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3: Assessment of Risk Factors

Screening and Assessment » Assessment
3: Assessment of Risk Factors

When performing a suicide risk assessment, we suggest including, but not limited to, factors (see Table 6) within the following domains:

  • Self-directed violence, thoughts, and behaviors
  • Current psychiatric conditions and current or past mental/behavioral health treatment
  • Psychiatric symptoms
  • Social determinants of health and adverse life events
  • Availability of lethal means
  • Physical health conditions
  • Demographic characteristics
Strength:

Weak for

Category:

ReviewedAmended

Grades and Definitions

Strong for
or "We recommend offering this option …"
Weak for
or "We suggest offering this option …"
No recommendation
or "There is insufficient evidence …"
Weak against
or "We suggest not offering this option …"
Strong against
or "We recommend against offering this option …"

Categories and Definitions

Evidence Reviewed* Recommendation Category* Definition*
Reviewed New-added New recommendation following review of the evidence
New-replaced Recommendation from previous CPG that has been carried over to the updated CPG that has been changed following review of the evidence
Not changed Recommendation from previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed but the recommendation is not changed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed based on review of the evidence
Not reviewed Not changed Recommendation from previous CPG that has been carried forward to the updated CPG, but for which the evidence has not been reviewed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has not been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed because it was deemed out of scope for the updated CPG
*Adapted from the NICE guideline manual (2012): The guidelines manual. London: National Institute for Health and Care Excellence;2012. and Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated recommendations: An assessment of NICE clinical guidelines. Implement Sci. 2014;9:72.

Recommendation Resources

The goal of suicide risk assessment is to help providers determine a patient’s risk of suicide at a given point in time. Although suicide risk assessments have poor predictive value in identifying those at risk, they can identify factors that are contributing to a patient’s risk, which can facilitate treatment planning. Evaluation of risk factors is a crucial component of suicide risk assessment. Several factors have been associated with increased risk for suicide.

Table 6. Suicide Risk Factors
Factor Category List of Factors to Consider
Self-directed violence related
  • Current suicidal ideation
  • Past or present suicidal intent
  • Prior suicide attempt or attempts
  • Preparaty behavior or behaviors
  • Non-suicidal SDV behavior or behaviors
Current psychiatric conditions and current or past mental/behavioral health treatment
  • Mood disorders
  • SUDs (including OUD)
  • PTSD (particularly when comorbid with depressive disorder)
  • Panic disorder
  • Psychotic disorders
  • Personality disorders (particularly BPD)
  • Eating disorders
  • History of psychiatric hospitalization
Psychiatric symptoms
  • Hopelessness
  • Depressed mood
  • Negative attributional style
  • Rumination
  • Agitation
  • Anxiety, panic, or both
  • Insomnia
  • Problem-solving difficulties
  • Impulsivity
  • Aggression, hostility, or both
  • Social withdrawal
Social determinants of health and adverse life events
  • Barriers to care
  • Food insecurity
  • History of abuse
  • Early separation from parents
  • Exposure to violence
  • Living arrangements (living alone, especially for men)
  • Social Isolation
  • Risk of losing stable housing or homelessness
  • Legal problems
  • Job loss and financial problems
  • Interpersonal conflict
  • Exposure to suicide
Availability of lethal means
  • Availability of lethal means, especially firearms
Physical health conditions
  • Any cancer diagnosis (particularly patients with intermediate to poor prognosis)
  • Respiratory illnesses (COPD, emphysema)
  • Neurological disorders (stroke, epilepsy)
  • Neurodegenerative Disorders (Alzheimer's disease, Parkinson's disease, Huntington's disease, ALS, multiple sclerosis)
  • TBI (moderate and severe)
Demographic Characteristics
  • Gay, lesbian, or bisexual sexual orientation
  • Marital status (divorced, separated, or single)
  • Lower SES
  • Unemployment
  • Years of education*

Training and Clinical Resources

This section includes links to recommended trainings about the assessment of risk factors.

VA Comprehensive Suicide Risk Evaluation (CSRE) printable worksheet
Thumbnail image of The Columbia Risk and Protective Factors Page The Columbia Risk and Protective Factors Page provides a checklist of risk and protective factors for suicide that can be used with any version of the Columbia Suicide Severity Rating Scale (C-SSRS)
Healthy People 2030: Social Determinants of Health
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Webinars

This section includes links to recommended webinars about the assessment of risk factors.

SRM Lecture Financial Well-Being and Suicide Risk in Military Veterans presented by Dr. Eric Elbogen
CPG Webinar Firearm Acquisition & Ownership — Decision Making Within the Context of Injury Risk presented by Dr. Joseph Simonetti
SRM Lecture Neurocognitive Disorders and Suicide presented by Dr. Joleen Sussman and Kelly Soberay, MA
SRM Lecture Preventing Suicide Among Veterans Experiencing Homelessness: Drivers or Risk and Tailoring Evidence-Based Care presented by Drs. Ryan Holliday, Kenneth Bruemmer, and Evan Polzer and Mr. Shawn Liu
SRM Lecture Suicide Prevention among those with Neurologic Conditions presented by Dr. Lisa Brenner
SRM Lecture Suicide Prevention in Veterans with Substance Use Disorders presented by Dr. James Haug and Erin Higgins, LCSW, LAC
CPG Webinar Suicide Risk Factors Research & Clinical Implications presented by Dr. Megan Harvey and Christie Machan, LCSW
SRM Lecture Suicide Risk and Prevention for Sexual and Gender Minority Populations presented by Dr. John Blosnich
SRM Lecture TBI, Suicide, and Evidence-Informed Intervention Strategies presented by Dr. Lisa Brenner
SRM Lecture The Role of Relationships in Risk for Self-Directed Violence presented by Dr. Danielle Weber
SRM Lecture Treating PTSD in the Context of Suicidality presented by Dr. Sadie Larsen and Dr. Lisa-Ann Cuccurullo
SRM Lecture Understanding and Addressing Suicide Among Homeless and At-Risk Veterans presented by Drs. Ryan Holliday and Jillian Weber and Mr. Shawn Liu, LCSW
SRM Lecture Understanding and Navigating Elevated Suicide Risk when Working with Justice-Involved Veterans presented by Drs. Ryan Holliday, Matthew Stimmel, Alicia Desai and Ms. Katherine Stewart, LCSW
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Podcasts

This section includes links to recommended podcasts about the assessment of risk factors.

Rocky Mountain MIRECC Short Takes on Suicide Prevention
Short Takes podcast icon Risk Factors, Warning Signs, and Drivers of Suicide with Dr. Peter Gutierrez
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Articles

This section includes links to recommended articles about the assessment of risk factors.

Dempsey, C. L., Benedek, D. M., Zuromski, K. L., Riggs-Donovan, C., Ng, T. H. H., Nock, M. K., Kessler, R. C., & Ursano, R. J. (2019). Association of Firearm Ownership, Use, Accessibility, and Storage Practices With Suicide Risk Among US Army Soldiers. JAMA network open, 2(6). e195383. https://doi.org/10.1001/jamanetworkopen.2019.5383
Favril, L., Yu, R., Uyar, A., Sharpe, M., & Fazel, S. (2022). Risk factors for suicide in adults: systematic review and meta-analysis of psychological autopsy studies. Evidence-based mental health, 25(4). 148–155. https://doi.org/10.1136/ebmental-2022-300549
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., Musacchio, K. M., Jaroszewski, A. C., Chang, B. P., & Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological bulletin, 143(2). 187-232. https://doi.org/10.1037/bul0000084
Lee, D. J., Kearns, J. C., Wisco, B. E., Green, J. D., Gradus, J. L., Sloan, D. M., Nock, M. K., Rosen, R. C., Keane, T. M., & Marx, B. P. (2018). A longitudinal study of risk factors for suicide attempts among Operation Enduring Freedom and Operation Iraqi Freedom veterans. Depression and anxiety, 35(7). 609–618. https://doi.org/10.1002/da.22736
Lynch, K. E., Gatsby, E., Viernes, B., Schliep, K. C., Whitcomb, B. W., Alba, P. R., DuVall, S. L., & Blosnich, J. R. (2020). Evaluation of Suicide Mortality Among Sexual Minority US Veterans From 2000 to 2017. JAMA network open, 3(12). e2031357. https://doi.org/10.1001/jamanetworkopen.2020.31357
Mitra, A., Pradhan, R., Melamed, R. D., Chen, K., Hoaglin, D. C., Tucker, K. L., Reisman, J. I., Yang, Z., Liu, W., Tsai, J., & Yu, H. (2023). Associations Between Natural Language Processing-Enriched Social Determinants of Health and Suicide Death Among US Veterans. JAMA network open, 6(3). e233079. https://doi.org/10.1001/jamanetworkopen.2023.3079
Nie, J., O'Neil, A., Liao, B., Lu, C., Aune, D., & Wang, Y. (2021). Risk factors for completed suicide in the general population: A prospective cohort study of 242, 952 people. Journal of affective disorders, 282. 707–711. https://doi.org/10.1016/j.jad.2020.12.132
Nock, M. K., Millner, A. J., Joiner, T. E., Gutierrez, P. M., Han, G., Hwang, I., King, A., Naifeh, J. A., Sampson, N. A., Zaslavsky, A. M., Stein, M. B., Ursano, R. J., & Kessler, R. C. (2018). Risk factors for the transition from suicide ideation to suicide attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Journal of abnormal psychology, 127(2). 139–149. https://doi.org/10.1037/abn0000317 
Qin, P., Syeda, S., Canetto, S. S., Arya, V., Liu, B., Menon, V., Lew, B., Platt, S., Yip, P., & Gunnell, D. (2022). Midlife suicide: A systematic review and meta-analysis of socioeconomic, psychiatric and physical health risk factors. Journal of psychiatric research, 154. 233–241. https://doi.org/10.1016/j.jpsychires.2022.07.037 
Shaw, R. J., Cullen, B., Graham, N., Lyall, D. M., Mackay, D., Okolie, C., Pearsall, R., Ward, J., John, A., & Smith, D. J. (2021). Living alone, loneliness and lack of emotional support as predictors of suicide and self-harm: A nine-year follow up of the UK Biobank cohort. Journal of affective disorders, 279. 316–323. https://doi.org/10.1016/j.jad.2020.10.026\ 
Stone, D. M., Mack, K. A., & Qualters, J. (2023). Notes from the Field: Recent Changes in Suicide Rates, by Race and Ethnicity and Age Group - United States, 2021. MMWR. Morbidity and mortality weekly report, 72(6). 160–162. https://doi.org/10.15585/mmwr.mm7206a4 
Swanson, S. A., Studdert, D. M., Zhang, Y., Prince, L., & Miller, M. (2023). Handgun Divestment and Risk of Suicide. Epidemiology (Cambridge Mass.), 34(1). 99–106. https://doi.org/10.1097/EDE.0000000000001549 
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