routinized assessment of suicide risk

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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 eval-uation 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 literatureon 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, irritabil-ity, weight loss, sleep disturbances, severe affective states, and social withdrawal). Results: Theseadditional indicators of suicide risk further facilitate the classification of patients into standardized cat-

egories 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 assessmentprotocols for suicide prevention and treatment, an updated suicide risk assessment form and decision

tree are provided. C 2015 Wiley Periodicals, Inc. J. Clin. Psychol. 71:1186–1200, 2015.

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 assessment—a 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, Talla-

hassee, FL 32306. E-mail: [email protected]

1In 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 suicide-

related 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, O’Carroll, & Joiner, 2007).

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 71(12), 1186–1200 (2015) C 2015 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22210

Edited by Foxit ReaderCopyright(C) by Foxit Software Company,2005-2008For Evaluation Only.


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Empirically Informed Suicide Risk Assessment 1187

flexible—patients 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 5–12 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, & Lönnqvist,

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 attempterwhen 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, Isometsä, Ostamo, & Lönnqvist, 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 oftenprovides a natural segue into inquiring about any and allmethods and plans for suicide, specificityof 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.



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1188 Journal of Clinical Psychology, December 2015

The efficacy of means safety (c.f. means restriction2) in suicide prevention has been demon-

strated 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 suffo-

cation 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 theirpreferred 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 friend’s 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 railroadtracks), 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, dura-tion or preoccupation, and content of suicidal thoughts. Suicidal thought content may include

passive thoughts of death (e.g., “I wish I weren’t around anymore”). However, compared with

passive ideation, having frequent, high intensity, and active thoughts of killing oneself and of sui-

cide (e.g., “I should jump from the roof of my apartment building” or “I’m going to get a gun toshoot 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 suiciderisk 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 determiningrisk, 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 bench-

mark 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 clinician’s ability to understand an

individual’s likelihood of engaging in suicidal behaviors and determine whether suicide risk

is imminent. However, in instances where subjective intent clearly contradicts other objective

2We 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.).



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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 patient’s overall

clinical presentation.

Thwarted belongingness, perceived burdensomeness, and capability for suicide. Theinterpersonal theory of suicide–one 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 attempt—thwarted

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 forthwarted belongingness and perceived burdensomeness (see sample questions in Supplementary

Materials). Clinicians should be particularly concerned if an individual seems to lack meaning-

ful 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 per-

ceived 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 one’s ownbody 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



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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 precip-

itated 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 attemptsincreases. 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 one’s present state and/or situation isintractable, 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 interac-

tion 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 moderatessuicide 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 salientrisk 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 90–95% 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 personalitydisorders, 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,



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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 whenintoxicated 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 individual’s 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, Tou-signant, 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, isalso associated with poor premeditation, which is characterized by a diminished ability to assess

consequences of one’s actions (Klonsky & May, 2010). Suicidal behavior itself is rarely, if ever,

an impulsive act because it is fearsome and physically distressing (Anestis, Soberay, Gutierrez,

Hernández, & 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 suicideplans 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 turmoilwith 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



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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 (Balázs

et al., 2006).

Others have also reported that symptoms of agitation in depression (i.e., restlessness, increasedtalkativeness, 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, whichrefers to a mood state characterized by increased proneness to annoyance and anger provoca-

tion (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, markedirritability was associated with a 101-fold increase in suicide risk (Balázs et al., 2006). Further-

more, significant irritability may diminish the patient’s social support, thereby decreasing social

interactions and increasing social withdrawal.

Social withdrawal. Social withdrawal may manifest externally and internally, such thatindividuals 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 de-pression, 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 suste-

nance. As such, it is recommended that any changes in weight, particularly visually apparentunhealthy weight loss, be considered.

Severe affective states. Recent studies have found that a unique, time-limited psychologi-cal 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, humilia-

tion, 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 in-

dicated 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 behav-

ior (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.



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Sleep disturbances. Sleep disturbances, including insomnia, nightmares, and nighttimepanic 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 areinsomnia 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 pre-

dict suicidal behaviors), concurrent validity (i.e., correlate with other risk measures), and relia-

bility are useful for assessing the presence and severity of the aforementioned risk factors (seeBrown, 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 self-

report 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 alternativemeans 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 impor-

tance 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



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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 med-

ications 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 andeven 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 ConsiderationsIt is critical that the clinician properly documents the patient’s suicide risk and takes clinical

actions that correspond to the patient’s 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, O’Connor 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 patientsat 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 patient’s 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 patient’s 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



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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.

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Appendix

Sample Suicide Risk Assessment Form1. 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 oneattempt, when was your most recent suicide attempt…in 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 you’ll have an opportunityto 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, givingaway personal items]

9. Have you ever intentionally caused yourself physical harm by cutting, burning, or othermeans, without the intent to die?

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 allafraid 10 very afraid

12. Do you feel connected to other people? Do you live alone? Do you have someone you

can call when you’re feeling badly? Who?

13. Sometimes people think: “the people in my life would be better off I were gone.” Do youthink that?

14. Do you feel hopeless? Tell me more about that.

15. Has anything especially stressful happened to you recently?

16. When you’re feeling badly, how do you cope? Sometimes when people feel badly, they doimpulsive 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) markedirritability

18. Consider past/current psychopathology e.g., Major Depression, Bipolar, Borderline

Personality, Schizophrenia, Eating Disorder

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 treatmentSafety plan

Consulted supervisor/colleague

Other: _____________________

BSS ideation score = ___________ (0-38)

[rule of thumb: > 11 = clinically significant]

Risk category (circle):

low moderate severe extreme

D e s i r e &

I d e a t i o n

R e s o l v e d P l a n s &

P r e p a r a t i o n s

O t h e r R i s k F a c t o r s


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routinized assessment of suicide risk

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