Article Review and Summary: Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments.

The assessment, management and treatment of suicidal patients is one of the most stressful tasks for clinicians. It is also one of the most difficult things for a clinician to predict. The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) is recommended as a practical multidimensional assessment protocol integrating the best-known risk and protective factors.

Suicide rates have risen approximately 60% over the last 45 years, with yearly estimates of one million suicides worldwide. More than 32,000 suicides occurred in the United States annually with suicide as the second leading cause of death among 25-34 year-olds and the third leading cause of death for people between 15-24 year-olds. Suicide attempts are 10 to 40 times greater than completed suicides, with U.S. estimates close to 650,000 per year.

Data has demonstrated that 28% of psychologists and 62% of psychiatrists have experienced the loss of a patient to suicide, most frequently in outpatient settings. The most important goal of suicide risk assessment should be conducted within a therapeutic frame in which collaboration and negotiation of role responsibilities are clearly expressed.

The clinical community does not yet possess a single test, or panel of tests that accurately identifies the emergence of a suicide crisis. One of the main reasons for this is that suicide risk is fluid, highly state-dependent, and variable over time. Research has shown that statistical associations among various risk factors gathered across large groups of individuals; however, translating elevated risk to the single individual falters because specific predictors are found among many individuals who are not suicidal (resulting in high false-positive prediction).

Among the hundreds of different interventions for suicidality, the following treatments appear particularly effective in randomized clinical control trials: lithium prophylaxis for mood disorders, clozapine for psychotic disorders, psychosocial treatments for suicidal patients with borderline personality disorder, and outreach through communicating care and concern, or in-home psychodynamic consultations. Developing and maintaining a caring interpersonal contact (even if by letter or phone) is important in reducing suicide risk. The quality of social relationships can either serve as a protective or risk factor. The quality of a collaborative therapeutic relationship, the clinician’s ongoing care and interest in the patient, and efforts to repair ruptures in the alliance may exert a powerful influence on the patient’s degree of hope for the future, and the degree to which suicidal-related behaviors decrease. Recent trials of a suicide prevention strategy that was based on collaboration, therapeutic alliance, and enhancing social contacts were found to reduce rates of suicidality. Due to these reasons, it is recommended that clinicians work to enhance the therapeutic alliance, consider recent ruptures that may contribute to suicidal ideation, and work to develop a collaborative approach to understanding the underlying causes for suicidal ideation.

Risk factors for suicide and suicide attempts include being younger than 25 years of age, female, less educated, unmarried, and having a mental disorder (mood disorders in high income countries, and impulsive disorders in middle and low income countries) each imparted a degree of risk for suicide-related behaviors, with risk increasing with greater psychiatric comorbidity. This information is useful in developing targeted programs for intervention and prevention.

Retrospective and psychological autopsy studies have indicated that a diagnosable mental illness is present in at least 90% of all completed suicides. Researchers have found increased suicide risk for all psychiatric disorders except for intellectual disability. Suicide mortality rates were highest for individuals diagnosed with substance abuse and eating disorders, moderately high rates for mood and personality disorders, and relatively low rates for anxiety disorders. Recent evidence from a 10-year prospective study of suicidal ideation, suicide plans and attempts revealed that the total number of co-occurring psychiatric disorders was consistently more predictive of subsequent suicide-related behaviors than types of disorders. A 3-year prospective study reveled that individuals with comorbid substance abuse disorders and borderline personality disorder were more likely to make future suicide attempts. Other researchers found that comorbid major depression and borderline personality disorder, in combination with poor social adjustment was predictive of suicide attempts at 12-month follow-up. Severity of personality pathology (meeting criteria for two or more personality disorders) was correlated with recurrent suicide attempts, but this effect held true only for younger females with severe personality disorders.

Currently the strongest risk factor for predicting suicide and suicide-related behavior is the history of suicide attempts. History of suicide attempt(s) is the greatest risk factor for future attempts, and death by suicide. Medically serious suicide attempts are strongly associated with the increased risk of mortality and repeated suicide attempts: a 5-year follow-up study found that individuals who made a single suicide attempt were 48 times more likely to die by suicide than the average person. Warning signs such as thoughts of suicide, preparatory acts, stressful life events, and cognitive/affective states are episodic, and therefore may be more predictive of an imminent suicidal crisis.

Most individuals contemplating suicide do so for extended periods without following through on the thoughts. Results from another study are chilling: a prospective study of 76 psychiatric inpatients found that 78% of individuals who completed suicide had denied suicidal ideation or intent during their last human contact before their death. Interview strategies focusing on current affective states while intentionally avoiding reference to suicide extract dimensions of cognition and affective functioning using the Rorschach Inkblot Method have shown considerable predictive validity with uncharacteristically low levels of false-positive prediction. Of considerable importance is the fact that two implicit measures demonstrated incremental validity over and above a history of past suicide attempts. Stressful life events, particularly those involving loss or threat to the stability of interpersonal relationships are associated with suicide risk. More recently, researchers examined the link between personality disorders and specific negative life events in the month preceding a suicide attempt and found that those who made suicide attempts were more likely to have experienced a negative stressful life event related to love and marriage problems, or legal troubles such as incarceration. Psychiatric hospitalization may function as a stressful life event, despite the intended purpose of decreasing suicide risk. Numerous studies demonstrate that risk of future suicide is greater shortly after admission and discharge. Suicide risk has found to spike immediately after admission and one-week post-discharge, and the risk of suicide is greatest for individuals with hospital stays less than the national median (estimated at 17 days). A second study found that the first day, first week, and first month post-discharge were the highest risk periods, and were strongly associated with patient-initiated discharge and failure to follow-up with post-discharge care, but not duration of hospitalization.

Most theories suggest an underlying genetic vulnerability that is triggered by early adverse events, resulting in impaired development and function of neurobiological systems regulating behavior, affect, and cognitive function. Impairments in stress response systems may then be overwhelmed (during adolescence and adulthood) in response to episodic negative life events, increasing the likelihood of triggering a suicidal crisis. Thus, underlying genetic and psychological vulnerabilities are assumed to be triggered by environmental stressors, increasing likelihood of negative outcomes including suicidal behavior. Studies generally support diathesis-stress models for predicting suicide-risk – interactions between early adverse events and current impulsivity, loneliness and recent stressful life events, and level of psychopathology and recent stressful life events in alcoholics confer increase risk of suicide-related behaviors. Multiple suicide attempts may lead to habituation by reducing normal barriers such as pain, fear of death, and negative social consequences. An intriguing gene-environmental study demonstrated a link between the serotonin transporter functional promoter polymorphism (5-HTTLPR), recent stressful life events, and suicide-related behavior. In this study, a combination of four or more stressful life events was associated with increased suicidal ideation and attempts for individuals with two copies of the short form of the 5-HTTLPR gene, but had minimal effect on those with long forms of the gene.

The ability to maintain a cognitive set regarding reasons for living appears to function as a protective factor. In a cross-sectional study, depressed patients who had not previously attempted suicide were found to have expressed more feelings of responsibility toward their children and families, feared social disapproval, had more moral objections to suicide, greater survival and coping skills, as well as greater fear of suicide than a matched cohort of depressed patients who had previously attempted suicide. In a two-year prospective study, reasons for living were a protective factor against future suicide attempts among depressed female inpatients, but not for their male counterparts. Health and well-developed coping skills may provide a buffer against stressful life events, decreasing the likelihood of suicidal behavior. Another protective factor includes moral objections and strength of religious convictions appears protective. In general, individuals are less likely to act on suicidal thoughts when they hold strong religious convictions and a belief that suicide is morally incompatible with belief. Religious and spiritual beliefs and techniques may decrease suicide risk by providing coping strategies and a sense of hope and purpose. Involvement in religious organizations may also increase resiliency by enhancing more stable supportive social networks. Marriage also imparts a degree of protecting against suicide, yet the presence of a high-conflict or violent marriage can function as a risk factor. Feeling safe at school was one of the most consistent protective factors against suicidal ideation and suicide attempts among teens. Strong family attachment when coupled with a cohesive neighborhood network also reduces the risk of adolescent suicide attempts.

When initiating treatment with high-risk patients, it is best to negotiate a collaborative treatment approach to suicidal thoughts and behaviors that includes: a clear plan for de-escalating a suicidal crisis, negotiation of the mutual and individual responsibilities of clinician and patient in establishing and maintaining the patient’s safety, and agreement to explore the precipitants and meaning of the crisis once it has past. Knowing that patients often deny suicidal thoughts before suicide attempt and death, clinicians should remain appropriately cautious regarding declarations of safety when a patient recently expressed suicidal ideation, feelings of hopeless, desperation, and/or affective flooding. This does not mean we adopt a suspicious or adversarial stance but a curious, concern, and calm acceptance of the patient’s emotional and cognitive states may serve to enhance the therapeutic alliance, encourage the patient to directly explore his or her current distress, and aid in the accurate evaluation of current functioning. Before conducting a formal suicide assessment, clinicians should conduct an introspective review of recent stressful life events facing the patient.

The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) includes clinicians following these steps: (1) identifying relevant risk factors (noting those that are modifiable and therefore targeted for treatment), (2) identifying protective factors, (3) conducting a suicide inquiry including current suicidal thoughts, plans, behavior, and intent, (4) determining level of risk and select interventions to reduce risk, and (5) documenting the assessment of risk, the rationale for the chosen interventions, and follow-up after assessment and interventions. Focusing on the therapeutic relationship, and using the therapeutic alliance as a platform for exploring the causes and meaning of suicidal thoughts, clinician and patient may increase the likelihood of working together to avert suicide-related outcomes.

Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy 49 (1). 81-90.

Cindy A. Geil, M.A.
WKPIC Doctoral Intern