Three important assessments to complete with patients whom are suicidal are the 4p’s, MSE, and alcohol use screening.
A comprehensive risk assessment to monitor for suicidal ideation is the 4p’s:
Predisposing Factors: The factors that increase vulnerability to develop psychological problems.
- Genetic factors: A history of mental illness in the family
- Age, sex, ethnicity
- Social/cultural determinants (Maori, male, low socioeconomics= high risk)
- Child abuse/ traumatic childhood
- Prenatal complications
- Social isolation
- Previous attempts
Precipitating Factors: The factors that trigger the onset or exacerbation of the psychological problems.
- Substance abuse
- Social stressors: financial, stress, grief and loss, abusive relationships
Perpetuating Factors: The factors that maintain the psychological problems and prevents its resolution.
- Poor coping skills
- A lack of support
- A feeling of worthlessness/hopelessness
- Traumatic events
- Substance abuse
Protective Factors: The factors that prevent any deterioration in the condition.
- Support system
- Access to resources
- Strong cultural identity
- Family/social responsibilities
- Successfully overcoming previous mental illnesses/ depressive episodes
There is a need to be direct with questioning the patient about thought of dying, self harm, and harm to others:
- Have you thought about killing yourself?
- Have you thought about hurting somebody else?
- Do you have a plan?
- Do you have access to the means of suicide?
- Have you attempted suicide in the past? How many times?
- At what times do the thoughts get worse?
- Have you known anyone that has committed suicide?
- What things stop you from acting on these thoughts?
The priority is to assess immediate risk to the patient or others.
- Initiate the MH act if there is imminent danger. Discuss with the patient whether they will voluntarily admit themselves to the MH ward.
- Restrict access to means
- Provide one on one nursing supervision
- Develop a relapse prevention plan
- Teach coping strategies
- Provide drug and alcohol support
- Provide support group information
- Refer to a community mental health nurse
- Discuss pharmalogical intervention for acute distress (benzos, antipsychotics)
- Encourage family participation and education
- Offer reassurance and hope
Other assessments to consider is a complete MSE
The link to access the full size versions of the MSE and article can be found here: http://www.primaryissues.org/2013/03/mental-status-exam/
A mnemonic to help remember the categories of the MSE is:
A- Appearance and behaviour
E- Emotion [mood and affect]
P- Perception [Hallucination and illusion]
T- Thought content and process
I- Insight and Judgement
An alcohol screening assessment is also recommended as alcohol use is a risk factor for suicide as it lowers inhibitions. A easy tool to use is the AUDIT-C tool. It consists of three questions to identify risky drinking behaviour.
The tool can be found here: http://www.integration.samhsa.gov/images/res/tool_auditc.pdf
Depending on the results of the screening a brief intervention may be needed.
A useful guide for brief interventions can be found here:
This video shows a clinical example of using brief interventions in practice:
Barker, P. (1988). Basic child psychiatry (5th ed.). Baltimore, MD: University Park Press.
Garand, L., Mitchell, A. M., Dietrick, A., Hijjawi, S. P., & Pan, D. (2006). Suicide in older addults: Nursing assessment of suicide risk. Issues in Mental Health Nursing, 27(4), 355–370. doi: 10.1080/01612840600569633
Granello, D. H. (2010). The process of suicide risk assessment: Twelve core principles. Journal of Counseling & Development, 88(3), 363–370. doi: 10.1002/j.1556-6678.2010.tb00034.x