Suicide risk assessment is ethically complex: the concept of "imminent suicide" (implying the foreseeability of an inherently unpredictable act) is a legal construct in a clinical guise, which can be used to justify rationing of emergency psychiatric resources or intrusion into patients' civil liberties.[1] Accurate and legally defensible risk assessment requires that a clinician integrates clinical judgement with the latest evidence-based practice,[2] although accurate prediction of low base rate events such as suicide is inherently difficult and prone to false positives. There are risks and disadvantages to both over-estimation and under-estimation of suicide risk. Over-sensitivity to risk can have undesirable consequences, including inappropriate deprivation of patients’ rights and squandering of scarce clinical resources. On the other hand, underestimating suicidality as a result of a dismissive attitude or lack of clinical skill jeopardizes patient safety and risks clinician liability.[3]
Key areas to be assessed include the person's predisposition to suicidal behavior; identifiable precipitant or stressors; the patient’s symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behavior; impulsivity and self-control; and protective factors. Suicide risk assessment should distinguish between acute and chronic risk: acute risk might be raised because of recent changes in the person's circumstances or mental state, while chronic risk is determined by a diagnosis of a mental illness, and social and demographic factors. Bryan and Rudd (2006) suggest a model in which risk is categorized into one of four categories: Baseline, Acute, Chronic high risk, and Chronic high risk with acute exacerbation.[4] Risk level can also be described as Nonexistent, Mild, Moderate, Severe, or Extreme, and the clinical response can be determined accordingly.
Key areas to be assessed include the person's predisposition to suicidal behavior; identifiable precipitant or stressors; the patient’s symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behavior; impulsivity and self-control; and protective factors. Suicide risk assessment should distinguish between acute and chronic risk: acute risk might be raised because of recent changes in the person's circumstances or mental state, while chronic risk is determined by a diagnosis of a mental illness, and social and demographic factors. Bryan and Rudd (2006) suggest a model in which risk is categorized into one of four categories: Baseline, Acute, Chronic high risk, and Chronic high risk with acute exacerbation.[4] Risk level can also be described as Nonexistent, Mild, Moderate, Severe, or Extreme, and the clinical response can be determined accordingly.
