Suicide risk assessment: where are we now?

Christopher J Ryan and Matthew M Large
Med J Aust 2013; 198 (9): . || doi: 10.5694/mja13.10437
Published online: 20 May 2013

A definitive way to identify patients who will suicide remains elusive

Patients who present in psychological crisis or after a suicide attempt are more than 50 times more likely than the general population to die by suicide in the following year.1,2 They require careful assessment and management. Numerous publications suggest, and some health department policies insist, that such patients should undergo a “comprehensive suicide risk assessment” in addition to a standard clinical assessment.3,4 Although most guidelines warn that suicide risk assessment does not substitute for clinical judgement, almost all also include long lists of patient characteristics that are claimed to enable identification of those patients at high risk of suicide. These lists are often fashioned into ad-hoc scales that purportedly stratify patients into categories of low, medium and high risk. However, it is simply not possible to predict suicide in an individual patient, and any attempt to subdivide patients into high-risk and low-risk categories is at best unhelpful and at worst will prevent provision of useful and needed psychiatric care. Here, we explain why this is so and outline what we believe clinicians should do instead.

  • 1 Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW.
  • 2 School of Psychiatry, University of New South Wales, Sydney, NSW.

Competing interests:

Matthew Large has received speaker fees from AstraZeneca.

  • 1. Steeg S, Kapur N, Webb R, et al. The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule. Psychol Med 2012; 42: 2383-2394.
  • 2. Choi JW, Park S, Yi KK, Hong JP. Suicide mortality of suicide attempt patients discharged from emergency room, nonsuicidal psychiatric patients discharged from emergency room, admitted suicide attempt patients, and admitted nonsuicidal psychiatric patients. Suicide Life Threat Behav 2012; 42: 235-243.
  • 3. Victorian Government Department of Health. Working with the suicidal person. Clinical practice guidelines for emergency departments and mental health services. Melbourne: Victorian Government, 2010.
  • 4. NSW Department of Health. Framework for suicide risk assessment and management for NSW Health staff. Sydney: NSW Government, 2004.
  • 5. Pokorny AD. Prediction of suicide in psychiatric patients. Report of a prospective study. Arch Gen Psychiatry 1983; 40: 249-257.
  • 6. Madsen T, Agerbo E, Mortensen PB, Nordentoft M. Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry 2012; 73: 144-151.
  • 7. Madsen T, Nordentoft M. Risk factors for inpatient suicide do not translate into meaningful risk categories — all psychiatric inpatients are high-risk [letter in reply]. J Clin Psychiatry 2012; 73: 1034-1035.
  • 8. Large MM, Nielssen O. Suicidal ideation and later suicide [letter]. Am J Psychiatry 2012; 169: 662.
  • 9. Goldney RD, Positano S, Spence ND, Rosenman SJ. Suicide in association with psychiatric hospitalisation. Aust N Z J Psychiatry 1985; 19: 177-183.
  • 10. Goldstein RB, Black DW, Nasrallah A, Winokur G. The prediction of suicide. Sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders. Arch Gen Psychiatry 1991; 48: 418-422.
  • 11. Large M, Sharma S, Cannon E, et al. Risk factors for suicide within a year of discharge from psychiatric hospitals: a systematic meta-analysis. Aust N Z J Psychiatry 2011; 45: 619-628.
  • 12. Large M, Smith G, Sharma S, et al. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric inpatients. Acta Psychiatr Scand 2011; 124: 18-29.
  • 13. Large M, Ryan C, Nielssen O. The validity and utility of risk assessment for inpatient suicide. Australas Psychiatry 2011; 19: 507-512.


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