The following document was written by Dr Satvir Singh FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry) Kent & Medway NHS and Social Care Partnership Trust Canterbury, Kent in Dec 2007.
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Risk Assessment in medicine is conscientious evaluation of all the relevant factors, which help the clinician to predict an adverse event or outcome.

In Psychiatry, the Risk Assessment is to predict suicide in a given social circumstance. However, the prediction of suicide in a specified timescale by any doctor, even after years of training and experience in this particular field is extremely difficult, probably, due to the large number of variables and their complex relationships, which are at play at any given time. Also, how these wide and varied factors influence the individual who finally commits suicide is unique to that individual only. Furthermore, from the innate psychological instinct point of view, killing oneself is entirely opposite to the survival instinct that we harbour.

There are well researched and painstakingly evaluated published studies, all of which have highlighted some specific factors, which should alert all clinicians of the adverse outcome. However, prediction based only on the factors “present or absent” has a very low sensitivity and specificity.

What is useful is an understanding of what circumstances are likely to lead to an increased risk, and how that can be minimised for a better outcome.

Risk Assessment for suicide requires willingness on part of the clinician for detailed assessment of the physical and mental health issues; financial circumstances and situations; under what circumstances the particular behaviours have arisen in the past and what has changed now; also, some understanding in effective and ineffective interventions in the past.

A Risk Assessment is only useful if it leads to a better and agreed management plan among all concerned individuals and professionals. Above all, faithful implementation of the agreed plan is the essential step for the safe, appropriate and effective care for the better outcome.

Following are the key factors, which should alert a clinician of a probable suicide attempt:

The Process of Risk Evaluation

The following are some of the essentials to carry out a thorough risk assessment:

  1. First of all the doctor should set aside enough time to complete the assessment in a sympathetic and unhurried fashion.

  2. It is always useful to ask another health professional to join you. A Community Nurse or a Senior Ward Nurse, who knows the patient well and has been involved with his/her clinical management, is very helpful.

  3. It is also important to invite a member of the patient’s family (with the patient’s consent) to join you or to interview him/her after the initial interview with the patient.

  4. The systematic review of personal history, particularly the recent losses (financial, partner, social status and others) and their significance from the patient’s point of view.

  5. Relevant past medical, psychiatric and family history.

  6. Current medical and mental health issues, prescribed treatment and the patient’s perception of the prognosis.

  7. Detailed evaluation of depressive symptoms, attitude towards life, being a burden on others, guilt feelings and thoughts about “suicide intent.”

  8. Differentiate between passive suicidal ideation and active plans for self-harm/suicide.

  9. Ask about religious, spiritual or personal beliefs about life and death. You will see many patients with extreme hardships in their lives and almost nothing to live for, but they simply will not consider the option of suicide because of their personal beliefs.

  10. Enquire about other protective factors. Almost all patients, except those who are suffering from psychotic depression or other psychotic disorders, will admit to some reasons for them to go on living, and one should be aware of those key factors in their personal lives. Knowing these reasons that give them hope for life will help the clinician in the management of the patient.

  11. In order to complete the Risk Assessment, one needs to speak to other relevant health professionals (GP & nursing staff, with patient’s consent) who have known the patient in the past

  12. It is also useful to complete at least one questionnaire about recent suicide attempts, if relevant. Beck Suicide Intent Scale (Aron Beck – 1974) or David Pierce’s “Modified Objective Intent Scale” (BJP 130, 1977) are the most widely used scales, which will translate the recent intent for suicide and its seriousness in numerical format. However, a very high or a very low score will not always correlate with the ultimate outcome. Hence, such scales do not replace your own detailed clinical assessment and thoughts for the management plan.

Limits of Risk Assessment

  1. It is not possible to identify and eliminate risk entirely.

  2. Risk fluctuates from day to day and/or sometimes, hour to hour, therefore, prediction is more accurate in the short term and even then, never a hundred percent accurate

  3. Often, the clinician will not have all the essential facts available at the time of assessment.

  4. A good Risk Assessment depends on the reliable information available from the patient and other informants, i.e., family, friends, colleagues, etc.

  5. A comprehensive assessment of risk should also incorporate the views of other health professionals who have been involved with the patient care currently and/or in the past, such as patient’s GP, hospital specialists, senior nursing staff, clinical psychologist, community nursing staff, and sometimes, if relevant, information from the Police and the Courts may be very valuable in the assessment of risk of self-harm and/or risk to others.

Formulation and Management of Risk

  1. Summarise the relevant personal details, such as age, gender, marital history and past medical and psychiatric history

  2. Identify the current stress factors and how they differ from previous circumstances. Essentially, make a note of precipitating factors of the current clinical state:

    • Recent bereavement

    • Recent break-up of a relationship

    • Recent discharge from hospital or change in legal status

    • Anniversaries or reminders of deaths or loss of loved ones

    • Recent loss or threat of loss of job

    • Loss of finance or reputation

    • Threat of criminal charges or imprisonment

    • Unwanted pregnancy and peer suicide in adolescence

  3. Then classify your patient in mild, moderate and severe risk categories, which would help you to plan the management of the patient and minimise the risk of adverse event.

Category – 1: Minimum Risk of Future Adverse Event

Key Factors

  1. First episode of deliberate self-harm with no evidence of:

    • Mental disorder

    • Continuing suicidal ideation or intent

    • History of drug or alcohol abuse

  2. And evidence that the “crisis” has been resolved

  3. Plus presence of one or more of the following protective factors:

    • Strong social support network

    • Supportive spouse/parents/others

    • Stable personality

    • Optimistic outlook and religious, spiritual, personal positive belief system

    • Responsibility towards parents, children, others

    • Willingness to receive medical and other help

Category – 2: Moderate Risk of Future Adverse Event

Key Factors

Category – 3: Severe (Serious) Risk of Future Adverse Event

Key Factors


Once the examination of the patient and others has been completed, all risk factors evaluated, understood and documented, the following decisions have to be made:

  1. That the patient can be safely discharged from the hospital and indeed, can be treated in the community

  2. That the patient should be admitted/transferred to a psychiatric in-patient unit

  3. Who else needs to be involved to complete the Risk Assessment?

  4. When, where and by whom will the Risk Assessment be reviewed?

“The Management of Suicidal patient and Deliberate Self-Harm and Consent for Treatment” will be dealt with in the next section

Dr Satvir Singh
FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS
Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry)
Kent & Medway NHS and Social Care Partnership Trust
Canterbury, Kent


  1. Shorter Oxford Textbook of Psychiatry, Fifth Edition, M Gelder et al, 2006
  2. Guidelines for Clinical Risk Assessment and Management in Mental Health Services, Ministry of Health, New Zealand, 1998
  3. Guidelines for the Management of Deliberate Self-Harm in Young People, The Royal Australian and New Zealand College of Psychiatrist, June 2000.


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