While the identification of risk factors for suicidal behavior is important for given populations and must always be considered, it is generally only partially helpful in determining the likelihood of suicide for any given individual case. Knowing, for example, that the person is an elderly male who is depressed, lives alone, and has suicidal thoughts alerts the clinician to the increased potential for suicide because of the loading of risk factors, but does confidently allow the evaluator to say whether this person may safely be sent home from the emergency room or left alone in his apartment. Other factors must be considered in the assessment of suicide potential that can only be gleaned through directly interviewing the patient.
The interviewer must make a decision based on what is learned about the psychological state of the patient at the time of the interview, the history of past suicidal behavior, the contribution of underlying mental illness, current stressors, and the availability and quality of social supports in the patient’s environment. Protective factors must also be explored in this assessment, as they may be life saving even when other risk factors for suicidal behavior are compelling. To complicate the process further, the patient may not wish help in his current circumstances: the suicidal individual is not always a willing partner in an evaluative process that might thwart his independence (involuntary hospital commitment) or potential plans for ending his own life. Furthermore, serious mental illness may cause confusion, incoherence or paranoia that may render him unable to participate meaningfully in the interview process.
General Psychiatric Intake
When evaluating the patient, all of the generally required areas of inquiry for a psychiatric intake must be performed including :
- History of present illness: the patient’s account of events/ stressors, leading up to the interview (and/or an account by another source such as a police officer or significant other) as well as current psychiatric symptoms and treatment; if suicidal ideation, intent, or recent suicide is the reason for the presentation, this section would serve as the suicide assessment;
- Past psychiatric history:previous diagnoses, hospitalizations, and treatments (both psychosocial and pharmacological);
- Social history: a developmental history, education, employment, interpersonal relationships, current social situation, drug and alcohol use;
- Family history: psychiatric diagnoses/symptoms/and suicide in family members;
- Medical history: current and past medical symptoms/diagnoses and treatment (medications and surgery);
- Mental status examination:assessment of psychiatric signs and symptoms;
- Physical examination (where indicated).
The general intake forms an indispensable piece of the suicide risk assessment
The suicide interview itself may conveniently be structured into two sections that are organized by time frame into: 1) recent suicidal thoughts/intent/behavior leading up to the current interview (last several days to the present time), and 2) past suicidal ideation/ attempts.
Recent Suicidal Ideation/Intent
In this section, the interview may begin with a direct inquiry, such as, "Are you having any thoughts of killing yourself?” Alternatively, an empathic statement about the patient’s reported distress may introduce the discussion by saying, “You have spoken about some very sad and painful feelings. It’s not unusual when feeling so bad to think about suicide. Have you been having any thoughts of ending your life?” It should be followed by an open-ended question about what the patient has actually been experiencing in his own words, “Tell me a little about these thoughts.”
The line of questioning can then be modeled from items on the Suicidal Ideation Scale (SIS). This is an excellent guideline for assessing the seriousness of the patient’s current suicidal ideation and intent. If the patient has been brought in for evaluation because of a suicide attempt, the interview can be modified to start with the recent suicide history (chronology of events and ideation leading up to and including the attempt) where the Suicide Intent Scale may also be used. It is important to inquire about the patient’s attitude toward the recent attempt and how suicidal ideation and intent may have changed since then. The relationship of the attempt to drug and alcohol intake must also be explored to assess the relative contribution of disinhibiting effects of these substances on the patient’s behavior.
Past History of Suicide Attempts
Taking a past history of previous suicide attempts (if present) is an essential part of the assessment of current suicide risk. As presented in the risk section, 40-60% of completed suicides have a history of at least one previous suicide attempt. It is important not only to quantify how many attempts were made, but also to appreciate the psychosocial circumstances surrounding them, the patient’s mental status at the time, the quality of suicidal ideation, degree of planning, and severity (lethality) of the suicidal behavior. This assessment is best carried out by “walking” the patient chronologically through the details of past suicide attempts beginning with the most recent one. By objectively inquiring about the suicidal behavior, feelings and consequences (medical treatment, hospitalization, impairment) associated with each past attempt, the interviewer is permitted to make his own assessment of how serious the attempt actually was rather than relying simply on what the patient volunteers. The Suicide Intent Scale is very helpful in structuring this assessment; it focuses on the seriousness of previous suicide attempts by exploring the motivation behind the attempt(s) and the behaviors associated with carrying out the attempt.
Patient reliability remains a serious difficulty in the assessment of suicidal risk. There are many explanations for the less than forthcoming information that patients report during the interview process. There are some simple principles that may make the assessment go more smoothly and reliably. Alternatively, there are some patients who will never be cooperative and this can engender feelings of failure and frustration in the interviewer, particularly when there are significant time constraints. First, engagement of the patient by attentively listening to them in the first few minutes of the interview goes a long way toward establishing rapport and giving the patient the sense that you are interested in what they have to say. Secondly, many patients do not report suicidal thoughts because they are ashamed of having these feelings. This can be made more acceptable to talk about if the interviewer is non-judgmental and forthright in the line of inquiry. It is a gross misconception that asking about suicide directly makes the patient suicidal; the interviewer must be comfortable about asking these questions directly to make the patient feel it is OK to talk about them. Additionally, it may sometimes be helpful to make a few statements normalizing suicidal thoughts, eg, expressing the idea that having suicidal thoughts is common when people are feeling overwhelmed or sad. It is also important to contact collateral sources about the patient’s status whenever possible and essential when there is any question or concern about the information the patient has provided (or not provided if uncooperative).