Suicide Risk Assessment

Introduction: This web page introduces the Suicide Risk Assessment (SRA) an evidence based assessment instrument or test. The Suicide Risk Assessment (SRA) assesses what are generally considered "core competencies" in suicide risk assessment. The SRA is available online (

Two Caveats

It is not enough to simply ask a patient about the presence of suicidal thoughts, or ask if they are suicidal (Gross, 2005).

There is little doubt that the majority of mental health professionals are untrained and unprepared to assess and treat suicidal patients (Schmitz, et al., 2012).

David Lang, J.D. (2013) emphasized clinicians should use a suicide screening tool with patients who have co-existing concerns like depression, anxiety, substance (alcohol/drug) use, etc.

Suicidal thinking (ideation) is more widespread than most people think. Worldwide approximately one million people die by suicide annually. In the United States there are, on average, 35,000 suicides a year. According to the Federal Substance Abuse and Mental Health Services Administration (SAMHSA), 1.1 million Americans attempt suicide each year, 2.2 million have a suicide plan, and 8.4 million have serious suicidal thoughts. Approximately 65,000 Americans receive emergency room treatment each year following a suicide attempt. The number of people thinking seriously about suicide, making suicide plans and attempting suicide is alarmingly high.

The following statistics come from “35 Years of Working with Suicidal Patients: Lessons Learned” (Meichenbaum, 2005).

  • 30% of psychologists and 50% of psychiatrists will experience a patient’s suicide.
  • 1 in 6 psychiatric patients that die by suicide are in active treatment at the time of their death.
  • After patients commit suicide, 25% of family members take legal action against the patient’s health care provider (physicians, psychiatrists, psychologists, mental health professionals, certified counselors, chemical dependency professionals, etc.).

Primary care physicians are the group most likely to see patients at risk of suicide before their suicide. Patients that die by suicide visit their primary care physicians more than twice as often before their death as their mental health clinician (Luoma, Martin, Pearson, 2002).

Civil lawsuits, referred to as tort actions, are increasingly being filed following a suicide. A tort is a civil wrong alleged to have caused injury or death (Maris, Berman & Silverman, 2000). Tort law specifies that a person may be held liable, if they failed in their duty to prevent harm to another (Smith, Witte, Teale, King, Bender, Joiner, 2008). Clinicians have a duty (responsibility) to prevent patient suicides. The preventative actions that are required depend upon the “foreseeability” of a suicide. In essence, a clinician’s duty is to protect their patients from foreseeable harm. That said, a prudent approach is for clinicians to administer “suicide risk assessments,” document their findings, and implement suicide-risk levels of care (e.g., closer monitoring, intensified levels of care) and document what they do. Suicide risk assessments are important in identifying suicide risk, clarifying foreseeability and adjusting the patient’s level of care to match their suicide risk.

To emphasize or highlight the evolving role of “suicide risk assessments,” in 1999 the U.S, Surgeon General’s “Call to Action to Prevent Suicide” stressed identification of suicide risk. Today there is little professional disagreement between clinicians and the courts that the standard of suicide patient care requires a suicide risk assessment be administered to guide the treatment of patients, inmates and others that are at suicide risk .

More and more hospitals, licensing boards, certifying agencies, outpatient care centers, inpatient programs, the courts, etc. mandate or require documentation of suicide risk assessments. Nevertheless, many clinicians may perform, or administer a suicide risk assessment but don’t document their suicide risk assessments. Why not? Answers vary, yet some of the clinician’s answers are summarized as follows: A lack of education and training (e.g., medical schools, doctorate level [Ph.D.] curriculums, masters’ level programs, etc.) in suicide assessment and treatment. Many licensing boards and certifying agencies do not require or enforce comprehensive suicide risk training. Some clinicians incorrectly assume that documenting suicide risk increases their legal exposure. This is incorrect, as completing a suicidal risk assessment and documenting it typically strengthens a clinician’s legal defense (Simon, 2002). Another rather naïve answer is “the clinician is too busy.” And in some instances the clinician delegates risk assessments to the treatment team or others. When treatment decisions are delegated, who is responsible or liable? Patient suicides are the most frequent source of malpractice claims against psychiatrists.

Courts tend to assume that suicide is preventable if it is “foreseeable.” As discussed earlier, a clinician’s duty is to protect their patients from foreseeable harm. Foreseeability is the reasonable anticipation that harm or injury (e.g., suicide) is likely to result from certain acts or omissions (e.g., not administering and documenting a suicide risk assessment or acting on the results). Properly administered and documented suicide risk assessments meet foreseeability criteria. Simon (2002) notes, “Courts have generally held psychiatrists liable in patient suicides if they (psychiatrists) did not complete a suicide risk assessment, document it and implement a suicide-risk-related treatment plan.” Generalizing to other clinicians (other than psychiatrists), administering a suicide risk assessment strengthens their legal defense when challenged.

Foreseeability and its role in tort law is carefully reviewed by Owen (2009) who concludes, “No one should doubt that foreseeability is an explicit central consideration in evaluating whether a person's conduct should be blamed or declared negligent.” Foreseeability permeates tort law, especially in malpractice and negligence cases.

Before moving on, it is worthwhile to note that jails, prisons, penitentiaries and other correctional and detention facilities have a legal duty to ensure the safety of their inmates. As part of this responsibility the department or facility and staff has a duty to prevent inmates from committing suicide. To prevent these suicides many programs (departments or facilities) have incorporated a suicide risk assessment at inmate intake (or at regional reception centers). Inmates identified as being at risk of suicide are closely monitored and as warranted medically supervised and/or enrolled in group counseling programs. Similar programs have saved lives while concurrently meeting detention or correctional facilities duty to ensure the safety of their inmates.

The standard of care in suicidology endorses the administration, documentation and incorporation of risk-appropriate treatment programs. Failure to administer and document these suicide risk assessments is usually considered malpractice or negligence. In summary, information derived from suicide risk assessments enables clinicians to better understand their patient’s suicide risk, increase their foreseeability, and develop treatment plans that are in the best interest of their patients (or inmates).

Other factors are included in suicide risk assessments that relate to foreseeability and suicide risk. For example: Suicidal history, suicidal thoughts (ideation), suicidal intentions and associated DSM-5 disorders (e.g., depression, anxiety, alcohol, drug, stress, and substance use, etc.). Also reviewed are risk factors (e.g., family history of suicide, availability of pills, guns, etc.) and protective factors (e.g., available social support, religious beliefs, fear of death, etc.). Although focused, comprehensive and meaningful, a suicide risk assessment alone does not prevent suicides. Once suicide risk has been determined, it is incumbent upon the clinician to adjust the patient’s treatment plan and take appropriate actions to prevent suicide. The standard of care for suicide risk assessments is to complete a comprehensive suicide risk assessment and then, take action appropriate to the patient’s level of suicide risk (Joiner, Walker, Rudd & Jobes, 1999). At a minimum, suicide risk requires closer monitoring and an intensified level of care.

Primary care settings are considered good opportunities for detection and early intervention of suicide risk (Katon, Unitzer & Simon, 2004). With regard to suicide liability exposure (Stuber & Quinnett, 2013) “Healthcare professionals are at risk for being sued if they do not assess at-risk patients in their care for suicide and intervene appropriately depending upon the level of risk that the patient presents.” There is little doubt that the majority of mental health professionals are untrained and unprepared to assess and treat suicidal patients (Schmitz, et al., 2012).

In summary, the Suicide Risk Assessment (SRA) helps structure the suicide risk assessment process for busy clinicians that may lack suicide-related education and training. The SRA takes 30 minutes to administer and less than three (3) minutes from data (answers) entry to score and print four (4) page SRA reports. An example SRA report is available via the link above. SRA reports help clinician's meet the "standard of care" in suicidology. In other words, the Suicide Risk Assessment (SRA) is readily available (24/7) over Behavior Data Systems, Ltd. (BDS) internet platform ( to help clinician's maintain a high level of standard of care in suicidologoy.

Who Uses the Suicide Risk Assessment?

The Suicide Risk Assessment (SRA) is a concise, yet comprehensive evidence-based suicide risk assessment or self-report test. The Suicide Risk Assessment (SRA) differentiates between acute and chronically suicidal patients. It identifies periods of heightened suicide risk, recognizes escalating suicide risk when it occurs, assists in determining suicide foreseeability, helps in establishing appropriate levels of care and documents treatment decisions. The SRA assesses core competencies and documents the assessment procedures involved. If you want to consistently incorporate these core competencies in your suicide risk assessments – you should consider using the Suicide Risk Assessment (SRA).

Some clinician’s have the education, training and time necessary to individually complete a comprehensive suicide risk assessment. Even so, many of these clinicians use self-report suicide risk assessments to focus and ensure comprehensiveness in their suicide risk assessments, while enhancing their foreseeability. The SRA is used by both experienced and new suicide assessors. Clinicians that lack suicide risk assessment training should consider using the Suicide Risk Assessment (SRA) to screen and identify patient’s suicide risk. They can then clarify any unresolved issues that emerge and modify the patient’s treatment program (level of care) accordingly. If a clinician does not assess their emotionally disturbed patient’s suicide risk and understand the foundation upon which their foreseeability is based, they are unnecessarily exposing themselves to tort and malpractice allegations.

Regular use of the SRA has several important advantages. It consistently assesses important suicide domains. It provides a sound basis for treatment decisions that assist the clinician’s suicide risk foreseeability. It documents the Suicide Risk Assessment methodology and enhances the quality of patient care. The SRA augments but does not replace a clinician’s follow-up on Suicide Risk Assessment findings.

Suicide Risk Assessment

The SRA is a clinical resource that is focused specifically on suicide risk assessment. As noted by O’Carrol et al. (1996) suicide behavior is distinguished by three characteristics: 1. Intention to die, 2. Suicide attempt-related self-inflicted injury, and 3. Outcome (injury or death). The SRA evaluates and documents each of these suicide-related characteristics. In addition the SRA analyzes two of the three “standards of practice” in suicidology: Foreseeability (a thorough risk assessment) and treatment planning (modify treatment plan based upon suicide risk assessment). The third “standard of practice” element, namely “follow-up” is endorsed and recommended. But determining whether or not the risk assessment based treatment plan was implemented is beyond the purpose or scope of the Suicide Risk Assessment (SRA). Suicide risk-related treatment implementation is the responsibility of the assessor or treatment staff. In summary, the SRA assesses what are generally considered “core competencies,” in suicide risk assessment.

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