Suicide and self-harm risk assessment

Form and record a clinical judgement about risk, and decide what to do about it.

At intake, whenever risk is disclosed or suspected, at any deterioration, and around transitions of care.31 fieldsLegally & ethically load-bearing

How this document is used well

The purpose of a risk assessment is not to predict suicide. Prediction at the individual level is, on the best available evidence, close to impossible: decades of research have produced risk factors whose positive predictive value is very poor, and instruments that stratify populations rather than identify individuals. The purpose is to understand this person’s risk state, identify what is modifiable, and construct a response proportionate to it.

Ask directly

Asking about suicide does not plant the idea; this has been examined repeatedly and the evidence is consistent. Vague questions, however, produce vague answers. "Have you had thoughts of killing yourself?" is a better question than "have you had any thoughts of harming yourself?", which conflates suicide with self-harm and lets both parties avoid the word.

The distinctions that change management

Distinction	Why it matters
Passive vs. active ideation	Both matter, but active ideation with intent and plan indicates a different level of response
Ideation vs. intent vs. plan vs. preparation	Preparatory acts — giving things away, writing notes, acquiring means, rehearsal — mark a substantially elevated state
Self-harm with vs. without suicidal intent	Non-suicidal self-injury usually functions to regulate affect; it also independently raises later suicide risk. Treat both facts as true
Chronic vs. acute-on-chronic risk	A person with long-standing ideation who has become acutely worse needs a response to the change, not to the baseline
Static vs. modifiable factors	Static factors inform context; only modifiable factors give you something to do

Means safety is the highest-yield intervention

Reducing access to lethal means has stronger evidence than almost anything else available in a crisis. Suicidal crises are often short-lived, and method substitution is far less complete than intuition suggests. Ask what the person has access to, and negotiate specific, time-limited restriction with a named person who will hold it.