Last updated January 5, 2022

Suicide Risk Assessment

Decision Options

INITIAL SUICIDE ASSESSMENTS

Suicide screening tools should be used as a part of the assessment process for all ED patients. (A)
320000
Previous episodes of deliberate self-harm are a strong predictor of future suicide attempts. (A)
320000
For initial suicide assessment, training ED personnel improves confidence in screening for suicide risk. (B)
320000

SUICIDE RISK INSTRUMENTS

There is a moderate amount of evidence to support that the following instruments are valid, feasible, and reliable for initial assessment of suicide risk in the ED:
  • The Ask Suicide-Screening Questions (ASQ)
  • Manchester Self-Harm Rule (MSHR)
  • Risk of Suicide Questionnaire (RSQ)
(B)
320000
There is a moderate amount of evidence to support that the following instruments may be used to evaluate lethality for discharge from the ED setting:
  • Behavioral Health Screening Emergency Department (BHS-ED)
  • Columbia Suicide Severity Rating Scale (C-SSRS)
  • Geriatric Depression Scale (GDS)
  • The ReACT Self-Harm Rule
(B)
320000
There is a weak amount of evidence to support that the following instruments are valid, feasible, and reliable for initial assessment of suicide risk in the ED:
  • Suicide Affect-Behavior-Cognition Scale (SABC)
  • Patient Safety Screener (PSS)
(C)
320000
There is insufficient evidence to make a recommendation for the following instruments can be used for further assessment in the ED setting:
  • Beck Hopelessness Scale (BHS)
  • Beck Scale for Suicide Ideation (BSS)
  • Behavioral Activity Rating Scale (BARS)
  • Centers for Epidemiologic Studies Depression Scale (CES-D)
  • Centers for Epidemiologic Studies Depression Scale for Children (CES-DC)
  • Death/Suicide Implicit Association Test (IAT)
  • General Health Questionnaire (GHQ-12)
  • Geriatric Suicide Ideation Scale (GSIS)
  • Modified SAD Persons Scale (MSPS)
  • Nurses Global Assessment of Suicide Risk (NGASR)
  • Patient Health Questionnaire (PHQ-2 and PHQ-9)
  • Patient Health Questionnaire for Adolescents (PHQ-A)
  • SAD Persons Scale (SPS)
  • Scale for Suicidal Ideation (SSI)
(I/E)
320000

SUICIDE RISK PREDICTORS

Previous episodes of deliberate self-harm are a strong predictor of future suicide attempts. (A)
320000
Patients with a history of Major Depressive Disorder (MDD) or Post Traumatic Stress Disorder (PTSD) should be considered at higher risk for suicide. (B)
320000
Patients with the following presentations should be considered at higher risk for suicide:
  • Chronic illness in adults
  • Binge or high episodic drinking in adolescents and young adults
  • History of lethal methods of self-harm and self-cutting
  • Living alone
  • Lower socioeconomic status
  • Males over 55 years of age
  • Recent negative life events
  • Substance abuse
  • Young females
(C)
320000

Recommendation Grading

Overview

Title

Suicide Risk Assessment

Authoring Organization

Publication Month/Year

September 1, 2018

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Emergency care, Hospice

Intended Users

Psychologist, nurse

Scope

Assessment and screening

Diseases/Conditions (MeSH)

D018570 - Risk Assessment, D013405 - Suicide

Keywords

risk assessment, Suicide