Suicide Risk Assessment1-6
1. Suicide risk is dynamic and may fluctuate over time. As such, suicide risk assessment should be viewed as an ongoing process that forms part of a comprehensive clinical evaluation.2
2. The purpose of suicide risk assessment is to identify current risk factors and warning signs to guide appropriate interventions. It is important to note that this process is not the same as predicting suicide risk.6
3. GPs should apply clinical judgment to assess, document, and communicate the level of suicide risk at the time of evaluation. This should be done with accuracy, sensitivity, and discretion, especially when sharing information. When uncertainty exists, it is prudent to err on the side of caution.2
4. When initiating antidepressant therapy, GPs should monitor patients closely for emerging suicidal ideation, especially in younger patients under 25 years of age or with pre-existing suicide risk. The risk of suicidal behaviour and self-harm is highest during the first 1 to 3 months after starting, and 1 month after discontinuing, an antidepressant. (Refer to Management Figure 6.)
5. The overall assessment and classification of suicide risk should be guided by the Columbia-Suicide Severity Rating Scale (C-SSRS) (Table 1), and informed by the presence of risk factors (Table 2) and protective factors (Table 3), alongside clinical judgment. The C-SSRS is a tool to support, not replace, clinical evaluation. For a comprehensive overview of suicide risk classification—including definitions, criteria, goals of care, recommended setting, and interventions—refer to Table 4.
Table 1. Columbia-Suicide Severity Rating Scale (C-SSRS)
|
Always ask questions 1 and 2. |
Past Month
|
1) Have you wished you were dead or wished you could go to sleep and not wake up? |
Low Risk
|
2) Have you actually had any thoughts about killing yourself? |
Low Risk
|
|
If YES to question 2, ask questions 3, 4, 5 and 6.
If NO to question 2, skip questions 3, 4, and 5 and go directly to question 6. |
3) Have you been thinking about how you might do this? |
Medium Risk
|
4) Have you had these thoughts and had some intention of acting on them? |
High Risk
|
5) Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan? |
High Risk
|
|
Always Ask Question 6 |
Life-time
|
Past 3 Months |
6) Have you done anything, started to do anything, or prepared to do anything to end your life?
Examples: Took pills, tried to shoot yourself, cut yourself, tried to hang yourself, or collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump, etc.
If yes, was this within past 3 months? |
Medium Risk
|
High Risk |
Source: Extracted from https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/risk-identification
6. The C-SSRS supports suicide risk screening by assessing suicidal ideation and suicidal behaviour through a series of 6 simple questions. The answers help providers identify whether someone is at risk of suicide, determine the severity and urgency of that risk, and gauge the level of support the person needs.
7. The presence and intensity of suicidal ideation is assessed by Questions 1 to 5 which reflect increasing intensity of suicidal ideation:
a. Question 1: Wish to be dead (passive ideation)
b. Question 2: Non-specific active suicidal thoughts
c. Question 3: Active suicidal ideation with any methods (not plan) without intent to act
d. Question 4: Active suicidal ideation with some intent to act, without specific plan
e. Question 5: Active suicidal ideation with specific plan and intent
8. Suicidal behaviour and its intensity are assessed by Question 6. Besides screening for its presence, risk is further stratified by the recency of the behaviour (Lifetime versus Last 3 months). Question 6 covers the full range of suicidal behaviour in increasing intensity which are:
a. Preparatory Behaviour: Acts or preparation towards making a suicide attempt. This can include writing a suicide note or assembling a suicide method
b. Aborted Attempt: When a person initiates a suicide attempt but stops himself/ herself before the act
c. Interrupted Attempt: When a person is interrupted by an external force or circumstance before the act. The act would have otherwise occurred if not for the interruption. (e.g., A person is stopped by another person from jumping off a ledge)
d. Actual Attempt: A potentially harmful self-directed act that is performed with a deliberate intent to die. Any degree of intent or desire to die associated with the act can be considered an actual suicide attempt. No actual harm needs to occur.
9. Questions 1, 2 and 6 must always be asked. If Question 2 is positive (Yes), ask Questions 3, 4 and 5. After completing the questions, classify the C-SSRS suicide risk based on the highest intensity of suicidal ideation and behaviour.
10. For further details on the C-SSRS, refer to here.
11. GPs can receive online training on the C-SSRS here.
Table 2. Risk Factors for Suicide
| Modifiable |
Non-modifiable |
1. Pervasive hopelessness
2. Alcohol/substance abuse
3. Unemployment
4. Recent stressful life event
5. Social isolation/poor social support (e.g., divorce, living alone, bereavement)
6. Relationship conflict, discord, loss
7. Barriers to accessing healthcare
8. Access to lethal means
9. Chronic physical illness |
1. Previous episodes of depression
2. Past history of other psychiatric disorders, including personality disorders
3. Prior suicide attempts (regret at failure to die)
4. Male gender
5. Older age
6. Previous psychiatric hospitalisation
7. Family history of suicide
8. Adverse childhood experiences (such as emotional neglect, parental separation or death of a parent) |
Table 3. Protective Factors of Suicide
Protective Factors of Suicide |
1. Strong interpersonal relationships
2. Strong religious faith
3. Positive coping strategies such as effective stress management and healthy lifestyle choices, including diet and exercise |
Table 4. Suicide Risk Classification and Management1
Suicide Risk
|
Definition |
Criteria |
Goals of Care |
Siting of Care and Interventions |
Red High Risk |
Suicidal Ideation with intent or intent with plan in the past month and/or suicidal behavior within the past three months |
1. Suicidal ideation with intent or with intent and plan in past 1 month (C-SSRS ideation Question 4 or Question 5)
And/or
2. Suicidal Behavior within past 3 months (C-SSRS Suicidal behavior Question 6) |
• Acute management
• De-escalation
• Provide a safe environment until transfer
• Safety Planning |
1. Should refer urgently to hospital psychiatrists or A&E/IMH Emergency Departments (if indicated) for assessment.
2. GPs with ASCAT support can contact ASCAT during operational hours for urgent advice and onsite management.
3. Refer to Paragraph 2 on acute management and de-escalation.
4. Refer to Table 1 on actions if facing acutely severe suicidal patients at imminent risk to self or others.
5. Consider having patients contact SOS^* for crisis support if feasible, while pending urgent psychiatrist or A&E/IMH Emergency Department review.
6. Consider providing safety planning if feasible, while pending urgent psychiatrist or A&E/IMH Emergency Department review.
7. Provide appropriate follow-upcare along with specialist psychiatry care upon discharge. |
Orange Medium Risk |
Suicidal ideation with method, without plan or intent in the past month, and/or suicidal behavior more than three months ago |
1. Suicidal ideation WITH method, WITHOUT plan or intent in past 1 month (C-SSRS ideation Question 3)
And/or
2. Suicidal behavior more than 3 months ago (C-SSRS Suicidal Behavior Question 6)
And/or
3. Multiple risk factors with few protective factors (Tables 2 and 3) |
• Close monitoring
• Suicide intervention
• Optimise environmental safety
• Safety Planning |
1. Exercise clinical discretion to determine if patients can be managed in the community or urgent assessment by hospital psychiatrists or the A&E/IMH Emergency Departments by evaluating the following:
a. Patient factors
i. Rapid suicide risk progression
ii. Fluctuating unstable suicide risk profile
iii. Complex medical and/or social issues
b. Ability to closely monitor
i. Provide frequent follow-up and close monitoring
ii. Regularly assess suicide risk
c. Availability of suicide intervention services
i. Offer to direct patients to contact Samaritans of Singapore (SOS)^* for suicide intervention and crisis support.
ii. Offer to refer patients for psychosocial intervention
2. GPs with ASCAT support can contact ASCAT during operational hours for advice and management.
3. Safety planning should be provided. |
Yellow Low Risk |
Wish to die and/or suicidal ideation, with no method, plan, intent, or behavior, or modifiable risk factors and strong protective factors, or no reported history of suicidal ideation or behavior |
1. Wish to die: Passive ideation (C-SSRS Ideation Question 1)
And/or
2. Suicidal ideation
(C-SSRS Ideation Question 2) WITHOUT method, plan, intent or behavior
And/or
3. Modifiable risk factors and strong protective factors (Tables 2 and 3) |
• Monitor risk
• Supportive care
• Refer to suicide prevention and intervention resources
• Safety planning |
1. GPs can generally manage patients graded Yellow with training.
2. GPs with ASCAT support can contact ASCAT during operational hours for advice and management.
3. Consider referral to hospital psychiatrists for specialist care of psychiatric and suicide issues if indicated.
4. Consider directing patients to contact SOS^* for suicide prevention, intervention and crisis support.
5. Consider referring patients for psychosocial intervention
6. Consider providing safety planning. |
^Samaritans of Singapore Limited (SOS) is a non-religious and non-profit organisation that provides dedicated support to persons facing suicide crisis, thinking about or affected by suicide. SOS focuses on suicide crisis intervention and suicide prevention.
*24-hour Hotline: 1767; 24-hour CareText: 9151 1767 (via WhatsApp).
References
1. Practice Guide for Tiered Care Model for Mental Health (Adult) for Service Providers (Tier 2-4).
2. Ng CW, How CH, Ng YP. Depression in primary care: assessing suicide risk. Singapore Med J. 2017 Feb;58(2):72-77. doi: 10.11622/smedj.2017006. PMID: 28210741; PMCID: PMC5311887.
3. National Healthcare Group Polyclinics. Clinical Practice Guidelines: Management of Depression and Anxiety (including suicide management workflow). Last updated Oct 2020.
4. SingHealth Polyclinics (SHP) Clinical Guidebook: MOOD AND ANXIETY DISORDERS CLINICAL CARE PATH. Updated: June 2024
5. Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for the assessment and management of patients at risk for suicide. 2019.
6. Ryan EP, Oquendo MA. Suicide Risk Assessment and Prevention: Challenges and Opportunities. Focus (Am Psychiatr Publ). 2020 Apr;18(2):88-99. doi: 10.1176/appi.focus.20200011. Epub 2020 Apr 23. PMID: 33162846; PMCID: PMC7587888.
7. Li X, Mu F, Liu D, et al. Predictors of suicidal ideation, suicide attempt and suicide death among people with major depressive disorder: A systematic review and meta-analysis of cohort studies. J Affect Disord. 2022;302:332-351.
8. Koh YS, Shahwan S, Jeyagurunathan A, et al. Prevalence and correlates of suicide planning and attempt among individuals with suicidal ideation: Results from a nationwide cross-sectional survey. J Affect Disord. 2023;328:87-94.
