care and communication among providers (APA, 2016).

Since suicide risk assessment is not a one-time, isolated event, a standardized form is recommended to gather essential information on risk and protective factors as well as collateral information and to make it readily accessible to other clinicians. The use of such a form ensures that all important facets of the assessment are included and allows the clinician as accurately as possible to make a clinical judgment about level of risk and the treatment plan that coincides with this level (APA, 2016).

SUICIDE RISK ASSESSMENT DOCUMENTATION ELEMENTS

The goal of documentation is to explain the clinical reasoning and decision-making behind the suicide assessment and the treatment plan that follows the assessment. The following elements should be included in the documentation:

• What prompted the suicide assessment (includes direct quotes as well as more subtle indications)
• Summary of the presenting complaints, including a detailed assessment of suicidal ideation
• Record of past suicide attempts and outcomes
• Evaluation of current risk factors, protective factors, and warning signs
• Presence or absence of firearms
• Listing of individuals who participated in the evaluation, including the patient’s family, friends, and any collaborative consultants
• Summary of treatment options discussed with the patient, including any suggestions and/or recommendations for hospitalization, if applicable
• Review of the treatment plan agreed upon with the patient, including why this plan provides the safest treatment in the least restrictive environment. Treatment plan may include:
  • Starting medications and/or therapy
  • Means restriction, and, if possible, verification from the patient’s support system that it will be completed
  • Substance use reduction or formal treatment
  • Safety or crisis plan creation (a copy of which is placed in the medical record)
  • Referral to a mental health provider
  • Hospitalization
• Follow-up plan (appointment, phone calls, etc.)
  (Weber et al., 2018)

There have been many court decisions involving patient suicide that clearly show that documentation is necessary to prove reasonable care occurred. The clinical record establishes exactly what data clinicians relied upon and how it was used to arrive at a suicide risk estimate. The goal of documentation in such instances is to show that reasoned judgment was exercised, not that the suicide risk estimate was right or correctly predicted suicidal behavior (Obegi, 2017).