Suicide Risk Assessment

Introduction
Suicide is a complex and multifactorial phenomenon that can occur in various settings,
including protected environments like hospitals, affecting not only the victim and their family
but also healthcare professionals. Healthcare professionals frequently encounter suicidality but
often feel unprepared to detect, prevent, and manage it effectively. Suicide is an immensely
sensitive and profound issue prevalent in society. It refers to the intentional act of ending one’s
own life. It is often closely connected to different mental health challenges such as depression,
anxiety, and substance use. In counselling, assessing suicide risk is a compassionate and
thoughtful process that seeks to understand an individual’s struggles while offering support and
hope.
Risk Factors
Risk factors can be broadly categorized as distal (e.g., genetics, childhood trauma) and
proximal (e.g., mental illness, substance use). The stress-diathesis model posits that suicide
arises from an interaction between these factors, with proximal stressors triggering vulnerability
in individuals with underlying predispositions. Given the heterogeneity of suicidal individuals,
research focuses on identifying specific subgroups and understanding their unique
neurobiological vulnerabilities. For instance, dysfunction in the HPA axis, a key player in the
stress response, has been implicated in impulsivity and aggression, suggesting a potential role in
suicide risk
Screening for suicide
In suicide screening, a standardized tool or protocol is used to identify individuals who
may be at risk for suicide. This process can be applied universally or targeted at specific groups.
A recent approach to addressing a recent suicide attempt or suicidal thoughts involved three
stages: a phase with standard treatment, a phase with universal screening, and a phase combining
universal screening with intervention (Ryan & Oquendo, 2020). A comprehensive approach to
assessing suicidal risk in psychiatric evaluations emphasizes a thorough exploration of the
patient's current mental state, including an extensive psychiatric history, family history,
psychosocial stressors, and protective factors. Key areas of focus include identifying psychiatric
disorders (especially mood, anxiety, psychotic, substance use, and personality disorders), past
suicide attempts, family history of mental illness and suicide, and current psychosocial stressors.
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By carefully examining these factors, clinicians can gain a better understanding of the patient's
current suicide risk and develop appropriate treatment plans. Suicide risk assessments (SRA) are
usually conducted by healthcare practitioners, which often utilise psychometric scales, such as
the SAD PERSONS scale, CSSRS, or BSSI, to evaluate an individual's risk of suicide and
determine the need for preventive measures. Addressing suicidal ideation is a crucial aspect of
suicide risk assessment. By having an open discussion, counsellors validate the client’s feelings
and acknowledge their distress, reinforcing that their struggles are understood and taken
seriously.
Instruments
For accurate assessment tools are critical. Commonly used instruments, such as the Beck
Scale for Suicide Ideation (BSI) and the Columbia–Suicide Severity Rating Scale (C-SSRS),
help professionals objectively evaluate factors like suicidal intent, planning, and previous
attempts. In the current world, there are also AI-driven tools which analyse text and speech
analyses to detect the risk, although many lack integration with established suicide theories
(Parsa et al., 2023).
The Beck Scale for Suicide Ideation (BSI)
The Beck Scale for Suicide Ideation (BSI) is a widely used tool to assess the severity of
suicidal ideation. Originally developed in the United States, it has been adapted for Mexican and
Brazilian populations. The Brazilian Portuguese version consists of 21 items, each scored from 0
to 2, with a total score ranging from 0 to 38, where higher scores indicate greater suicidal
ideation. The BSI is divided into three sections. While the BSI is a valuable tool for assessing
suicidal ideation, intent, and attempts, it is often used with individuals already identified as at
risk. Healthcare professionals use the BSI to guide clinical assessments and tailor care plans
based on individual needs, ensuring more effective interventions.
The Columbia–Suicide Severity Rating Scale (C-SSRS)
The Columbia-Suicide Severity Rating Scale (C-SSRS) is a comprehensive tool designed
to assess suicide risk in both suicidal and non-suicidal individuals. It comprises four key
sections: severity of ideation, intensity of ideation, suicidal behavior, and lethality of attempts.
The C-SSRS is valuable for clinicians as it helps differentiate between various levels of suicide
risk and guides treatment decisions by providing a structured framework for assessing and
monitoring an individual's risk.(Andreotti et al., 2020)
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Comparison between two tools

The BSI is easier to use but limited to individuals already at risk. At the same time, the C-
SSRS is more accessible for a wider range of individuals but may be more complex to
administer. Both scales have limitations and lack a "gold standard" for accurate assessment.
Studies comparing the BSSI with the Columbia-Suicide Severity Rating Scale (C-SSRS) found
no significant differences in their ability to detect past suicide attempts, with both scales
demonstrating high sensitivity and specificity (Al-Chalabi et al., 2024; Cha et al., 2022).

Gaps between theory, research and practice

Slow Integration of Research into Practice

It is widely acknowledged that implementing research findings and theoretical

advancements into routine clinical care happens slowly (Balas & Boren, 2000). Practitioners face
multiple challenges, including lack of training, fear, complex decision-making, practical barriers,
inadequate use of assessment tools, and issues with psychometric principles.

Lack of Training

The limited skills among mental health professionals often stem from a lack of formal,
systematic, and evidence-based training in handling suicidality (Jacobson et al., 2012). Many
training programs still rely on outdated methods, such as excessive focus on inpatient care or
“no-suicide contracts” (Oordt et al., 2009). Additionally, suicide-specific training is rarely
offered as a core course and is often only available as an elective.

Fear Among Clinicians

Clinicians frequently experience fears related to malpractice litigation, losing a client to

suicide, and the emotional trauma or loss of confidence that may result (McAdams & Kenner,
2008). Working with suicidal clients is often seen as an “occupational hazard” (Chemtob et al.,
1989). Emotional paralysis, guilt, anger, and hypersensitivity to legal and clinical issues often
follow after a client dies by suicide (Miller et al., 2012).
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Practical Barriers

Practical barriers include the lack of institutional support for treatment plans and time
constraints due to competing demands like documentation and heavy caseloads (Bonner et al.,
2005). These factors, driven by administrative and cost-related pressures, limit the interactive
process needed to assess and manage suicide risk effectively.

Limited Use of Assessment Tools

Clinicians often rely too heavily on interviews and avoid using structured assessment
tools, believing that such tools fail to address critical aspects of suicidality (Jobes et al., 2004).
Single-item self-report questions are prone to misclassification, highlighting the need for multi-
item tools for better accuracy (Millner et al., 2015).

Violations of Psychometric Principles

Many suicide risk assessments lack reliability because they depend on single-item scales,
which fail to meet essential psychometric standards for clinical application (Markon et al., 2011).
Simplifying suicide risk into binary yes/no responses leads to a significant loss of information,
whereas continuous measures are more valid across clinical settings (Harris et al., 2017).

Suicide in the Indian Context

Some of the key causes of suicide in India are

Personal and Social Factors (Dandona et al., 2017)

● Socioeconomic circumstances
● Interpersonal problems
● Social and cultural conflicts
● Alcoholism,
● Unemployment, and poor health

Interpersonal & Individual Risk Factors (Patel et al., 2012)

● Previous suicide attempts.

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● Social isolation and feelings of loneliness.

● Chronic pain or living with health issues.
● Experiencing physical or sexual abuse.
● Academic pressures like fear of failure, competition, and parental expectations.
● Family conflicts and intergenerational issues.
● Absenteeism in school or college and living alone.

Societal Risk Factors (Patel et al., 2012)

● Caste discrimination.
● Social stigma and cultural pressures.

Cultural and Social Risk Factors for Suicide among Women in India (Amudhan et al., 2020)

● Reduced protection due to an early and arranged marriage

● Young motherhood
● Domestic violence
● Economic dependence

Marital Status

Individuals who are divorced, separated, widowed, or single have a higher likelihood of
committing suicide compared to those who are married. Those living alone are especially
vulnerable (Schmidtke et al., 1996).

Education

Low intelligence significantly increases the risk of suicide, possibly due to challenges in
job competition, lower income, and social status. Additionally, individuals with low intelligence
may struggle more with stress management (Gunnell et al., 2005).

Family Structure

Risk factors in family structure include parenting style, family history of mental illness
and suicide, and childhood physical or sexual abuse. ‘Affectionless Control ‘ a parenting style
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with low emotional warmth and high parental control or overprotection, increases the risk of
suicidal behaviour by three times (Martin & Waite, 1994).

Suicide Prevention and Policies

Role of Media

Media reporting of suicide in India often lacks sensitivity, with explicit and repetitive
details about the deceased and the method of suicide, and minimal focus on prevention resources
(Armstrong et al., 2019; Jain & Kumar, 2016). Reports tend to disproportionately cover suicides
of individuals from higher social status or groups that resonate more with the media's audience,
like students and farmers. (Armstrong et al., 2020). During the COVID-19 pandemic, many
reported suicides in Indian newspapers involved individuals diagnosed within a week, with a
male predominance and common methods being hanging and jumping (Sripad et al 2021).

Policies and Laws

Mental Healthcare Act, 2017. Decriminalized suicide attempts, presuming individuals

attempting suicide have severe stress and mandating government-provided care. Aims to provide
mental health care and services for persons with mental illness, ensuring rights and dignity.
Focuses on suicide prevention, rehabilitation, and community-based care. (Vijaykumar, 2007).

National Mental Health Policy, 2014. Aims to reduce suicides through prevention
programs, pesticide regulation, media guidelines, risk recognition training, better data collection,
and addressing key risk factors like alcohol misuse and depression (Singh, 2015).

District Mental Health Programme. Operates in 500 districts, offering

multidisciplinary mental health support, including psychiatrists as part of the multidisciplinary
team (Singh, 2015).

Suicide Prevention and Interventions

The Suicide Prevention Multisite Intervention. A study in Chennai tested a low-cost

brief intervention and contact strategy, showing significantly fewer suicide deaths and attempts
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compared to the control group, making it a promising approach for healthcare settings in India
(Vijaykumar et al., 2011).

The Healthy Activity Program. A randomized study, used lay counsellors to support
people with moderate to severe depression in primary care. It proved to be effective and
affordable, reducing suicidal thoughts and attempts while improving overall care (Patel et al.,
2017).

Suicide Prevention and Non-Governmental Organisations

SNEHA, a non-governmental organisation pioneered India's first suicide prevention

helpline in Chennai in 1986. Several helplines now provide support, and public education, and
act as a bridge to professional help. These helplines educate gatekeepers, or those who are likely
to interact with individuals exhibiting suicide behaviour, increase public and media awareness
and serve as a gateway for those in need of professional assistance (Vijaykumar and Armson,
2005).

Conclusion

Suicide prevention research highlights that timely, appropriate, and sustained

interventions can significantly help those at risk. A holistic, scaffolded approach is essential,
starting with building resilience from childhood and adolescence. This should be complemented
by societal changes, community support, improved mental health services, and targeted
assistance for vulnerable groups to reduce suicide risks and foster a safer, more supportive
environment for all (Haslam et al., 2019).
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