Suicide Risk – a current perspective

Food for thought

This is a literature review that was initially developed to inform a clinical audit proposal. All details relating to a particular work environment have been removed; I think it is useful to identify current national strategic directions and local initiatives that may promote growth in our response to this issue that affects so many.


Implications for ‘frontline clinicians’ working in

Area Mental Health Services.


This paper seeks to utilise evidence based research  to identify a best  practice clinical standard in assessment of suicide risk during the intake process.  The intention is to support  frontline clinicians working in Area Mental Health Services. Part A addresses the rationale for why this topic, at this time, and in this place.

Part B provides a review of the literature, a critique of the evidence before clearly stating measureable recommendations of best practice to form a set of bottom line clinical standards informing future practice for suicide risk assessment.


Rationale & Background

The body of evidence identifying suicide as a major international concern for health systems to identify and effectively treat is strong (DHHS, 2016; WHO, 2014; HSS, 2012; DHS, 2010 a). Across demographic and geographic boundaries there is a similarity in both individual and situational risk factors indicating risk of suicide.

The evidence “of people with a psychiatric disorder among suicides (is), about 90 per cent” (DHS, 2010:13). A case –control study into medically serious suicide attempts, “confirm and reinforce the strong association between the presence of mental disorders … and greater risk of a serious suicide attempt.” (Beautrais, et al, 1996:1009); an association clearly supported in a U.S.A. based national representative sample (Bolton & Robinson, 2010).

Mortenson , et al, conducting a population based, nested case control study on psychiatric illness and risk factors for suicide, using 5% of the Danish population over a 15 year period identified that “the strongest risk factor was mental illness” (2000:9) with further factors of unemployment, being single and low income as of significance.

A systemic review of suicide risk assessment and management in emergency departments by the Victorian Department of Human Services (DHS, 2010 (a)), noted the issues of mental illness, previous suicidal behaviour, and dysfunctional developmental history including exposure to abuse, access to weapons, family history of suicide and stressful life events as clear risk indictors of potential suicide.

Global figures identify more than 20 attempted suicides for 1 completed suicide (WHO, 2014); New South Wales reported the suicide deaths of 700 people, and attempts by 21,000 (Black Dog Institute, 2016), and similar ratio figures in Victoria for 2014, (DHHS, 2016:2-3).

A Danish national representative population study over 12 months of 16-35 year old indicate multiple indicators of suicide including 11.6 % experiencing suicidal ideation over previous 12 months and 3.2 % having attempted suicide in their lifetime (Norlev, et al, 2005:295).


Figure 1. Summary of individual and situational risk factors

Risk factors for suicide (non-exhaustive)

Individual Socio-cultural/situational
  • Family history of suicidal behaviour
  • Mental illness: mood disorders, schizophrenia and other psychotic disorders, and substance- related disorders
  • Previous history of suicidal behaviour
  • Childhood and adult trauma
  • Low coping potential
  • Hopelessness
  • Aggression and impulsivity
  • Worry and rumination
  • Psychological pain
  • Neurobiological and genetic factors
  • Drug and/or alcohol use
  • Indigenous status
  • Exposure to suicidal behaviours through sensationalist reporting by the media
  • Access to and availability of lethal means of suicide
  • Unemployment or financial crisis
  • Stressful life events
  • Relationship breakdown
  • Poor social networks
  • Social isolation, lack of social support
  • Imprisonment
  • Bereavement

Centre of Research Excellence in Suicide Prevention (NHMRC, 2015:7)


Literature review

 International influence

In 2014, the World Health Organization (WHO) released ‘Preventing suicide. A global imperative’. This report has been influential in recognising international evidence-based outcomes and advising on future direction approaches by national governments. (WHO, 2014). Training for frontline health workers is recognised as vital for developing “knowledge, attitudes and skills for identifying individuals at risk” (WHO, 2014:38), initial and further periodic training of health workers is identified as of significant importance (pp.68).

The WHO refers to the example of the United States 2012 National Strategy for Suicide Prevention as a systems approach to suicide prevention with multi – focused strategies incorporating all levels of government and community service providers noting its effectiveness in training and implementation of support programs for military personnel (WHO, 2014:38). This national strategy clearly identified that programs be comprehensive, coordinated, “culturally sensitive and locally relevant.” (HSS, 2012:20). Program delivery is underpinned by training for frontline workers that provides, “the essential foundation of attitudes, knowledge, and clinical prevention skills to address and reduce suicide risk and increase protective factors among patients.” (HSS, 2012:46).

The benefit of a unified approach is the result of a National Strategy for Suicide Prevention, a national strategic direction applied in England and Wales (HSS, 2012:28). A descriptive, cross sectional analysis of the impact of of nine recommendations initially introduced across 91 mental health services noted that the average of implemented recommendations rose from “0.3 per service in 1998 to 7.2 in 2006” (While, et al, 2012:1005), with corresponding clear yearly reductions in suicide rates as the number of recommendations were introduced. One of the recommendations was: “Training; front – line clinical staff receive training in the management of suicide risk every 3 years.” (While, et al, 2012:1005).

Australian context

‘One World Connected’ (Suicide Prevention Australia, 2014) – informs the National Coalition for Suicide Prevention (NCSP), and shapes the Australian response to recommendations by the WHO (2014). This response includes a key strategy of establishing best practice by the adopting of a systems based approach across all community and government sectors involved in suicide prevention; with the training “of front line staff every three years”. (Suicide Prevention Australia, 2014:14), as a key proposal. The need for “a quality standard for suicide prevention training programs” is advised, and the development of same, encouraged. (Suicide Prevention Australia, 2014:19).

The National Mental Health Commission (NMHC) recommends a “nationwide introduction of sustainable, comprehensive, whole of community approaches to suicide prevention.” (2015: 17), and highlights the commitment to building workforce capacity with reference to provision of relevant training to drive evidence based treatment principles. (NMHC, 2014).

The Victorian Government has recently announced the Victorian Suicide Prevention Framework 2016 -2025. Working closely with the recommendations of the National Mental Health Commission, the framework “will trial a systemic, coordinated approach to suicide prevention in six local government areas over six years” DHHS, 2016:10). Each site will provide the same:

‘nine proven suicide prevention interventions:

  • Prevention awareness programs
  • School – based programs
  • Responsible media reporting
  • Gatekeeper training
  • Frontline staff training
  • General practitioner support
  • Reduce access to lethal means
  • High – quality treatment
  • Continued care after suicide attempt ‘                 (DHHS, 2016:10).

Interpersonal theory

The current conceptual framework underpinning standards of best practice in suicide prevention and treatment is the Interpersonal Theory of Suicide which has gained significant traction in its capacity to provide a theoretical framework linking suicidal ideation and attempting suicide (O’Connor, 2011; WHO, 2014; NHMRC, 2015).

 Ribeiro, et al identify interpersonal theory as a “guide to streamline risk assessment techniques and associated management strategies” (2013:207).

The key concepts underpinning this theory state the need for three important elements to be present in determining a high risk of suicide.

  1. Thwarted belongingness – Social isolation is a proven predictor “of suicidal ideation, attempts and lethal suicidal behaviour across the lifespan.” (Van Orden, et al, 2010:581).
  2. Perceived burdensomeness – To family, community or a loss of personal capacity in health or status (Van Orden, et al, 2010:581).
  3. Suicidal behaviours are enacted when there is the heightened evidence and impact of these constructs, plus the capacity, capability and desire, to act in risking ones life (Van Orden, et al, 2010).

Reviews of applied national strategic recommendations

A mixed methods systemic review of the Irish mental health system recommended:

 ‘A cluster-randomised trial of a ‘train the trainer’ supported by e-learning, “showed stronger guideline adherence, more self-perceived knowledge of suicidal behaviour and more provider confidence in dealing with suicidal behaviour than professionals who were only exposed to traditional guideline dissemination. “ (de Beurs, et al, 2015:450).

An American based review of literature of Emergency Department (ED) based initial assessment of suicide risk recommended specialist suicide assessment training for health professionals to support structured clinical judgement of risk factors, namely “previous history of suicide attempts, current lethal plan, recent psychosocial stressor, demographic features, and psychiatric diagnosis.” (Ronquillo, et al, 2012:840).

 A single qualitative study (Zisook, et al, 2013) on an initiative by National Institute of Health (USA) identified increased confidence in suicide risk assessment and safety planning, and recommended that evidence based approaches should be embedded into psychiatric training for suicide assessment.

 Australian context – training

The Western Victorian Mental Health Learning & Development Cluster is part of the the responsible body for professional development for Area Mental Health Services, and delivery of best practice training material (Western Cl uster, 2016). The ‘Approaches To Suicide Assessment and Prevention’ (ASAP), has been reviewed to reflect current evidence based practice developments; and is relevant from May 2016 (Western Cluster, 2016:1-3).

The current ASAP training program is structured directly in response to significant developments in evidence based practice and refers directly to the WHO (2014) Preventing Suicide: a global imperative, and the Australian response, (2014) ‘One World Connected’, as influential documents; and further utilises the theoretical influence of the Interpersonal Theory of Suicide (Western Cluster, 2016:5-7).

ASAP is offered as a one day training package for frontline mental health clinicians; a ‘train the trainer’ day post initial training, allows trained clinicians to develop necessary skills to provide internal training for staff of Area Mental Health Services (Western Cluster, 2016:4).


A mixed methods systemic review of the Irish mental health system recommended: “A standardised risk screening tool and care template should be developed that can be used across all services and evaluated from all stakeholder perspectives”(Higgins, et al, 2015:3).

A systemic review of suicide risk assessment and management in emergency departments by the Victorian Department of Human Services (DHS,(b), 2010) identifies:

  • “Few well – validated screening measures exist and many of the available assessment instruments are cumbersome” (p.16);
  • The ineffective nature of current screening tools in a high pressure, time limited work environment.
  • An absence of any “published intervention or risk assessment study for indigenous or culturally and linguistically diverse communities conducted in an acute care setting” (p.19).

Clifford, Doran & Tsey (2013), conducted a systemic review of indigenous sensitive, suicide prevention interventions – Australia, Canada & New Zealand, which recommended:

“effective partnerships between government and research agencies, health – care providers and Indigenous health – care services” (p. 9), (and ) “combining and tailoring best evidence and culturally – specific individual strategies into one coherent suicide prevention program for delivery to whole indigenous communities and/or population groups at high risk of suicide offers considerable promise.” (p. 1).

A literature review of research studies, systemic reviews and existing guidelines, informing clinical practice guidelines (in America),  by the Emergency Nurses Association (ENA, 2012) provided graded recommendations of 22 sourced screening tools for suicide risk, 9 were recommended as appropriate for use in emergency departments, and that use of such tools should form a part of intake assessment.

Evidence indicates significant inconsistency between suicide risk assessment tools. A British mixed methods review of 53-risk assessment proforma’s (RAP) (from 83 mental health services) found a wide variance in design layout, recommending that the NHS “adopt a more unified, evidence based, approach to RAP development.” (Hawley, et al, 2006:446) and further, that “the introduction of standardised tools would be an advantage” (p.447).

 Current clinical practice guidelines (DHS, (a) 2010 (2)), for Victorian emergency departments and mental health services identify a number of points of importance:

  • “Suicide is almost impossible to predict with any certainty” (p.13).
  • Making a structured clinical judgement is a combination of interview process, collateral history and safety planning.
  • Risk assessment tools vary in nature and style between mental health services and “are not complete assessments in themselves but can inform a management plan.” (p. 26).

There is some faint, but emerging evidence of some uniformity in risk assessment tools. MasterCare Electronic Medical Record is a product of Global Health and increasingly used by a number of Australian mental health services, including two Area Mental Health Services (AMHS) in Victoria; and reported to meet all required standards of data reporting as per the Federal Department of Health (Global Health, 2016).

The Suicide Risk Assessment Tool provides opportunity via both ‘tick box’ and ‘comments’ section to adequately explore the key elements of suicide risk assessment as identified as a standard of best practice in suicide assessment and safety planning by ASAP. (Figure 2, Western Cluster, 2016:76).

Clinical bottom line

  • Evidence identified a reduction in national rates of suicide as national recommendations were adopted (While, et al, 2012).
  • There is strong evidence for a systems based national strategic approach which includes best practice training in suicide assessment and prevention for frontline mental health clinicians identified in specialist research advised reports, and national and state policy frameworks (WHO, 2014; HSS, 2012; Suicide Prevention Australia, 2014; NMHC, 2014; DHHS, 2016).
  • Evidence identifies support for a conceptual framework that can inform a structured clinical decision in the assessment of suicide risk (O’Connor, 2011; Van Orden, et al, 2010; NHMRC, 2015; WHO, 2014).
  • The evidence indicates training of clinicians in best practice assessment of suicide risk, increases knowledge and confidence in assessment, and underpins improved patient outcomes via structured clinical judgement and safety planning (Higgins, et al, 2015; de Beurs, et al, 2015; Ronquillo, et al, 2012; Zisook, et al, 2013; Western Cluster, 2016).
  • It is clearly indicated in current evidence that frontline mental health workers should receive regular best practice training in suicide assessment
  • The ‘Approaches To Suicide Assessment and Prevention’ (ASAP) is a one-day training program available to Area Mental health Services,  utilising current known best practice principles in suicide assessment and planning, as identified in the literature search (Van Orden, et al, 2010; Suicide Prevention Australia, 2014; Western Cluster, 2016; WHO 2014).
  • Evidence indicates that developing a standardised risk assessment tool as best practice, is a consistent recommendation (Higgins, et al, 2015; Hawley, et al, 2006).
  • There is a strong level of evidence that identifies high variance and some unsuitability of current risk screening tools to crisis assessment (DHS, 2010; Hawley, et al, 2006).
  • Evidence indicates a lack of cultural sensitivity in current available assessment approaches (DHS, 2010), although more recent evidence identifies some emergence of cultural sensitivity in assessment tool development and planning (Clifford, Doran &Tsey (2013).
  • There is little evidence to indicate the development of a standardised suicide risk assessment tool (DHS, 2010; Hawley, et al, 2006).
  • There is a consistent level of evidence indicating that despite the variance between suicide risk assessment tools, they remain an important component of suicide risk assessment and should be utilised as part of an assessment of suicide risk (ENA, 2012; DHS, 2010 (2) Western Cluster, 2016; South West Healthcare, 2015).

Best practice recommendations

  • It is reasonable that all ‘frontline clinicians’ working in Area Mental Health Services (AMHS) should complete the one-day training course in ‘Approaches To Suicide Assessment and Prevention’ (ASAP).
  • It is reasonable that all ‘frontline clinicians’ working in AMHS should repeat the one day training course in ‘Approaches To Suicide Assessment and Prevention’ (ASAP) training, every three years.
  • Despite the lack of a uniform suicide risk screening tool it remains reasonable that all ‘frontline clinicians’ working in AMHS should complete a Suicide Risk Assessment Tool on every occasion when conducting an intake assessment.


This paper has sought to identify a standard of best practice relative to the assessment of suicide risk during intake process, for Area Mental Health Services . A lack of initial, and then periodic training in best practice assessment of suicide risk, and poor levels of completion of the current suicide risk assessment tool increases the general risk to a vulnerable patient population. This literature review provides recommendations from which to build the capacity of ‘frontline clinicians’ working in AMHS to achieve a consistent best practice standard for suicide risk assessment.


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