Suicide Risk Assessment and Risk Formulation Part I: A Focus on Suicide Ideation in Assessing Suicide Risk

Abstract

The main procedure used by clinicians to determine whether an individual may be at risk of suicidal behaviors is the suicide risk assessment (SRA). The purpose of the SRA is to identify risk and protective factors that then provide the data for the formulation of suicide risk. The suicide risk formulation (SRF) assigns a level of suicide risk that ideally leads to triage and treatment deemed appropriate for that level of risk. Some of the problems with the SRA are explored here, with an emphasis on addressing the over reliance on communicated suicide ideation, and recommendations are made for improvements. Part II of this article (Berman & Silverman, 2013, also appears in this issue of STLB) examines the process of an SRF and, similarly, makes recommendations to improve clinical practice toward the desired end of saving lives.

Evaluating a Multimedia Tool for Suicide Risk Assessment and Management: The Linehan Suicide Safety Net

“…However, it is common practice for many clinicians to ask only about the presence of suicide ideation (Silverman & Berman, ). LSSN, and the LRAMP within it, were designed to guide clinicians through conducting a thorough suicide risk assessment that covers the evidence‐based factors in each of the recommended domains.…”

Training for Suicide Risk Assessment and Suicide Risk Formulation

“…Elsewhere, we have articulated that traditional guidelines for conducting an SRA have overemphasized long-standing approaches that have little empirical support [53]. Among these unquestioned approaches is that the presence of communicated suicidal ideation has traditionally been the gateway to the investigation of whether an individual might be "suicidal."…”

“…These authors concluded that no one factor, or combination of factors, was strongly associated with suicide in the year after discharge and, further, that risk categorization is of no value in efforts to decrease the numbers of patients who will die by suicide after hospital discharge. Our interpretation of this meta-analysis is that the "low risk" patients may have been misdiagnosed or poorly assessed, in part because once they denied suicidal ideation they were deemed to be free of suicide risk and ready for discharge [53].…”

“…In the legal context, this judgment is one of "foreseeability." Again, if the court holds clinicians accountable for formulating a patient's imminent risk for suicide, should we not try to base this judgment on something more than intuition [53]?…”

How do healthcare professionals interview patients to assess suicide risk?

“…Silverman and Berman [14] suggest that assessing suicidal risk in clinical practice is influenced by the skills and philosophy of the individual clinician. Nonetheless, there are various guidelines on what to assess including life history, previous suicidal attempts and mental state [15–17], `along with helpful frameworks for how to assess risk [12, 18, 19].…”