What to Expect in an Initial Suicide Risk Assessment

Suicide remains one of the leading causes of death globally, with particularly high rates among individuals aged 10 to 24 in the United States. Tens of thousands of lives are lost each year, underscoring the urgency of early intervention. Despite its prevalence, many healthcare settings still lack routine assessments for suicide risk. This gap highlights the importance of the initial suicide treatment interview, a critical tool for identifying and addressing suicidal ideation. By initiating a focused and compassionate conversation, clinicians can begin to understand the individual’s emotional state and take the first step toward potentially life-saving care.

The Goals of the Suicide Treatment Interview

The initial suicide treatment interview is a vital clinical tool used by medical professionals to assess individuals for suicidal ideation. While it is often conducted in response to current warning signs, it may also be used with individuals who have a history of suicidal thoughts or behaviors ^[1]. Though emotionally challenging, this process is essential for identifying those at risk and intervening appropriately.

This first interview serves as the foundation for understanding an individual’s current mental state and level of suicide risk. Importantly, the goal is not to predict suicide; doing so may place additional strain on the individual, but rather to assess risk factors, gather relevant context, and determine the best course of action. Clinicians are tasked with asking sensitive, targeted questions, analyzing responses, and making informed decisions about the need for further intervention or care ^[2].

The interview typically aims to achieve several key objectives:

Risk Assessment

The primary goal of the interview is to determine whether or not an individual is at risk of suicide. Healthcare providers accomplish this by assessing the individual’s mental state, looking for any distressing or alarming signs. These questions involve being upfront with the patient about self-harm and suicide.

Creating Comfort

An individual experiencing severe psychological distress may be reluctant to share information on such sensitive topics, so the assessor must develop a rapport and make the patient feel comfortable. It’s essential to check in with the individual throughout the initial interview.

Accuracy

Assessing for suicidal ideation involves accurately identifying the patient’s level of intent. Providers should learn about how often these thoughts occur, how severe they are, and if they’ve made any plans due to these thoughts. After letting them talk through such thoughts, providers can determine how likely the patient is to act on their feelings.

Acknowledging Distinctions

Self-harm and depressive mental health disorders are both examples of serious mental health concerns, but they are not always indicative of suicidal intent. Not every individual who is actively engaging in self-harm wants to end their life, so it’s vital to know where these behaviors stem from. Once they make the distinction, healthcare providers can recommend appropriate resources ^[2].

The initial suicide treatment interview is designed to be the first step in developing a more extended safety plan to lower an individual’s risk. If patients screen positive for suicide risk, healthcare professionals will direct them to a further brief assessment conducted by a trained healthcare provider, such as a nurse practitioner or physician.

If this safety assessment concludes the individual is at high risk, they may be referred again for a more in-depth mental health evaluation. Professionals must carry out every assessment stage in a medical setting to ensure patients feel safe, comfortable, and heard ^[1]. 

Key Components of the Suicide Risk Assessment

A comprehensive suicide risk assessment involves covering every base to ensure an individual’s suicide intent is accurately assessed. They do this by evaluating a range of patient behaviors associated with self-destructive attitudes and actions. Chronic suicide risk factors include past suicidal behaviors, a family history of suicide, recent hospitalization for self-harm, and current suicidal thoughts and actions ^[3].  

There are also acute suicide risk factors that a risk assessment should take into consideration, including signs of poor mental health, like loneliness, anxiety, social withdrawal, hopelessness, purposelessness, rage, and lack of personal care. Assessing for suicidal ideation also entails evaluating an individual’s current situation, such as any legal issues, relationship breakdowns, job losses, and traumatic experiences. These all denote a potential decline in mental health, increasing the individual’s risk of committing suicide as a means of escape ^[3]. 

Common Suicide Risk Assessment Questions

The initial suicide treatment interview is question-based, allowing the patient to talk through their feelings and the healthcare provider to assess their risk level. The questions asked differ between assessments, but there are several common suicide risk assessment questions.

Healthcare providers use general screening questions to identify risk factors and better understand the individual’s situation. These may include:

How Do You Get Along with Each Family Member?

This question establishes the patient’s family background, current living situation, and any information on familial relationships that may contribute to suicidal ideation.

What Do You Do in Your Spare Time?

This question probes the individual’s recreational life to get an idea of how social they are, how many friendship groups or clubs they belong to, and how they occupy their time. It’s key to identifying loneliness or social withdrawal, both of which contribute to depressive feelings.

Have You Tried Drugs or Any Other Substances?

Substance use can be an acute suicide risk factor due to the correlation between abusing drugs or alcohol and poor mental health. It’s crucial that individuals feel comfortable revealing this information.

What Do You Do If You Are Feeling Sad or Angry?

Feelings of sadness and anger aren’t automatic indicators that an individual is suicidal. However, if they cope with these by harming themselves, abusing substances, or retreating into an unhealthy mental state, their suicide risk level increases ^[3]. 

After asking screening questions to get an idea of the patient’s background, personal life, and general mental state, the assessor will then move on to more complicated but necessary questions on the topic of suicide. They may include:

Have You Recently Wished That You Were Dead?

Assessing suicidality usually begins with investigating the patient’s feelings towards themselves, particularly a lack of desire to live. Suicidal ideation can manifest into harmful actions, so the assessor needs to know the severity of these thoughts.

Have You Had Recent Thoughts About Killing Yourself?

An individual’s suicide risk drastically increases if they have considered taking action. These thoughts often pre-empt concrete plans to commit suicide.

Have You Made Any Plans to Kill Yourself?

If the patient confirms or strongly indicates they have made plans to end their own life, the assessor will take immediate action to protect them.

Have You Ever Tried to Kill Yourself?

Prior suicide attempts don’t always prove that an individual will make another attempt on their life, but it shows intent and the will to act, which places them at a very high risk ^[4]. 

Creating a Safe and Supportive Environment

The suicide risk assessment questions are vital to identifying individuals at high risk, so they require the utmost sensitivity. If the individual being interviewed has been having suicidal thoughts or made plans for their suicide, they will be reticent and won’t be able to articulate their feelings fully. They may also deny or downplay suicidal ideation to avoid screening positive, so the assessor must build a non-judgmental rapport and make them feel comfortable ^[5].  

Developing an empathetic approach when assessing for suicide takes time and work, but it’s the best way to encourage honesty and promote comfort. Patients being screened for suicide risk respond more openly to open-ended questions and a gentle attitude because it shows the assessor wants to help them, not just make a diagnosis. The more accurate information obtained during the interview, the more successful the intervention and further treatments will be in lowering the patient’s risk of committing suicide ^[5]. 

Confidentiality in Suicide Risk Assessment Interviews

Despite efforts to create a private and supportive environment for patients to express their feelings, the extent of confidentiality ultimately depends on the information disclosed. To foster openness, the assessor conducts the interview one-on-one and determines appropriate next steps based on the individual’s responses. If there is reason to believe the person is at risk of attempting suicide within the next 24 to 48 hours, immediate intervention is initiated ^[6].

Interventions are tailored to the individual’s assessed level of risk. In high-risk cases, healthcare professionals are legally and ethically obligated to breach confidentiality within the clinical setting to ensure the patient’s safety. This often involves placing the individual under close supervision and removing potentially harmful objects such as belts, shoelaces, or sharp items. High-risk patients may be admitted for inpatient treatment, which can include a combination of medication, psychotherapy, and ongoing observation. Hospitalization provides the most immediate and intensive care and is typically reserved for those facing imminent risk ^[6].

The Next Steps After a Suicide Risk Assessment

Once immediate safety concerns are addressed, particularly for individuals at high risk of acting on suicidal thoughts, the second phase of the suicide risk assessment process begins. At this stage, all individuals screened for suicidality are recommended for follow-up care tailored to their specific risk level. Medical professionals work to develop a long-term treatment plan that addresses the underlying causes of suicidal ideation.

For instance, a patient experiencing suicidal thoughts due to depression may be treated with a combination of medication and psychotherapy. In contrast, someone considering suicide to escape chronic physical pain may be referred to a specialized pain management program. Substance use disorders, especially when tied to suicidal behavior, can present complex clinical challenges. If appropriate, medications may be prescribed to stabilize mental health symptoms, but providers must also assess the risk of misuse or overdose. In such cases, alternative treatments may be pursued to reduce the risk of self-harm ^[6].

Effective long-term treatment requires consistent communication between the patient and their healthcare team. Ongoing engagement in care has been shown to significantly reduce suicidal ideation and lower the risk of future suicide attempts. The initial suicide treatment interview plays a critical role in gathering the information needed to align individuals with the most appropriate and potentially life-saving interventions ^[6].

Involving Family and Support Systems

Although assessors typically conduct the initial interview privately to encourage honesty, they may involve family members during the assessment. This is usually only done if the patient requests it or the interviewee is a child. Any other visitors who aren’t immediate family are asked to leave during the screening process. The assessment will continue as long as the patient is comfortable ^[1].

Professionals may involve family members during the intervention stage if they determine the individual is at imminent risk. They may be monitored at home by relatives or be hospitalized with support from close family to minimize distress. When drawing up a treatment program for the affected individual, healthcare providers may request information from family members to provide further accounts of the patient’s story. Although rare, clinicians will check if the information coincides with the patient’s account to prevent involuntary attempts at forcing treatment ^[5].

Once the individual has been prescribed a treatment plan, family and other support persons can act as a non-medical support system during recovery. Even individuals who aren’t immediately hospitalized to prevent a suicide attempt need constant support and supervision to ensure their mental health is improving. They aren’t acting on feelings of suicide or self-harm ^[5]. 

It is strongly recommended that immediate support persons, such as family members, friends, and caregivers, educate themselves on suicidal ideation and how to recognize the warning signs. Suicidal thoughts can be subtle and difficult to detect, but if they escalate into action, the risk of a fatal outcome is high ^[7]. Increased awareness among those closest to the individual is critical in early intervention. By learning to identify red flags and offering informed, compassionate support, loved ones can help reduce the risk of suicide and ensure more individuals receive the care they need. 

A Path Forward

The initial suicide risk assessment serves as a foundation for understanding an individual’s emotional pain while prioritizing their safety. By centering the interview on empathy, active listening, and nonjudgmental inquiry, clinicians create a space where individuals feel safe to share their most vulnerable thoughts. This approach fosters trust and ensures that critical details are gently uncovered, enabling interventions that address both immediate risks and long-term struggles.

By balancing clinical knowledge with empathetic understanding, healthcare providers can guide individuals toward treatment, ensuring that they feel their pain is seen, their voice matters, and their life holds inherent value.