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A Practical Approach to Suicide Risk Assessment. Dr. Sinéad O’Brien College Health Service Trinity College. Thursday, June 29 th 2006. Overview. The Problem of Prediction and the Clinical Usefulness of Risk Factors Identification of Risk Factors for Suicide

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a practical approach to suicide risk assessment

A Practical Approach to Suicide Risk Assessment

Dr. Sinéad O’Brien

College Health Service

Trinity College

Thursday, June 29th 2006

  • The Problem of Prediction and the Clinical Usefulness of Risk Factors
  • Identification of Risk Factors for Suicide
  • Risk Reduction and Intervention Strategies
risk factors vs risk predictors
Risk Factors Vs Risk Predictors
  • Risk Factor: A characteristic of a large sample of people who have committed suicide that appears to be statistically more common than would be expected;
  • Risk predictor: A characteristic of a specific living person that indicates the likelihood of imminent suicide for that individual.

Risk Factors vs Risk Predictors

  • Hoped that R.Fs if studied collectively in a specific patient, would also serve as reliable risk predictors, alerting the clinician to an immediate danger of suicide; this has not been demonstrated.
  • Their usefulness lies in the fact that the patient may be at higher risk (not ‘is’at higher risk’). Red flags that alert the clinician to the need to perform a careful suicide assessment in the patient.
categorization of risk factors
Categorization of Risk Factors
  • Static
  • Dynamic
  • Short-Term (Acute)
  • Long-term (Chronic)
examples of static risk factors
Examples of Static Risk Factors
  • Age
  • Gender
  • Marital status
  • Socioeconomic status
  • Intelligence
  • Educational level
  • Family history
  • Personal history
examples of dynamic risk factors
Examples of Dynamic Risk Factors
  • Depression / Anxiety / Panic attacks
  • Psychosis
  • Substance abuse
  • Insomnia
  • Impulsivity
  • Agitation
  • Physical illness
  • Difficult life situation
  • Availability of lethal means
protective factors
Protective Factors
  • P. F. lower the risk of following through with the idea or planned action;
  • Like R.F.s they vary with the clinical presentation of individual patients at risk;
  • An ebb and flow exists between suicide risk and protective factors;
  • Protective factors can be overcome by the acuteness and severity of mental illness
examples of protective factors
Examples of Protective Factors
  • Strong family and social support
  • Pregnancy
  • Dependent children
  • Strong religious beliefs against suicide
  • Cultural sanction against suicide
examples of short term acute risk factors
Examples of Short-term (Acute) Risk Factors
  • Panic attacks
  • Severe anxiety
  • Moderate alcohol abuse
  • Dysphoric mood (mixed states)
  • Global insomnia
long term chronic risk factors
Long-term (Chronic) Risk Factors
  • Family History
  • Male gender
  • Living alone
  • Lack of social support
long term chronic risk factors1
Long-term (Chronic) Risk Factors
  • Alcohol abuse
  • Impulsivity
  • Profound hopelessness
  • Medical illness
  • Rejection by boy-friend / girl-friend
  • Anniversary of important loss
  • Suicidal ideation
  • Prior suicide attempts
key concept
Key Concept

The presence of a psychiatric disorder


a previous history of suicide attempts

are the best predictors of

future suicide attempts and suicide

greatest risk of suicide
Greatest Risk of Suicide
  • During the week after hospital admission
  • The month immediately after discharge
  • During the early stages of recovery from a mental illness: patient’s energy level usually increases before the depressed mood improves
suicide ladder
Suicide Ladder
  • How bad do you feel?
  • Do you wish you were dead?
  • Have you had thoughts of ending your life? (How often, when, how long do they last?)
  • Have you thought about a particular way?
  • How close have you come to it?
profound hopelessness
Profound Hopelessness

Can be reliably assessed by 2 questions:

Will to live: none, weak, moderate to strong

Will to die: none, weak, strong

Individuals are ambivalent; all suicidal patients wish

to die; but those without a will to live are the most

hopeless and hence at highest risk

intervention options
Intervention Options
  • Institutional – what the College can do
  • Clinical
institutional intervention options
Institutional Intervention Options
  • Raise awareness
  • Design opportunies for student involvement in entire community
  • Staff training
  • Suicide Prevention Programmes – Stress Magement, Problem Solving, Alcohol/Drugs etc
  • Ready and easy access to services
  • Re-evaluation of Conventional Counselling Approach; increased access to Action-Orientated Models and Brief Therapy
alcohol brief intervention for substance use disorders frames
Alcohol Brief intervention for substance use disorders (FRAMES)

Feedback: Concern about current health status, substance use behaviour

Responsibility: Open acknowledgement that you can’t make them change that only they can

Advice: To reduce or abstain from use

Menu of Options: Limit drinks to 4 or less/day, spacing drinks, switching to lower alcohol drinks, not drinking to cope, limiting drinking to social venues, keeping track of drinks, trial of abstinence seeming treatment

Empathy: Non-confrontational attempt to see the situation from the patients perspective while still maintaining objectivity

Self-Efficacy: Encouraging belief they can change

clinical interventions
Clinical Interventions
  • In-patient / Out-patient treatment;
  • If Out-patient:
    • Attend to patient safety;
    • Determine a setting for treatment and supervision; evaluate available support;
    • Work to establish a cooperative and collaborative physician-patient relationship;
    • Prescribe Somatic Treatment / psychotherapy
    • See daily; list emergency contact phone numbers etc.
key concept1
Key Concept

Assessment of suicide risk and prevention of suicide are daunting tasks because of the multidimensional nature of ideation and behaviour

Despite clinicians’ best efforts at suicide assessment and treatment, suicides can and do occur in clinical practice.