Routinized Assessment of Suicide Risk

Edited by Foxit Reader
Copyright(C) by Foxit Software Company,2005-2008

For Evaluation Only.
Routinized Assessment of Suicide Risk in Clinical Practice: An

Empirically Informed Update
Carol Chu, Kelly M. Klein, Jennifer M. Buchman-Schmitt, Melanie A. Hom,
Christopher R. Hagan, and Thomas E. Joiner
Florida State University
Objective:
Empirically informed suicide risk assessment frameworks are useful in guiding the evaluation and treatment of individuals presenting with suicidal symptoms. Joiner et al. (1999) formulated
one such framework, which has provided a concise heuristic for the assessment of suicide risk. The
purpose of this review is to ensure compatibility of this suicide risk assessment framework with the
growing literature on suicide-related behaviors. Methods:
This review integrates recent literature
on suicide risk factors and clinical applications into the existing model. Further, we present a review
of risk factors not previously included in the Joiner et al. (1999) framework, such as the interpersonal
theory of suicide variables of perceived burdensomeness, thwarted belongingness, and capability for
suicide (Joiner, 2005; Van Orden et al., 2010) and acute symptoms of suicidality (i.e., agitation, irritability, weight loss, sleep disturbances, severe affective states, and social withdrawal). Results: These
additional indicators of suicide risk further facilitate the classification of patients into standardized categories of suicide risk severity and the critical clinical decision making needed for the management
of such risk. Conclusions:
To increase the accessibility of empirically informed risk assessment
protocols for suicide prevention and treatment, an updated suicide risk assessment form and decision
C 2015 Wiley Periodicals, Inc. J. Clin. Psychol. 71:11861200, 2015.
tree are provided.
Keywords: suicide risk assessment; standardized care; suicidal behavior; suicidal ideation; suicide
Over a decade has passed since the publication of Joiner et al.s (1999) empirically informed
framework for suicide risk assessmenta framework rooted in comprehensive models of suicide.
This framework aimed to bridge the gap between research and clinical practice and to aid in the
efficient assessment of suicide risk to facilitate decision making and action in both outpatient
and inpatient settings (Cukrowicz, Wingate, Driscoll, & Joiner, 2004). Given that community
mental health providers continue to be tasked with identifying and treating patients with suicidal
ideation and behaviors (i.e., suicidality1 ) and the seriousness of managing suicide risk, it is
critical that guidelines for assessing risk and implementing clinical actions are up to date. This
review extends the previous framework by integrating suicide risk classification with risk factors
grounded in the interpersonal theory of suicide (Joiner, 2005) and acute symptoms of suicidality
(see Appendix). We conclude with a discussion of appropriate evidence-based interventions and
documentation practices.
Classification of Suicide Risk Level

The present framework describes four risk categories (low, moderate, severe, extreme), but
these categories should not be rigidly used. Rather, the present framework is intended to be
Please address correspondence to: Carol Chu, Department of Psychology, Florida State University, Tallahassee, FL 32306. E-mail: chu@psy.fsu.edu
1 In
this article, we use the term suicide to refer to a death caused by a self-inflicted injury motivated by
at least some intent to die. Suicidal ideation refers to thoughts about dying by suicide. We refer to suiciderelated behaviors as actions directly related to suicide, including suicide attempts and associated preparatory
behaviors. A suicide attempt refers to self-injurious behaviors engaged in with at least some intent to die,
regardless of actual injury incurred (Silverman, Berman, Sanddal, OCarroll, & Joiner, 2007).
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 71(12), 11861200 (2015)

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).

C 2015 Wiley Periodicals, Inc.
DOI: 10.1002/jclp.22210

For Evaluation
Empirically
Informed Only.
Suicide Risk Assessment
1187
flexiblepatients may fall between categories (e.g., low/moderate or moderate/severe) and/or
shift between categories as their clinical presentation changes. Suicide risk categories guide
clinical decision making and allow clinicians to titrate the level of clinical action insofar that
efficiency and efficacy are maximized.
Previous Suicidal Behavior

Prior suicide-related behaviors are an important indicator of current risk. Mounting evidence
suggests that both adults (Forman, Berk, Henriques, Brown, & Beck, 2004) and adolescents
(Miranda et al., 2008) with a history of multiple attempts (multiple attempters) are at greater
risk for suicidal behaviors and associated risk factors (e.g., severe psychopathology, interpersonal
stress) compared with those with a history of one attempt (single attempters) and those who
think about suicide (suicide ideators) but have never attempted suicide. However, recent research
calls for a more nuanced consideration of the relationship between attempt history and future
suicide risk.
Although a suicide attempt continues to influence risk for decades (Suominen et al., 2004),
growing evidence from 512 year-long longitudinal studies suggest that risk for death by suicide
is greatest immediately after the attempt and decreases over time. Specifically, the greatest risk
for death by suicide appears to occur in the 6 months to 2 years immediately after a suicide
attempt, at which point risk decreases for several more years before stabilizing (Christiansen &
Jensen, 2007; Gibb, Beautrais, & Fergusson, 2005; Haukka, Suominen, Partonen, & Lonnqvist,
2008). As such, although any history of suicide attempts should be noted, more recent attempts
(i.e., within approximately 2 years) indicate relatively greater suicide risk, pending findings from
other components of the risk assessment.
Individuals with a history of multiple recent attempts and any other significant risk factor
(described below) would be considered, at minimum, at moderate risk for suicide. In cases in
which a patient has a history of one attempt in the past 2 years but is a multiple attempter
when considering more distant clinical history, the application of this guideline will require
consideration of other risk factors (e.g., severity of ideation, desire, and intent; specificity of
suicide plans) and consultation with trained colleagues.
Current Suicidal Symptoms

Despite evidence supporting the robustness of previous suicide attempts as a risk factor for
suicide (Nock et al., 2008), approximately half of individuals who die by suicide do so on their
first attempt (Suokas, Suominen, Isometsa, Ostamo, & Lonnqvist,

2001). Therefore, in addition
to gathering information on past self-injury, comprehensive risk assessments require evaluation
of current suicidal symptoms. Two evidence-based markers of particularly high suicide risk are:
(a) suicidal thoughts and desire and (b) resolved plans and preparation for suicide. Severe suicidal
ideation, in the absence of plans or preparations for suicide and other notable risk factors, does
not indicate an especially high risk for suicide (Joiner et al., 2003) Therefore, the assessment of
current suicidal ideation should include factors related to suicidal thoughts and desire, as well
as resolved plans and preparations for suicide, including the availability and ease of access to
means for suicide.
Plans, methods, and means for suicide. Assessing the content of suicidal thoughts often
provides a natural segue into inquiring about any and all methods and plans for suicide, specificity
of the plans, availability of means, and preparatory behaviors (e.g., acquiring or researching
means for suicide, buying materials for an attempt, preparing a will). Note that although a plan
to jump from a tall building is worrisome, a plan to jump on an identified day from a specific
tall building to which the patient has access is an indicator of much higher risk.
1188

Evaluation
Only.
Journal For
of Clinical
Psychology,
December 2015
The efficacy of means safety (c.f. means restriction2 ) in suicide prevention has been demonstrated across a variety of means, including firearms (Conwell et al., 2002), drug overdoses
(Hawton et al., 2001), bridges (Beautrais, 2001), self-poisoning (Pearson et al., 2011), and suffocation by toxic domestic gas (Mann et al., 2005). Of these, firearms are especially worrisome as
they are among the most lethal and are responsible for more than half of deaths by suicide in the
United States (Conwell et al., 2002). Although some individuals may seek alternatives to their
preferred method, research suggests that the risk for substitution of means is relatively small as
suicidal crises are often short-lived (Yip et al., 2012). Additionally, when these individuals do
seek alternative methods, the means chosen tend to be less lethal and are associated with fewer
deaths (Yip et al., 2012). Limited access to other lethal means can be an obstacle to dying by
suicide, which indicates that means safety is a crucial aspect of suicide prevention.
It is also important to ask patients whether they have conducted any research regarding
suicide methods or identified locations where they can procure means for an attempt (e.g.,
stores, their own or a friends home, workplace). Finally, less commonly endorsed, but still vital
to assess, is whether the individual has been practicing for a suicide attempt. This may include
visiting high places, handling guns to reduce fear or increase competency of use, placing oneself
in potentially dangerous situations (e.g., crossing streets with closed eyes, walking on railroad
tracks), or ingesting hazardous chemicals followed by activated charcoal to prevent death.
Patients who have detailed and specific plans for suicide, imminent opportunity to use their
plans, and access to means are considered to be elevated on the resolved plans and preparations
factor. If the aforementioned patient simultaneously presents with one other risk factor, they
would be classified as moderate risk.
Suicidal desire. This factor is based upon an assessment of the intensity, frequency, duration or preoccupation, and content of suicidal thoughts. Suicidal thought content may include
passive thoughts of death (e.g., I wish I werent around anymore). However, compared with
passive ideation, having frequent, high intensity, and active thoughts of killing oneself and of suicide (e.g., I should jump from the roof of my apartment building or Im going to get a gun to
shoot myself with) indicate greater risk for future suicidal behavior. Individuals with high levels
of suicidal desire in the absence of elevated resolved plans and preparations may be classified as
moderate risk if they simultaneously present with two additional risk factors (see below).
Suicidal intent. Current suicidal intent is also useful in the conceptualization of suicide
risk and an important addition to the framework. In this context, intent is characterized by
explicit plans and intention to enact a suicide attempt and is distinct from suicidal desire (Nock
& Kessler, 2006). Stronger suicidal intent has been associated with more lethal self-injury (Brown,
Henriques, Sosdjan, & Beck, 2004) and an increased likelihood of death by suicide (Nock &
Kessler, 2006). Suicidal intent and desire can vary drastically and independently of each other
(Van Orden et al., 2010). Therefore, although current suicidal desire is informative in determining
risk, it is important to interpret desire and intent as two distinct constructs.
When evaluating suicidal intent, we suggest using a Likert scale (e.g., 0 to 10 rating) because
it provides not only a guideline for discussion of suicidal intent but also a numerical benchmark for subsequent risk assessments, allowing clinicians to track significant changes. It is also
helpful to provide a time frame when asking about suicidal intent (e.g., How strong is your
intent to kill yourself in the next week?). This enhances a clinicians ability to understand an
individuals likelihood of engaging in suicidal behaviors and determine whether suicide risk
is imminent. However, in instances where subjective intent clearly contradicts other objective
2 We
view the term means safety to be a more accurate reflection of a core principle of this approach, which
is to promote the safety of patients by minimizing access to means for maladaptive and potentially harmful
behaviors. A focus on safety rather than on restriction has the advantage of respecting patients autonomy,
which is advisable under any conditions (Ryan & Deci, 2000), particularly regarding issues that may be
sensitive or highly charged (e.g., firearm access and use in the U.S.).

For Evaluation
Empirically
Informed Only.
1189
evidence of suicide risk, attention should be paid to the latter. In addition to other previously
discussed risk factors (Joiner et al., 1999), clinicians should be familiar with acute warning signs
(i.e., agitation, social withdrawal, insomnia/nightmares, irritability, talking about suicide); the
relative objectivity of these indicators may be useful, particularly when evidence is mixed.
Other Significant Risk Factors

Although a significant number of individuals report suicidal ideation over their lifetime (9.2%),
only 3.1% make suicide plans and only 2.7% make at least one attempt (Nock et al., 2008). Many
frequently cited risk factors increase risk for suicidal ideation, but they do not differentiate suicide
ideators from attempters (Klonsky & May, 2014). Many of the suicide risk factors presented
below are significant indicators of risk for suicidal ideation. Nonetheless, we encourage clinicians
to consider the suicide risk factors below as adjunctive indicators of suicide risk that may clarify
risk level and illuminate targets for clinical intervention. When determining risk level, key suicide
risk factors, including attempt history, ideation, plans, intent, and access to means, should be
considered in the context of the other significant risk factors that contribute to a patients overall
clinical presentation.
Thwarted belongingness, perceived burdensomeness, and capability for suicide. The

interpersonal theory of suicideone of few theories that distinguishes suicidal ideation from
behavior (Klonsky & May, 2014)posits that individuals who die by suicide have not only
the desire but also the capability to enact lethal self-injury (Joiner, 2005; Van Orden et al.,
2010). The theory identifies three central constructs necessary for a suicide attemptthwarted
belongingness and perceived burdensomeness, which constitute suicidal desire, and the third is
the capability for suicide.
Thwarted belongingness is characterized by social isolation and an unmet need for social
connectedness, while perceived burdensomeness is the view that one is a burden or liability to
family, friends, and/or society (Van Orden et al., 2010). These two constructs, when co-occurring,
lead to passive ideation. When these two symptoms are viewed as stable and unchanging, active
ideation arises (Van Orden et al., 2010). As the prospect of death by suicide is frightening, even
among those with suicidal ideation (Malone et al., 2000), this theory asserts that pain tolerance
and fearlessness in the face of death are key conditions that shift suicidal desire to suicidal
intent and attempts. This model connects many disparate risk factors for suicide (e.g., history of
past suicide attempts, nonsuicidal self-injury [NSSI], child abuse, combat exposure), suggesting
that each factor elevates risk by decreasing fear of death and increasing habituation to pain
(Van Orden, Witte, Gordon, Bender, & Joiner, 2008). Furthermore, the interpersonal theory
has garnered empirical support across a variety of populations (Cukrowicz, Jahn, Graham,
Poindexter, & Williams, 2013; Czyz, Berona, & King, 2014).
In addition to asking about the presence of suicidal desire, clinicians may also probe for
thwarted belongingness and perceived burdensomeness (see sample questions in Supplementary
Materials). Clinicians should be particularly concerned if an individual seems to lack meaningful social connections, has a strong sense of being a burden, and expresses hopelessness about
either of these conditions improving. Clinicians may also simultaneously assess for capability
for suicide by inquiring about prior suicide attempts, NSSI, or other painful and provocative
experiences (e.g., exposure or participation in physical violence, intravenous drug use). If an
individual reports experiences that reveal a habituation to pain or fearlessness about self-injury
and death, and they are also experiencing a high degree of thwarted belongingness and perceived burdensomeness, inquiring about resolved plans and preparations will be particularly
informative in determining whether the individual is at imminent risk. For detailed guidelines
on assessing these constructs, see Joiner, Van Orden, Witte, and Rudd (2009).
NSSI. Recent evidence suggests that NSSI (i.e., the direct, purposeful damage of ones own
body tissues without any intent to die) is associated with elevated risk for future suicidal behavior
(Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Victor & Klonsky, 2014). NSSI is
an equally strong, if not stronger predictor, of future suicide attempts across diverse populations
1190

Evaluation
Only.
Journal For
of Clinical
Psychology,
December 2015
when compared with past suicide attempts (Asarnow et al., 2011; Bryan, Bryan, May, & Klonsky,
2014; Guan, Fox, & Prinstein, 2012; Horwitz, Czyz, & King, 2014). As such, any and all current
and past self-injurious behaviors should be considered when determining risk.
Precipitating stressors. Research indicates that the majority of suicidal acts are precipitated by a stressful life event (SLE; e.g., death of a loved one, termination from employment,
and marital separation or divorce; Foster, 2011). Recent, acute stressors (i.e., occurring within
the past year) have been identified as particularly pernicious risk factors for suicide, above and
beyond the risk imposed by high levels of chronic stress (Phillips et al., 2002). For example, past
studies have shown that the majority of individuals who have attempted suicide (Conner et al.,
2012) and suicide decedents (Martin et al., 2013) experienced a SLE on the day of the attempt.
This suggests that SLEs may act as acute risk factors for imminent suicidal acts and indicates
that clinicians should attend to the possibility of increased risk after any notable SLE, especially
in the hours and days immediately after the event.
Less is known, however, about how the stress levels caused by a SLE may differentially affect
risk over time. Some researchers have proposed that stress sensitization occurs, such that the
stress level required to initiate a suicidal crisis decreases as the number of suicide attempts
increases. Beck (1996) proposed that suicidal thoughts and behaviors become more sensitive to
stress over time; thus suicidal thoughts are more accessible with each successive experience with
suicide-related behaviors. Stress sensitization has since received empirical support from Joiner
and Rudd (2000); however, additional research testing this hypothesis is needed. SLEs might
contribute to elevated suicide risk, and although the nature of the relationship between SLEs
and suicidality is not well understood, their evaluation is informative in suicide risk assessment.
Hopelessness. Hopelessness, or the belief that ones present state and/or situation is
intractable, remains one of the most robust predictors of future suicide attempts and death
by suicide (McMillan, Gilbody, Beresford, & Neilly, 2007). Hopelessness is an important risk
factor given research postulating that feelings of hopelessness reflect a diathesis, or vulnerability,
for suicide (c.f. hopelessness theory of suicide; Abramson, Metalsky, & Alloy, 1989). Support for
this perspective has been found across populations (Forman et al., 2004; Kuo, Gallo, & Eaton,
2004; Mustanski & Liu, 2013).
More recently, hopelessness has been implicated as a moderator between various risk factors
and suicidality. For example, Hagan, Podlogar, Chu, and Joiner (2015) found that the interaction between thwarted belongingness and perceived burdensomeness predicted suicidal desire
only when individuals also had elevated levels of hopelessness. Hopelessness is a key variable
linking suicide-related behaviors and psychiatric disorders (Klonsky, Kotov, Bakst, Rabinowitz,
& Bromet, 2012), particularly disorders of emotional dysfunction, such as major depressive
disorder (c.f. hopelessness depression; Abramson et al., 1989) and bipolar disorder (Hawton,
Sutton, Haw, Sinclair, & Harriss, 2005). Given that hopelessness both confers and moderates
suicide risk, and that the combination of known risk factors with high hopelessness is especially
dangerous, it is important to assess for symptoms of hopelessness.
Psychopathology. Psychiatric disorders have been repeatedly demonstrated to be a salient
risk factor for suicide-related behaviors in youth, adult, and elderly populations, and nearly all
psychiatric disorders are associated with increased suicide risk (APA, 2013; Chesney, Goodwin,
& Fazel, 2014). Psychological autopsy studies have found that 9095% of suicide decedents had
a diagnosable psychiatric disorder at death (Cavanagh, Carson, Sharpe, & Lawrie, 2003), with
high likelihood that the remaining decedents suffered from undiagnosed or subclinical forms of
mental illness. Mood and anxiety disorders (especially depressive and bipolar disorders), eating
disorders, impulse-control disorders, psychotic illnesses, substance use disorders, and personality
disorders, confer the highest risk for suicide and suicidal behavior (Chesney et al., 2014; Nock
et al., 2008). Many decedents suffer from multiple disorders simultaneously, a factor associated
with particularly high levels of suicide risk (Nock et al., 2008).
The use of substances, alcohol in particular, is commonly associated with lowered inhibitions,
which increases suicide risk and the lethality of suicide attempts (Borges et al., 2010). Notably,

For Evaluation
Empirically
Informed Only.
1191
however, recent research paints a more nuanced picture of this relationship. A review of 92
studies of suicide decedents found that 73% of decedents had a blood alcohol concentration
of 0.00%; that is, they had not consumed alcohol before their death (Anestis, Joiner, Hanson,
& Gutierrez, 2014). Importantly, not all of the 27% with nonzero blood alcohol concentration
levels were necessarily inebriated. Therefore, although problematic alcohol use increases risk of
suicide and some people do die when intoxicated (Borges et al., 2010), death by suicide when
intoxicated is quite infrequent. Further, the vast majority of decedents, even those with a history
of alcohol use disorders (Conner et al., 2000), do not consume any alcohol before their deaths
(Anestis, Joiner, et al., 2014). Consequently, the presence of an alcohol use disorder should be
interpreted in terms of the individuals overall risk profile. Therefore, in addition to clarifying
the diagnostic picture, clinicians should assess the extent to which alcohol abuse is the main
impetus for increased suicidality and note any significant changes in use.
Impulsivity. Research supports a robust link between suicide and impulsivity (Zouk, Tousignant, Seguin, Lesage, & Turecki, 2006). Studies suggest that suicidal ideation and behavior
are associated with high negative urgency, which is defined as the tendency to act impulsively
in the face of negative emotions (Klonsky & May, 2010). Suicidal behavior, but not ideation, is
also associated with poor premeditation, which is characterized by a diminished ability to assess
consequences of ones actions (Klonsky & May, 2010). Suicidal behavior itself is rarely, if ever,
an impulsive act because it is fearsome and physically distressing (Anestis, Soberay, Gutierrez,
Hernandez, & Joiner, 2014).
In studies comparing suicide decedents and controls, trait impulsivity was not a significant
predictor of death by suicide (Anestis, Soberay, et al., 2014). Anestis, Soberay, et al. (2014)
proposed that although impulsive individuals engage in suicidal behavior at an elevated rate,
they do so with substantial forethought and planning. More frequent exposure to painful and
fearsome behaviors that enhance the capacity for suicide may account for these small effects in
the relationship between trait impulsivity and suicidal behavior (Anestis, Soberay, et al., 2014;
Bender, Gordon, Bresin, & Joiner, 2011). As such, increased attention should be paid to suicide
plans and preparations if there is evidence of impulsivity (e.g., impulsive coping methods).
Acute Symptoms of Suicidality
Although the assessment of desire, plans, preparations, and intent is essential, evidence suggests
that a significant percentage of suicide decedents deny suicidal ideation at their final mental
health encounter (Busch, Fawcett, & Jacobs, 2003). Additionally, reliance on chronic risk factors
(e.g., psychopathology, past suicidal behavior, family history of suicide) limits our ability to
determine whether an individual is at imminent risk. Therefore, it is imperative to assess acute and
objective risk factors, which are time-limited and associated with an increased risk for suicide over
a period of hours to days, not months or years (Bryan & Rudd, 2006). Research (described below)
has identified multiple acute indicators of suicide risk, including agitation, social withdrawal,
severe weight loss, marked irritability, severe affective states, and sleep disturbances. Acute risk
factors should not be considered in isolation but in the context of other risk factors described
above. Among those presenting at a moderate risk or higher, the presence of acute risk factors
for suicide may signal the need for more immediate clinical action.
In addition to signaling imminent suicide risk, acute risk factors have the advantage of being
observable by a clinician. This allows clinicians to assess suicidality without directly asking
about suicide. Even when explicitly assessed, these factors also have little face validity. As such,
it may not be evident to the patient that suicide risk is being assessed, which may increase the
likelihood of disclosure.
Agitation. Suicide-related agitation often manifests as a subjective sense of inner turmoil

with outward behavioral signs of overarousal, such as hand-wringing, grimacing, and pacing
(Ribeiro, Bender, Selby, Hames, & Joiner, 2011). Although the role of agitation in suicidal
behavior it not well understood, evidence for agitation as an indicator of imminent suicide risk
exists. Sani et al. (2011) found that over a third of suicide decedents within an inpatient population
1192

Evaluation
Only.
Journal For
of Clinical
Psychology,
December 2015
presented with an agitated depressive episode. Additionally, 54.2% of the decedents reported
experiencing inner tension, 53.1% reported racing thoughts, and 30.2% reported psychomotor
agitation during the week before death (Sani et al., 2011). Another study found that psychomotor
agitation was associated with a sixty-one-fold increase in risk for future suicidal behavior (Balazs
et al., 2006).
Others have also reported that symptoms of agitation in depression (i.e., restlessness, increased
talkativeness, and irritability) are associated with more severe suicidal ideation (Akiskal, Benazzi,
Perugi, & Rihmer, 2005). Of note, Akiskal et al. (2005) identified mixed depressive states, or
agitated depression, as a pernicious precursor to suicidality. In addition to conferring increased
risk for suicide, evidence indicates that severe symptoms of anxiety or agitation were experienced
by 79% of suicide decedents within the week preceding suicide (Busch et al., 2003). Overall, these
findings suggest that elevated agitation symptoms may signal acute risk for suicide.
Marked irritability. Relatedly, recent research suggests that marked irritability, which
refers to a mood state characterized by increased proneness to annoyance and anger provocation (Safer, 2009), may represent an acute suicide risk factor (Trivedi et al., 2011). In a study of
100 psychiatric inpatients who had made a suicide attempt in the preceding 24 hours, marked
irritability was associated with a 101-fold increase in suicide risk (Balazs et al., 2006). Furthermore, significant irritability may diminish the patients social support, thereby decreasing social
interactions and increasing social withdrawal.
Social withdrawal. Social withdrawal may manifest externally and internally, such that
individuals may be physically removed or, despite physical presence, psychologically distanced.
With regards to outward social withdrawal, psychological autopsy studies have shown that in
the days, weeks, and months preceding death by suicide, in comparison to matched controls,
suicide decedents exhibited a significant decrease in activities that were once routine, including
social outings (Duberstein et al., 2004) and alcohol use among individuals who had been heavy
daily drinkers for a long time (Anestis, Joiner, et al., 2014). Inwardly, social withdrawal may
present as resignation (c.f. the thousand-yard stare in PTSD patients), which also appears to
occur among individuals with intense suicidality (Joiner, 2014). As such, adequate assessment
of suicide risk requires an evaluation of any marked changes in social activation.
Severe weight loss. Significant weight loss, distinct from weight loss associated with depression, may also signify imminent suicidal behavior. Psychological autopsy studies have found
that over 85% of suicide decedents demonstrated significant weight or appetite loss during the
depressive episode preceding death (McGirr et al., 2007). Additionally, research suggests an
association between agitation and weight/appetite loss. Akiskal et al. (2005) found that weight
loss was more prominent in individuals with agitated depression and associated with increased
suicidality. Severe weight loss may be a consequence of social withdrawal from life and sustenance. As such, it is recommended that any changes in weight, particularly visually apparent
unhealthy weight loss, be considered.
Severe affective states. Recent studies have found that a unique, time-limited psychological state of suicidal crisis typically precedes death by suicide. One facet of this psychological crisis
is the severe states of affect (Hendin, Al Jurdi, Houck, Hughes, & Turner, 2010). Nine affective
states have been identified as potential indicators of imminent suicide risk when perceived as
intolerable and uncontrollable: abandonment, anxiety, desperation, guilt, hopelessness, humiliation, loneliness, rage, and self-hatred (Maltsberger, Hendin, Haas, & Lipschitz, 2003). Relatedly,
Joiner et al. (2015, Tucker, MIchaels, Rogers, Wingate, & Joiner Jr., in press) have recently indicated that these severe affective states support a one-factor solution resembling acute suicidal
affective disturbance. Specifically, the authors propose that acute suicidal affective disturbance,
a construct distinct from other disorders in the Diagnostic and Statistical Manual of Mental
Disorders Fifth Edition (American Psychiatric Association, 2013), reflects a rapid-onset mood
disturbance that escalates geometrically and results in potentially life-threatening suicidal behavior (Joiner et al., 2015; Tucker et al., in press). Overall, preliminary evidence supports the presence
of these indicators, possibly as a distinct clinical entity, in individuals at acute risk for suicide.

For Evaluation
Empirically
Informed Only.
1193
Sleep disturbances. Sleep disturbances, including insomnia, nightmares, and nighttime
panic attacks, are common symptoms associated with suicidal acts (Bernert & Joiner, 2007). A
case-control psychological autopsy study found that approximately 75% of suicide decedents
experienced sleep disturbances in the month before suicide compared with 11% of matched
controls; findings were also significant above and beyond the effect of mental disorder diagnoses
(Kodaka et al., 2014). Arguably, the symptoms that have garnered the most empirical support are
insomnia and nightmares. Li, Lam, Yu, Zhang, and Wing (2010) found that insomnia predicted
an increase in suicide attempts over a 1-year period. In a longitudinal study of inpatients with
a history of multiple suicide attempts, Sjostrom, Hetta, and Waern (2009) found that frequent
nightmares predicted future suicide attempts. Thus, questions probing nighttime sleep routines
and average quality and quantity of sleep are particularly crucial if imminent risk is suspected.
Use of Validated Measures
Empirically validated self-report measures with demonstrated predictive validity (i.e., that predict suicidal behaviors), concurrent validity (i.e., correlate with other risk measures), and reliability are useful for assessing the presence and severity of the aforementioned risk factors (see
Brown, n.d., for review). We also encourage clinicians to periodically review the literature to
ensure that the use of specific instruments for risk assessment is consistent with the most recent
empirical evidence. We do acknowledge, however, that there are limitations associated with selfreport measures (e.g., reluctance to disclose). As such, those limitations should be considered
when selecting measures, and these measures should not be used as the sole determinant of risk
level.
Despite the limitations, we view quantitative assessments as useful complements to clinical
interviews. Given the stigma associated with suicidality and mental health problems, reservations
about disclosing sensitive information in a clinical interview are not uncommon. When assessing
acute symptoms of suicidality, although severe presentations may be readily observable, mild
symptoms may not be as apparent. In these instances, self-report measures provide an alternative
means for obtaining risk-related information. Additionally, self-report measures often have
established cutoffs, which facilitate their use in clinical settings. Further, as an adjunct to a
clinical interview, self-report measures provide additional data points about relevant symptoms
and risk factors, which improves accuracy of suicide risk determinations.
Clinical Actions
A detailed list of clinical actions corresponds to the different levels of suicide risk. We view
the list as a hierarchy, with several options for appropriately managing risk. On the low risk
end of the spectrum, clinicians should encourage the patient to seek social support and provide
them with emergency numbers (e.g., National Suicide Prevention Lifeline in the United States
[1-800-273-8255] and Samaritans in the United Kingdom [08457 90 90 90]). Patients near the
middle of the spectrum (i.e., low to moderate symptoms) should be provided with a safety plan
(see Rudd, Joiner, & Rajab, 2001; Stanley & Brown, 2012). Importantly, the plan should be
listed in a stepwise manner: first, engage in multiple distracting activities; second, repeat the
list of activities more than once; and finally, call emergency numbers and/or voluntarily go
to the hospital (Rudd et al., 2001). If an individual is above moderate risk, all prior actions
should be taken, along with frequent phone check-ins. Previous research has shown that this
approach is effective in preventing suicide (Fleischmann et al., 2008). Voluntary and involuntary
hospitalization should be considered in cases when individuals are at severe to extreme risk for
suicide (e.g., intent = 10/10) and unable to guarantee their safety. Consultation with a trained
and experienced colleague is always recommended.
In light of recent evidence for the efficacy of means safety, we emphasize the clinical importance of restricting access to means for suicide plans. Limiting access to these means can be
straightforward, such as removing the firearm from the home or setting out only the number
of pills necessary for the week and locking away the rest. Occasionally, means safety requires
creativity and planning in collaboration with the patient, for example, locking away kitchen
1194

Evaluation
Only.
Journal For
of Clinical
Psychology,
December 2015
knives and razor blades in the trunk of a car. If patients are unwilling to take these steps, simpler
steps can still be effective, such as using a gunlock, storing ammunition and guns separately,
disassembling guns, placing knives in a drawer instead of on the counter, or storing excess medications out of reach (Grossman et al., 2005). Patient resistance is not uncommon; however,
any amount of detachment or distance between the means and the individual at risk should be
viewed as a gain. For example, distancing and shielding the means from view can be helpful and
even discussion of means safety can plant the seed of doubt in patients minds regarding suicide
(see Britton, Bryan, & Valenstein, 2014, for details on means safety counseling).
The process of risk categorization and management can also be modified for children and
adolescents. Depending upon the age of the child, the risk assessment can be completed directly
with the child and/or through parent report. The same factors are assessed in children as in
adults, but age-appropriate language should be used. The same clinical actions should also be
followed; however, the safety plan should include coping skills familiar to the child, and means
safety should involve parents, particularly when securing items such as guns or knives.
Legal Considerations
It is critical that the clinician properly documents the patients suicide risk and takes clinical
actions that correspond to the patients level of risk. Documenting risk involves stating which risk
level the patient falls under, describing the clinical information used to make that categorization
(e.g., ideation, plans, intent), and clearly listing the interventions used to promote safety (e.g.,
created a safety plan, provided patient with emergency numbers). Any documentation should end
with an indication that suicide risk will continue to be monitored and managed proportionate
to risk.
Relatedly, there are two main points of legal consideration in suicide risk management:
whether or not the clinician (a) anticipated elevated suicide risk and (b) followed appropriate
precautionary protocols (Packman, OConnor Pennuto, Bongar, & Orthwein, 2004). Bongar
and Sullivan (2013) and others (e.g., Jobes & Drozd, 2004) have made several recommendations
for reducing legal risk. Briefly, these include properly assessing risk, taking actions to minimize
risk, consulting with other professionals about the risk level, and documenting all actions.
Others who also emphasize the importance of assessing, consulting, and documenting suicide
risk information support these recommendations (Cukrowicz et al., 2004). Of note, suicide
prevention contracts, which are not an empirically supported method of suicide prevention, are
not a legally sufficient replacement for proper risk assessment and management (Lewis, 2007).
Conclusion
Training in empirically informed suicide risk assessment for all individuals working with patients
at risk for suicide (e.g., clinicians, police, nurses, clergy, psychiatrists, physicians, firefighters) is
valuable because it can improve the management of suicide risk (McNiel et al., 2008). We hope
this article will benefit clinicians in the following ways: (a) increase their sense of self-efficacy,
(b) ease the burden of determining a patients level of suicide risk, and (c) serve as a guide
to the provision of appropriate care. These guidelines are intended to increase precision in
clinical decision making and should not be implemented without exercising clinical judgment
and considering the patients comprehensive symptomatology. If available, consultation with
colleagues who have a strong background in suicide-risk training is also recommended.
Regular updating of suicide risk assessment protocols to ensure their compatibility with the
growing literature on suicide-related behaviors is important. This review endeavored to bridge
Joiner et al.s (1999) suicide risk assessment procedures with recent literature. The goal of
translating research into standardized risk assessment procedures is to provide mental health
practitioners with objective, updated criteria to implement in clinical practice. Although the risk
factors discussed in this framework are empirically informed and provide valuable information
about suicide risk, future research is needed to validate the associated risk assessment protocol.
Given that nearly one million people die by suicide each year and approximately half die on
Empirically Informed Suicide Risk Assessment
1195
their first attempt (Chesney et al., 2014; Suokas et al., 2001), empirically informed suicide risk
assessments are a vital component of effective prevention and treatment of suicidality.
References
Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory-based subtype
of depression. Psychological Review, 96(2), 358372.
Akiskal, H. S., Benazzi, F., Perugi, G., & Rihmer, Z. (2005). Agitated unipolar depression reconceptualized as a depressive mixed state: Implications for the antidepressant-suicide controversy.
Journal of Affective Disorders, 85(3), 245258.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
Anestis, M. D., Joiner, T., Hanson, J. E., & Gutierrez, P. M. (2014). The modal suicide decedent did not
consume alcohol just prior to the time of death: An analysis with implications for understanding suicidal
behavior. Journal of Abnormal Psychology, 123(4), 835840.
Anestis, M. D., Soberay, K. A., Gutierrez, P. M., Hernandez, T. D., & Joiner, T. E. (2014). Reconsidering
the link between impulsivity and suicidal behavior. Personality and Social Psychology Review, 18(4),
366386.
Asarnow, J. R., Porta, G., Spirito, A., Emslie, G., Clarke, G., Wagner, K. D., . . . Brent, D. A. (2011). Suicide
attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: findings from
the TORDIA study. Journal of the American Academy of Child and Adolescent Psychiatry, 50(8), 772
781.
Balazs, J., Benazzi, F., Rihmer, Z., Rihmer, A., Akiskal, K. K., & Akiskal, H. S. (2006). The close link
between suicide attempts and mixed (bipolar) depression: Implications for suicide prevention. Journal
of Affective Disorders, 91(2-3), 133138.
Beautrais, A. L. (2001). Effectiveness of barriers at suicide jumping sites: A case study. Australian and New
Zealand Journal of Psychiatry, 35(5), 557562.
Beck, A. T. (1996). Beyond belief: A theory of modes, personality, and psychopathology. In P. M. Salkovskis
(Ed.), Frontiers of cognitive therapy (pp. 125). New York: Guilford Press.
Bernert, R. A., & Joiner, T. E. (2007). Sleep disturbances and suicide risk: A review of the literature.
Neuropsychiatric Disease and Treatment, 3(6), 735743.
Bongar, B., & Sullivan, G. (2013). The suicidal patient: Clinical and legal standards of care (3rd ed.).
Washington, DC: American Psychological Association.
Borges, G., Nock, M. K., Haro Abad, J. M., Hwang, I., Sampson, N. A., Alonso, J., . . . Kessler, R. C. (2010).
Twelve-month prevalence of and risk factors for suicide attempts in the World Health Organization World
Mental Health Surveys. Journal of Clinical Psychiatry, 71(12), 16171628.
Bender, T. W., Gordon, K. H., Bresin, K., & Joiner, T. E. (2011). Impulsivity and suicidality: The mediating
role of painful and provocative experiences. Journal of Affective Disorders, 129(1), 301307.
Britton, P. C., Bryan, C. J., & Valenstein, M. (2014). Motivational interviewing for means restriction counseling with patients at risk for suicide. Cognitive and Behavioral Practice. doi:10.1016/j.cbpra.2014.09.004
Brown, G. K. (n.d.). A review of suicide assessment measures for intervention research
with adults and older adults (Tech. Rep. No. 263-MH914950). Bethesda, MD: National
Institute of Mental Health. Retrieved from: http://www.sprc.org/sites/sprc.org/files/library/
BrownReviewAssessmentMeasuresAdultsOlderAdults.pdf
Brown, G. K., Henriques, G. R., Sosdjan, D., & Beck, A. T. (2004). Suicide intent and accurate expectations
of lethality: Predictors of medical lethality of suicide attempts. Journal of Consulting and Clinical
Psychology, 72(6), 11701174.
Bryan, C. J., & Rudd, M. D. (2006). Advances in the assessment of suicide risk. Journal of Clinical Psychology,
62(2), 185200.
Bryan, C. J., Bryan, A. O., May, A. M., & Klonsky, E. D. (2014). Trajectories of suicide ideation, nonsuicidal
self-injury, and suicide attempts in a nonclinical sample of military personnel and veterans. Suicide and
Life-Threatening Behavior. doi: 10.1111/sltb.12127
Busch, K. A., Fawcett, J., & Jacobs, D. G. (2003). Clinical correlates of inpatient suicide. Journal of Clinical
Psychiatry, 64(1), 1419.
Cavanagh, J. T., Carson, A. J., Sharpe, M., & Lawrie, S. M. (2003). Psychological autopsy studies of suicide:
a systematic review. Psychological Medicine, 33(3), 395405.
1196
Journal of Clinical Psychology, December 2015
Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders:
A meta-review. World Psychiatry, 13(2), 153160.
Christiansen, E., & Jensen, B. F. (2007). Risk of repetition of suicide attempt, suicide or all deaths after an
episode of attempted suicide: A register-based survival analysis. Australian and New Zealand Journal
of Psychiatry, 41(3), 257265.
Conner, K. R., Duberstein, P. R., Conwell, Y., Herrmann, J. H., Cox, C., Barrington, D. S., & Caine, E. D.
(2000). After the drinking stops: Completed suicide in individuals with remitted alcohol use disorders.
Journal of Psychoactive Drugs, 32(3), 333337.
Conner, K. R., Houston, R. J., Swogger, M. T., Conwell, Y., You, S., He, H., . . . Duberstein, P. R. (2012).
Stressful life events and suicidal behavior in adults with alcohol use disorders: Role of event severity,
timing, and type. Drug and Alcohol Dependence, 120(1-3), 155161.
Conwell, Y., Duberstein, P. R., Connor, K., Eberly, S., Cox, C., & Caine, E. D. (2002). Access to firearms
and risk for suicide in middle-aged and older adults. American Journal of Geriatric Psychiatry, 10(4),
407416.
Cukrowicz, K. C., Jahn, D. R., Graham, R. D., Poindexter, E. K., & Williams, R. B. (2013). Suicide risk in
older adults: evaluating models of risk and predicting excess zeros in a primary care sample. Journal of
Abnormal Psychology, 122(4), 10211030.
Cukrowicz, K. C., Wingate, L. R., Driscoll, K. A., & Joiner, T. E., Jr. (2004). A standard of care for the
assessment of suicide risk and associated treatment: The Florida State University Psychology Clinic as
an example. Journal of Contemporary Psychotherapy, 34(1), 87100.
Czyz, E. K., Berona, J., & King, C. A. (2014). A prospective examination of the interpersonal-psychological
theory of suicidal behavior among psychiatric adolescent inpatients. Suicide and Life-Threatening Behavior. doi:10.1111/sltb.12125
Duberstein, P. R., Conwell, Y., Conner, K. R., Eberly, S., Evinger, J. S., & Caine, E. D. (2004). Poor social
integration and suicide: fact or artifact? A case-control study. Psychological Medicine, 34(7), 13311337.
Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Bolhari, J., Botega, N. J., . . . Thanh, H. T. T.
(2008). Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled
trial in five countries. Bulletin of the World Health Organization, 86(9), 703709.
Forman, E. M., Berk, M. S., Henriques, G. R., Brown, G. K., & Beck, A. T. (2004). History of multiple
suicide attempts as a behavioral marker of severe psychopathology. American Journal of Psychiatry,
161(3), 437443.
Foster, T. (2011). Adverse life events proximal to adult suicide: A synthesis of findings from psychological
autopsy studies. Archives of Suicide Research, 15(1), 115.
Gibb, S. J., Beautrais, A. L., & Fergusson, D. M. (2005). Mortality and further suicidal behaviour after
an index suicide attempt: A 10-year study. Australian and New Zealand Journal of Psychiatry, 39(1-2),
95100.
Grossman, D. C., Mueller, B. A., Riedy, C., Dowd, M. D., Villaveces, A., Prodzinski, J., . . . Harruff,
R. (2005). Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA:
Journal of the American Medical Association, 293(6), 707714.
Guan, K., Fox, K. R., & Prinstein, M. J. (2012). Nonsuicidal self-injury as a time-invariant predictor of
adolescent suicide ideation and attempts in a diverse community sample. Journal of Consulting and
Clinical Psychology, 80(5), 842849.
Hagan, C. R., Podlogar, M. C., Chu, C., & Joiner, T. E. (2015). Testing the interpersonal theory of suicide:
The moderating role of hopelessness. International Journal of Cognitive Therapy, 8(2), 99113.
Haukka, J., Suominen, K., Partonen, T., & Lonnqvist,

J. (2008). Determinants and outcomes of serious
attempted suicide: A nationwide study in Finland, 19962003. American Journal of Epidemiology,
167(10), 11551163.
Hawton, K., Sutton, L., Haw, C., Sinclair, J., & Harriss, L. (2005). Suicide and attempted suicide in bipolar
disorder: A systematic review of risk factors. Journal of Clinical Psychiatry, 66(6), 693704.
Hawton, K., Townsend, E., Deeks, J., Appleby, L., Gunnell, D., Bennewith, O., & Cooper, J. (2001). Effects of
legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom:
Before and after study. BMJ, 322(7296), 12031207.
Hendin, H., Al Jurdi, R. K., Houck, P. R., Hughes, S., & Turner, J. B. (2010). Role of intense affects in
predicting short-term risk for suicidal behavior: A prospective study. Journal of Nervous and Mental
Disease, 198(3), 220225.
1197
Horwitz, A. G., Czyz, E. K., & King, C. A. (2014). Predicting future suicide attempts among adolescent and
emerging adult psychiatric emergency patients. Journal of Clinical Child and Adolescent Psychology,
111.
Jobes, D. A., & Drozd, J. F. (2004). The CAMS approach to working with suicidal patients. Journal of
Contemporary Psychotherapy, 34, 7385.
Joiner, T. (2014). The perversion of virtue: Understanding murder-suicide. New York: Oxford University
Press.
Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous
suicide attempts and negative life events. Journal of Consulting and Clinical Psychology, 68(5), 909916.
Joiner, T. E., Steer, R. A., Brown, G., Beck, A. T., Pettit, J. W., & Rudd, M. D. (2003). Worst-point suicidal
plans: A dimension of suicidality predictive of past suicide attempts and eventual death by suicide.
Behaviour Research and Therapy, 41(12), 14691480.
Joiner, T. E., Turner, J. B., Hames, J. L., Buchman-Schmitt, J. M., Chu, C., & Hendin, H. (2015). The factorial
structure of affective states aligns with the existence of a proposed new clinical entity. Unpublished
manuscript.
Joiner, T. E., Jr., Van Orden, K. A., Witte, T. K., & Rudd, M. D. (2009). The Interpersonal Theory of suicide:
Guidance for working with suicidal clients. Washington, DC: American Psychological Association.
Joiner, T. E., Jr., Walker, R. L., Rudd, D. M., & Jobes, D. A. (1999). Scientizing and routinizing the
assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30(5),
447453.
Klonsky, E. D., Kotov, R., Bakst, S., Rabinowitz, J., & Bromet, E. J. (2012). Hopelessness as a predictor
of attempted suicide among first admission patients with psychosis: A 10-year cohort study. Suicide &
Life-Threatening Behavior, 42(1), 110.
Klonsky, E. D., & May, A. (2010). Rethinking impulsivity in suicide. Suicide & Life-Threatening Behavior,
40(6), 612619.
Klonsky, E. D., & May, A. M. (2014). Differentiating suicide attempters from suicide ideators: A critical
frontier for suicidology research. Suicide and Life-Threatening Behavior, 44(1), 15.
Kodaka, M., Matsumoto, T., Katsumata, Y., Akazawa, M., Tachimori, H., Kawakami, N., . . . Takeshima,
T. (2014). Suicide risk among individuals with sleep disturbances in Japan: A case-control psychological
autopsy study. Sleep Medicine, 15(4), 430435.
Kuo, W. H., Gallo, J. J., & Eaton, W. W. (2004). Hopelessness, depression, substance disorder, and suicidality
A 13-year community-based study. Social Psychiatry and Psychiatric Epidemiology, 39(6), 497501.
Lewis, L. M. (2007). No-harm contracts: A review of what we know. Suicide & Life-Threatening Behavior,
37(1), 5057.
Li, S. X., Lam, S. P., Yu, M. W., Zhang, J., & Wing, Y. K. (2010). Nocturnal sleep disturbances as a predictor
of suicide attempts among psychiatric outpatients: A clinical, epidemiologic, prospective study. Journal
of Clinical Psychiatry, 71(11), 14401446.
Malone, K. M., Oquendo, M. A., Haas, G. L., Ellis, S. P., Li, S., & Mann, J. J. (2000). Protective factors
against suicidal acts in major depression: Reasons for living. American Journal of Psychiatry, 157(7),
10841088.
Maltsberger, J. T., Hendin, H., Haas, A. P., & Lipschitz, A. (2003). Determination of precipitating events in
the suicide of psychiatric patients. Suicide & Life-Threatening Behavior, 33(2), 111119.
Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., . . . Hendin, H. (2005). Suicide
prevention strategies: A systematic review. Journal of the American Medical Association, 294(16), 2064
2074.
Martin, J. S., Ghahramanlou-Holloway, M., Englert, D. R., Bakalar, J. L., Olsen, C., Nademin, E. M., . . .
Branlund, S. (2013). Marital status, life stressor precipitants, and communications of distress and suicide
intent in a sample of United States Air Force suicide decedents. Archives of Suicide Research, 17(2),
148160.
McGirr, A., Renaud, J., Seguin, M., Alda, M., Benkelfat, C., Lesage, A., & Turecki, G. (2007). An examination of DSM-IV depressive symptoms and risk for suicide completion in major depressive disorder:
A psychological autopsy study. Journal of Affective Disorders, 97(13), 203209.
McNiel, D. E., Fordwood, S. R., Weaver, C. M., Chamberlain, J. R., Hall, S. E., & Binder, R. L. (2008).
Effects of training on suicide risk assessment. Psychiatric Services, 59(12), 14621465.
1198
Miranda, R., Scott, M., Hicks, R., Wilcox, H. C., Harris Munfakh, J. L., & Shaffer, D. (2008). Suicide attempt
characteristics, diagnoses, and future attempts: Comparing multiple attempters to single attempters and
ideators. Journal of the American Academy of Child and Adolescent Psychiatry, 47(1), 3240.
Miranda, R., Tsypes, A., Gallagher, M., & Rajab, K. (2013). Rumination and hopelessness as mediators
of the relation between perceived emotion dysregulation and suicidal ideation. Cognitive Therapy and
Research, 37(4), 786795.
Mustanski, B., & Liu, R. T. (2013). A longitudinal study of predictors of suicide attempts among lesbian,
gay, bisexual, and transgender youth. Archives of Sexual Behavior, 42(3), 437448.
Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., . . . Williams, D. (2008).
Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of
Psychiatry, 192(2), 98105.
Nock, M. K., Joiner, T. E., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non-suicidal selfinjury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research,
144(1), 6572.
Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide
gestures: Analysis of the National Comorbidity Survey. Journal of Abnormal Psychology, 115(3), 616
623.
Packman, W. L., OConnor Pennuto, T., Bongar, B., & Orthwein, J. (2004). Legal issues of professional
negligence in suicide cases. Behavioral Sciences and the Law, 22, 697713.
Pearson, M., Konradsen, F., Gunnell, D., Dawson, A. H., Pieris, R., Weerasinghe, M., . . . Eddleston, M.
(2011). A community-based cluster randomised trial of safe storage to reduce pesticide self-poisoning in
rural Sri Lanka: Study protocol. BMC Public Health, 11, 879.
Phillips, M. R., Yang, G., Zhang, Y., Wang, L., Ji, H., & Zhou, M. (2002). Risk factors for suicide in China:
A national case-control psychological autopsy study. Lancet, 360(9347), 17281736.
Ribeiro, J. D., Bender, T. W., Selby, E. A., Hames, J. L., & Joiner, T. E. (2011). Development and validation of
a brief self-report measure of agitation: The Brief Agitation Measure. Journal of Personality Assessment,
93(6), 597604.
Rudd, M. D., Joiner, T. E., & Rajab, H. (2001). Treating suicidal behavior: An effective time-limited approach.
New York: Guilford Press.
Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation,
social development, and well-being. American Psychologist, 55(1), 6878.
Safer, D. J. (2009). Irritable mood and the Diagnostic and Statistical Manual of Mental Disorders. Child
and Adolescent Psychiatry and Mental Health, 3(1), 35.
Sani, G., Tondo, L., Koukopoulos, A., Reginaldi, D., Kotzalidis, G. D., Koukopoulos, A. E., . . . Tatarelli,
R. (2011). Suicide in a large population of former psychiatric inpatients. Psychiatry and Clinical Neurosciences, 65, 286295.
Sjostrom, N., Hetta, J., & Waern, M. (2009). Persistent nightmares are associated with repeat suicide attempt:
A prospective study. Psychiatry Research, 170(2-3), 208211.
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate risk.
Cognitive and Behavioral Practice, 19, 256264.
Suokas, J., Suominen, K., Isometsa, E., Ostamo, A., & Lonnqvist,
J. (2001). Long-term risk factors for
suicide mortality after attempted suicideFindings of a 14-year follow-up study. Acta Psychiatrica
Scandinavica, 104(2), 117121.
Suominen, K., Isometsa, E., Suokas, J., Haukka, J., Achte, K., & Lonnqvist,
J. (2004). Completed suicide
after a suicide attempt: A 37-year follow-up study. American Journal of Psychiatry, 161(3), 562563.
Tucker, R. P., Michaels, M. S., Rogers, M. L., WIngate, L. R., & Joiner Jr., T. E. (in press) Construct validity
of a proposed new diagnostic entity: Acute Suicidal Affective Disturbance (ASAD) Journal of Affective
Disorders.
Trivedi, M. H., Wisniewski, S. R., Morris, D. W., Fava, M., Kurian, B. T., Gollan, J. K., . . . Rush, A.
J. (2011). Concise Associated Symptoms Tracking scale: A brief self-report and clinician rating of
symptoms associated with suicidality. Journal of Clinical Psychiatry, 72(6), 765774.
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E., Jr.
(2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575600.
Van Orden, K. A., Witte, T. K., Gordon, K. H., Bender, T. W., & Joiner, T. E. (2008). Suicidal desire and the
capability for suicide: Tests of the interpersonal-psychological theory of suicidal behavior among adults.
Journal of Consulting and Clinical Psychology, 76(1), 7283.
1199
Victor, S. E., & Klonsky, E. D. (2014). Correlates of suicide attempts among self-injurers: A meta-analysis.
Clinical Psychology Review, 34(4), 282297.
Yip, P. S., Caine, E., Yousuf, S., Chang, S. S., Wu, K. C., & Chen, Y. Y. (2012). Means restriction for suicide
prevention. Lancet, 379(9834), 23932399.
Zouk, H., Tousignant, M., Seguin, M., Lesage, A., & Turecki, G. (2006). Characterization of impulsivity
in suicide completers: Clinical, behavioral and psychosocial dimensions. Journal of Affective Disorders,
92(2-3), 195204.
Appendix
Resolved Plans & Preparations
Desire & Ideation
Sample Suicide Risk Assessment Form
1. Have you been having thoughts of suicide? of killing yourself? Tell me about that.
a.
How often?
b.
How long lasting (preoccupation)?
2. Do you think about wanting to be dead?

a.
How often?
b.
How long lasting?
3. Have you attempted suicide in the past? Did you hurt yourself with the intent to die? How
many times? Methods used? What happened (e.g., outcome, severity)? If more than one
attempt, when was your most recent suicide attemptin the last two years?
4. How strong is your intent to kill yourself [e.g., current, next week, past week]? 0 no
intent at all, 10 definite intent
5. Do you have any plan(s) for how you would kill yourself [detail, specificity]? If no, ever?
6. Do you know when you expect to use your plan? Do you think youll have an opportunity
to kill yourself?
7. Have you acquired means for use in a suicide attempt [pills, a gun, etc.]?
8. Have you made preparations for a suicide attempt? [e.g., buying pills, suicide note, giving
away personal items]
9. Have you ever intentionally caused yourself physical harm by cutting, burning, or other
means, without the intent to die?
Other Risk Factors
10. Is there any history of self-injury or suicide in your family?

11. Do you feel confident you could attempt suicide? Do you feel afraid to die? 0 not at all
afraid 10 very afraid
12. Do you feel connected to other people? Do you live alone? Do you have someone you
can call when youre feeling badly? Who?
13. Sometimes people think: the people in my life would be better off I were gone. Do you
think that?
14. Do you feel hopeless? Tell me more about that.
15. Has anything especially stressful happened to you recently?
16. When youre feeling badly, how do you cope? Sometimes when people feel badly, they do
impulsive things to feel better. Has this ever happened to you? [e.g., cutting your skin,
drinking alcohol, running away, binge eating, promiscuous sex, physical aggression,
shoplifting].
17. Other warning signs: 1) agitation, 2) social withdrawal, 3) insomnia/nightmares, 4) marked
irritability
18. Consider past/current psychopathology e.g., Major Depression, Bipolar, Borderline
Personality, Schizophrenia, Eating Disorder
BSS ideation score = ___________ (0-38)
[rule of thumb: > 11 = clinically significant]
Risk category (circle):
low
moderate severe extreme
Actions taken:
Will continue to monitor regularly
Given emergency numbers (incl. 1-800-273-TALK)
Scheduled mid-week phone check-in
Means safety for any form of self-injury
Provided info about adjunctive treatment
Safety plan
Consulted supervisor/colleague
Other: _____________________
YES
Any Other
Significant
Finding = At
Least Moderate
Risk
YES
Two or More
Other Significant
Findings = At
Least Moderate
Risk
9) Consult supervisor or colleague

before client leaves
10) Client should be monitored &
accompanied at all times
11) Consider emergency mental health
options (e.g. hospitalization)
*stop here if moderate risk

------------
5) Mid-week phone check-in

6) Means safety
7) Inform about adjunctive treatment
8) Encourage check-in from family
*stop here if low risk & current ideation

------------
4) Create a safety plan

[Create symptom matching hierarchy]
*stop here if no symptoms

------------
1) Encourage seeking social support

(i.e., family & friends)
2) Give emergency numbers: 1-800-273TALK, 911, ER
3) Monitor risk regularly & document
ACTIONS TAKEN:
Moderate Risk:
-MA + other significant finding
-Non-MA + mod/severe plans/prep
-Non-MA + mod/severe
desire/ideation, no/mild plans/prep,
and 2+ significant findings
Severe Risk:
-MA + 2+ significant findings
-Non-MA + mod/severe
plans/prep, and 1+ significant
finding(s)
Extreme Risk:
-MA + severe plans/prep
-Non-MA + severe plans/prep and 2+
significant findings
Consult if: a) unsure of risk level or actions taken, b) mod to severe risk level or above, c) notable increase in symptoms
Documentation: Suicide risk was assessed according to Joiner et al. (1999) and determined to be [low/moderate/severe/extreme] due to[e.g., ideation,
plans, preparations, etc.]. ACTIONS TAKEN: [e.g., safety plan, emergency numbers, consulted with supervisor, etc.]. Risk will continue to be monitored.
Low Risk:
-No symptoms
-MA + no other risk factors
-Non-MA + ideation [limited
intensity/ duration], no/mild
plans/prep, and no/few
significant findings
Other Significant Risk Factors: capability for suicide (e.g., non-suicidal self-injury; fearlessness about death); thwarted belongingness; perceived burdensomeness; hopelessness;
family history; recent stressful life events; impulsivity; presence of acute indicators of risk (agitation; social withdrawal; insomnia/nightmares; marked irritability; severe affective
states, significant weight loss)
Is the person
a Multiple
Attempter
(MA)?
(i.e., multiple
attempts in
past ~ 2
years)
NO
Elevated on
Resolved Plans
& Preparations?
NO
Elevated on
Suicidal Desire
& Ideation?
Elevated Resolved Plans & Preparations: detailed and/or

specific plans for suicide, imminent opportunity to use plan,
access to the means, significant suicidal intent
NO
Low Risk
Sample Suicide Risk Assessment Decision Tree
Elevated Suicidal Desire & Ideation: frequent, enduring

active ideation (i.e., of killing oneself)
1200

Routinized Assessment of Suicide Risk

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Routinized Assessment of Suicide Risk

Uploaded by

Copyright:

Available Formats

Edited by Foxit Reader

Copyright(C) by Foxit Software Company,2005-2008