As a National Patient Safety Goal in both general and psychiatric hospitals, the Joint Commission mandates suicide risk assessments for patients who are identified as being at risk.65
This mandate stems from inpatient suicides being a frequent sentinel event over time.
Performance of a suicide risk assessment is a long-standing psychiatric practice recommendation. It is typically documented in the assessment/plan of a clinical note; identifies and discusses risk factors or warning signs that increase the likelihood of suicide; describes possible protective factors that may decrease suicidal behavior; states the level of suicide risk as low, medium, or high; and defines the care setting required to maintain safety (eg, outpatient, referral to the emergency department, hospitalization). Although this assessment is primarily a documentation requirement, with almost no research data to support its validation of risk levels or its effect on future suicide, it allows for a structured process to organize clinical impressions and decision making and to suggest clinical interventions.
The Suicide Assessment Five-step Evaluation and Triage (SAFE-T)66
provides a framework for performing a suicide risk assessment and is publicly available. Clinical decision making begins by identifying the presence of warning signs and risk factors increasing the likelihood of suicide-related behaviors ().34,36
These include psychiatric diagnoses and particular symptoms known to increase immediate suicide risk, including agitation or anxiety, command hallucinations, and sleep problems.
Protective factors may include the ability to manage stress appropriately, religious beliefs that increase the stigma of suicide, and the capacity to tolerate frustration. External factors that may mitigate risk include a sense of responsibility to family or friends, a healthy network of social supports, and positive therapeutic relationships. However, in the setting of acute risk and multiple risk factors in unfamiliar patients, the ability of protective factors to decrease risk should not be overestimated. In a crisis, protective factors may be easily overwhelmed, particularly in an impulsive, intoxicated, or otherwise disinhibited patient.
In questioning the patient perceived to be at risk, clinicians should ask specifically about suicide with a focus on suicidal thoughts, plans for suicide, and intent. The level of risk and care required should then be defined using the general recommendations in the following paragraph. As a caveat, when questions about level of risk or management remain, consultation with an experienced colleague or psychiatric clinician is valuable.
According to the SAFE-T model, low-risk patients—with or without suicidal ideation—have no specific plans or intent to commit suicide and have no history of active suicidal behavior. These patients should have recommended outpatient follow-up. Those at moderate risk include those with suicidal ideation plus a plan but with no intent or behavior. The decision whether to urgently refer a patient to a psychiatrist or emergency department depends on that patient's presentation. Patients who are referred may be hospitalized if further evaluation reveals that their level of illness or other clinical findings warrant it. High-risk patients include those with serious thoughts of suicide, those with a plan and/or intent to commit suicide, and those with prominent agitation, impulsivity, psychosis, or a recent suicide attempt. In such cases, clinicians should ensure constant observation and monitoring before arranging for immediate transfer for psychiatric evaluation or hospitalization. As the final steps in the process of suicide risk assessment, clinicians should document the data supporting the assigned level of risk, the level of care required, and treatment plans to reduce suicide risk.