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Suicide Assessment

Suicide-jumper caught by Assess-man
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It is important to complete a comprehensive psychiatric assessment on all patients, especially those who by either direct (overt) or indirect (covert) statements have indicated suicidal ideations (thoughts or preoccupation with suicide leading to feelings of hopelessness and helplessness). When patients are admitted in a suicidal crisis, they need suicidal precautions instituted to protect them from self-harm.
12 KEY FACTS
SAD PERSONS Scale
SAD PERSONS Scale

The SAD PERSONS scale is an acronym to help remember risk factors for suicide. The score is calculated from 10 yes or no questions, with one point given for each affirmative answer. The higher the number, the greater the risk. S - sex, A - age, D - depression, P- previous attempt, E - excess alcohol or substance abuse, R - rational thinking loss, S - social supports lacking, O - organized plan, N - no spouse, S - sickness (chronic illness) or stated future intent.

VERBAL CUES
Direct (Overt) Statements
Direct-route Speech

Direct statements such as, “I want to die or you would be better off if I was dead” may indicate a desire to commit suicide.

Indirect (Covert) Statements
Indirect-route Speech

Subtle comments such as, “Everything will be fine in just a little while or I won’t be a burden to you for much longer” can also be indicative of a suicide plan.

BEHAVIORAL CUES
Giving Away Prized Possessions
Giving Away Prizes

An early warning sign is noting an individual beginning to give away prized possessions, because they are contemplating suicide.

Sudden Improvement in Mood
Good Mood

Low serotonin levels are associated with depressed mood. The patient who is beginning to respond to the effectiveness of antidepressant medication will experience a sudden improvement of mood, which gives them the energy and focus to move forward with their suicide plan and act on their ambivalent feelings regarding suicide.

Putting Personal Affairs in Order
Signing Will and Testament

Another behavioral response noted in the suicidal patient is their focus on putting their personal affairs in order, such as organizing finances, making burial/cremation plans, changing wills, etc.

LETHALITY OF PLAN
Detail of Plan
Detailed Plan with Time of Day

Factors such as the timing, location, and availability to go through with the act contribute to how capable the person is of causing death. The lethality of the plan is paramount in assessing, as it evaluates how quickly the patient would die if the plan was carried out. It is usually classified as high or low risk method.

Availability of Means
Available Bridges

This refers to the patient having access to carry out the plan. If the patient has the availability of carrying out the proposed method, then the situation is serious, such as having access to a handgun. Patients who are experiencing a psychotic episode are at high risk for completing the suicide act, especially if they have command hallucinations.

Proposed Method
Proposed Method-grab

A high risk (or hard method) proposed suicide plan would involve the patient using a gun, hanging themselves, jumping from a high place, suffocating with carbon monoxide, or staging a car crash. A lower risk (or soft method) involves slashing the wrists, ingesting pills, or inhaling natural gas.

SUICIDE PRECAUTIONS
Safe Environment
Safe-house

Patients that are at high risk should be hospitalized in a safe environment.

One-on-One Monitoring
One-on-One Monitor

When the patient is admitted, there needs to be one-on-one monitoring, so that the patient does not injure themselves. Reduce environmental hazards to minimize suicidal behavior (plastic eating utensils, no long cords, belts, shoelaces, nail files, tweezers, matches, razors, tamper-proof windows, locked utility rooms, etc.)

No Suicide Contract
Signing No Suicide Contract

This is also called a “no-harm” contract, which is a written document that the patient agrees to not harm themselves, but to reach out to staff or a suicide crisis line, when suicidal feelings emerge.

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