Assessing Suicide Risk
In a Zero Suicide approach, suicide risk assessment is done by a licensed clinician who has specialized training in assessing the level of suicide risk for individuals. The process of assessment should be standardized and also leave room for clinical judgment.
Organizations should use a standardized tool and/or processes (see below for a list of assessment tools/processes) to guide the clinician through the assessment. This ensures they gather all pertinent information to inform the risk formulation.
The assessment process is not used to predict whether someone is going to attempt or die by suicide, it is to develop the risk formulation that will inform the plan to support the individual.
In a Zero Suicide approach:
- Clinicians conduct a thorough suicide risk assessment when an individual screens positive for suicide risk.1 All staff members use a standardized assessment tool or process to gather relevant information to fully assess an individual’s suicide risk and create a plan to address that risk.
Collaboration and Empathy
Individuals who are experiencing a suicidal crisis are in a vulnerable state and might have fears that they will be involuntarily admitted to a hospital if they share all their suicidal thoughts and actions. It is imperative that clinicians develop a safe environment (physical and psychological). Individuals will then be more likely to engage in the assessment and collaboratively develop the plan to improve their safety.
When organizations develop a caring, confident, and competent workforce then staff members are comfortable talking with individuals about suicidal thoughts and behaviors. When staff have confidence in their ability to manage an individual’s suicide risk they can determine the least restrictive and supportive environment for the individual.
Training for staff should include:
- How to adopt a collaborative stance that reflects empathy, genuineness, and hope.
- How to express understanding of the individual’s ambivalence and that their desire to die is to relieve their intolerable pain.
- Engender confidence that there are alternatives to suicide and how to empower the individual in care to use the available services to help reduce their pain.
- How to treat the screening and assessment process as an exploration of what happened to the individual, not as a task to complete or an examination of what is wrong with the individual.
Information Gathered Through Assessment
There are several aspects to fully assessing for suicide risk which then allows clinicians to develop a risk formulation that will inform treatment planning:
- Gather complete information about present, recent and past suicidal ideation and behavior.
- Gather information about current stressors, relevant risk and protective factors, and history, including treatment history.
- Understand long-term risk factors and ways that impulsivity might impact the individual’s suicide risk.
When assessment is complete the information is synthesized into a prevention-oriented suicide risk formulation anchored in the individual’s life context. The purpose of assessment is not to predict which person might take their own life but to do the best job we can to increase safety, reduce risk, and promote wellness and recovery.
In inpatient behavioral health treatment, the assessment process will be unique to that setting. Even if the admission is not due to suicide risk, the admission process should include a suicide risk assessment. It is important to understand the individual’s history with suicidal thoughts and behaviors as well as other risk factors. Also, it is important that policies and procedures address the frequency of observation, when to rescreen and what prompts a full reassessment.
The SPRC report Caring for Adult Patients with Suicide Risk: A Consensus-Based Guide for Emergency Departments provides comprehensive guidelines for screening and assessment in emergency departments (ED) and offers a quick guide tool for screening and assessment. It recommends asking all individuals reporting suicidal ideation or with suspected suicide risk if they would like a mental health evaluation that includes a comprehensive suicide risk assessment (provided a mental health specialist is available to complete one in a timely manner).
The risk formulation tab further explores how to conceptualize an individual's context and history and synthesize a risk formulation based on multiple points of information.
Billing Codes for Screening and Assessing
Assessing suicide risk takes time and healthcare providers are already struggling to fit everything they need to do into the allotted time. However, there are ways to bill for screening and assessing for suicide risk. The SAMHSA-HRSA Center for Integrated Health Solutions offers a set of state billing and financial worksheets to help clinic managers, integrated care project directors, and billing/coding staff at community mental health centers and community health centers identify the available current procedural terminology codes they can use in their state to bill for services related to integrated primary and behavioral health care. The worksheets can be found in the Tools below. Also, some medical providers are able to use procedure codes for a 15-minutes screen for depression for Medicare patients.
Below are some evidence-based assessment tools and processes that can support clinican’s as they assess the suicide risk of individuals in care.
Assessment Tools
Assessing and Managing Suicide Risk (AMSR)
AMSR is a comprehensive assessment process that identifies an individual's risk of suicide within their own context using a risk formulation that includes the individual's risk status and risk state. It differs from other suicide risk assessments in that it does not include a specific "score" or categorization (i.e., high, moderate, low). AMSR is used in various settings and with different populations and has been validated for ages 12+.
Beck Scale for Suicide Ideation
The Beck Scale for Suicide Ideation is a brief assessment tool that reviews an individual's thoughts of suicide to identify suicide risk. The full scale assessment tool includes 21 question. It is also available in Spanish.
Columbia Suicide Severity Rating Scale (C-SSRS)
The C-SSRS offers multiple versions for different settings and populations and has been translated into many languages. Some versions are used by organization as a screener and other, longer versions are used as part of an assessment. For example, the C-SSRS screen is a 6 question tool that is often used as a screening too. The C-SSRS Full Scale Lifetime/Recent also includes an exploration of current and lifetime suicidal thoughts (intensity and duration) as well as a thorough examination of the individual’s current and lifetime suicidal behaviors.
Free Training: There is a free, online course from the New York State Office of Mental Health and Columbia University that provides an overview of the C-SSRS instrument and teaches how and when to administer it.
Assessment of Suicidal Risk Using the Columbia Suicide Severity Rating Scale
SAFE-T
The SAFE-T is a thorough assessment of the nature and extent of an individual’s suicidal thoughts and behaviors and when used in conjunction with information from other sources is likely to yield the detailed information needed to develop a full picture of an individual’s suicide risk. The items in the SAFE-T explore:
- Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever.
- Plan: timing, location, lethality, availability, preparatory acts.
- Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self-injurious actions.
- Intent: extent to which the patient, one, expects to carry out the plan and, two, believes the plan/act to be lethal vs. self-injurious. Explore ambivalence: reasons to die vs. reasons to live.
Here is a webinar that explains the SAFE-T and how it was integrated into the Epic EMR.