assessment of suicide risk assessment of suicide risk suicide risk assessment is a process of estimating the likelihood for a person to attempt or die by suicide. the goal of a thorough risk assessment is to learn about the circumstances of an individual person with regard to suicide, including warning signs, risk factors, and protective factors. risk for suicide is re-evaluated throughout the course of care to assess the patient's response to personal situational changes and clinical interventions.: 230 accurate and defensible risk assessment requires a clinician to integrate a clinical judgment with the latest evidence-based practice, although accurate prediction of low base rate events, such as suicide, is inherently difficult and prone to false positives. suicide social aspects altruistic copycat epidemic legislation philosophy religious views right to die voluntary euthanasia crisis assessment of risk crisis hotline (list) intervention prevention suicide watch types assisted bullying and suicide (list) copycat familicide forced honor jauhar mass murder–suicide prisoner suicide pact internet prayopavesa sallekhana sati self-sacrifice senicide seppuku sokushinbutsu suicide attack vatakkiruttal epidemiology gender differences methods rate by country youth suicide among lgbt youth history list of suicides suicide in antiquity list of suicides in the 21st century in warfare banzai charge kamikaze suicide mission related phenomena suicide attempt locations ideation major depressive disorder non-suicidal self-injury suicide note suicide terminology by country rate by country australia bangladesh cameroon canada china france greenland india iran ireland japan lithuania nepal pakistan romania russia singapore south korea spain sri lanka sweden switzerland ukraine united kingdom united states organizations compassion & choices death with dignity national center dignitas exit international final exit network hemlock society the assessment process is ethically complex: the concept of "imminent suicide" (implying the foreseeability of an inherently unpredictable act) is a legal construct in a clinical guise, which can be used to justify the rationing of emergency psychiatric resources or intrusion into patients' civil liberties. some experts recommend abandoning suicide risk assessment as it is so inaccurate. in addition suicide risk assessment is often conflated with assessment of self-harm which has little overlap with suicide. instead, it is suggested that the emotional state which has caused the suicidal thoughts, feelings or behaviour should be the focus of assessment with a view to helping the patient rather than reducing the anxiety of clinician who overestimates the risk of suicide and are fearful of litigation. given the difficulty of suicide prediction, researchers have attempted to improve the state of the art in both suicide and suicidal behavior prediction using natural language processing and machine learning applied to electronic health records. in practice there are risks and disadvantages to both over-estimation and under-estimation of suicide risk. over-sensitivity to risk can have undesirable consequences, including inappropriate deprivation of patients' rights and squandering of scarce clinical resources. on the other hand, underestimating suicidality as a result of a dismissive attitude or lack of clinical skill jeopardizes patient safety and risks clinician liability. some people may worry that asking about suicidal intentions will make suicide more likely. in reality, regarding that the enquiries are made sympathetically, it does not. key areas to be assessed include the person's predisposition to suicidal behavior; identifiable precipitant or stressors such as job loss, recent death of a loved one and change of residence; the patient's symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behavior; impulsivity and self-control; and protective factors. suicide risk assessment should distinguish between acute and chronic risk. acute risk might be raised because of recent changes in the person's circumstances or mental state, while chronic risk is determined by a diagnosis of a mental illness, and social and demographic factors. bryan and rudd (2006) suggest a model in which risk is categorized into one of four categories: baseline, acute, chronic high risk, and chronic high risk with acute exacerbation. risk level can be described semantically (in words) e.g. as nonexistent, mild, moderate, severe, or extreme, and the clinical response can be determined accordingly. others urge use of numbers to describe level of relative or (preferably) absolute risk of suicide. ssi/mssi the scale for suicide ideation (ssi) was developed in 1979 by aaron t. beck, maria kovacs, and arlene weissman to quantify intensity in suicide ideators. it was developed for use by clinicians during semi-structured interviews. the scale contained 19 items rated on a scale from 0 to 2, allowing scores between 0 and 38. the items could be grouped into three categories: "active suicidal desire, preparation, and passive suicidal desire." initial findings showed promising reliability and validity. the modified scale for suicide ideation (mssi) was developed by miller et al., using 13 items from the ssi and 5 new items. the modifications increased both reliability and validity. the scale was also changed to range from 0 to 3, yielding a total score ranging from 0 to 54. joiner found two factors, suicidal desire and ideation, and resolved plans and preparation. the mssi was also shown to have higher discrimination between groups of suicide ideators and attempters than the bdi, bhs, psi, and sps. sis the suicide intent scale (sis) was developed in order to assess the severity of suicide attempts. the scale consists of 15 questions which are scaled from 0–2, which take into account both the logistics of the suicide attempt as well as the intent. the scale has high reliability and validity. suicide ranked higher in the severity of the logistics than attempted suicides (it was impossible to measure intent for suicide), and those with multiple attempts had higher scores than those who only attempted suicide once. sabcs the suicidal affect behavior cognition scale (sabcs) is a six-item self-report measure based on both suicide and psychological theory, developed to assess current suicidality for clinical, screening, and research purposes. substantial empirical evidence was found, from four independent studies, confirming the importance of assessing suicidal affect, behaviors, and cognition as a single suicidal construct. the sabcs was the first suicide risk measure to be developed through both classical test theory (ctt) and item response theory (irt) psychometric approaches and to show significant improvements over a highly endorsed comparison measure. the sabcs was shown to have higher internal reliability, and to be a better predictor of both future suicidal behaviors and total suicidality over an existing standard. suicide behaviors questionnaire main article: suicide behaviors questionnaire-revised the suicide behaviors questionnaire (sbq) is a self-report measure developed by linehan in 1981. in 1988 it was transformed from a long questionnaire to a short four questions that can be completed in about 5 minutes. answers are on a likert scale that ranges in size for each question, based on data from the original questionnaire. it is designed for adults and results tend to correlate with other measures, such as the ssi. it is popular because it is easy to use as a screening tool, but at only four questions, fails to provide detailed information. life orientation inventory the life orientation inventory (loi) is a self-report measure that comes in both a 30 question and 110 question form. both forms use a 4-point likert scale to answer items, which are divided into six sub-scales on the longer form: self-esteem vulnerability, over-investment, overdetermined misery, affective domination, alienation, and suicide tenability. this scale has strong reliability and validity, and has been shown to be able to differentiate between control, depressed, possibly suicidal, and highly suicidal individuals. it also contains 3 validity indices, similar to the mmpi. however, while useful, this inventory is now out of print. reasons for living inventory the reasons for living inventory (rfl) is theoretically based, and measures the probability of suicide based on the theory that some factors may mitigate suicidal thoughts. it was developed in 1983 by linehan et al. and contains 48 items answered on a likert scale from 1 to 6. the measure is divided into six subscales: survival and coping beliefs, responsibility to family, child concerns, fear of suicide, fear of social disproval, and moral objections. scores are reported as an average for the total and each sub-scale. the scale is shown to be fairly reliable and valid, but is still mostly seen in research as compared to clinical use. other variations of the scale include the college students reasons for living inventory, and the brief reasons for living inventory. the college students reasons for living inventory replaced the responsibility to family sub-scale with a responsibility to family and friends sub-scale and that replaced the child concerns sub-scale with a college/future concerns sub-scale. the brief reasons for living inventory uses only 12 of the items from the rfl. nurses global assessment of suicide risk the nurses global assessment of suicide risk (ngasr) was developed by cutcliffe and barker in 2004 to help novice practitioners with assessment of suicide risk, beyond the option of the current lengthy checklists currently available. it is based on 15 items, with some such as "evidence of a plan to commit suicide" given a weighting of 3, while others, such as "history of psychosis" are weighted with a 1, giving a maximum total score of 25. scores of 5 or less are considered low level of risk, 6-8 are intermediate level of risk, 9-11 are high level of risk, and 12 or more are very high level of risk. each item is supported theoretically by studies that have shown a connection between the item and suicide. however, the validity and reliability of the test as a whole have not yet been empirically tested. demographic factors within the united states, the suicide rate is 11.3 suicides per 100,000 people within the general population. age in the united states, the peak age for suicide is early adulthood, with a smaller peak of incidence in the elderly. on the other hand, there is no second peak in suicide in black men or women, and a much more muted and earlier-peaking rise in suicide amongst non-hispanic women than their male counterparts. older white males are the leading demographic group for suicide within the united states, at 47 deaths per 100,000 individuals for non-hispanic white men over age 85. for americans aged 65 and older, the rate is 14.3 per 100,000. suicide rates are also elevated among teens. for every 100,000 individuals within an age group there are 0.9 suicides in ages 10–14, 6.9 among ages 15–19, and 12.7 among ages 20–24. sex china and são tomé and príncipe are the only countries in the world where suicide is more common among women than among men. in the united states, suicide is around 4.5 times more common in men than in women. u.s. men are 5 times as likely to die from suicide within the 15- to 19-year-old demographic, and 6 times as likely as women to die from suicide within the 20- to 24-year-old demographic. gelder, mayou and geddes reported that women are more likely to die from suicide by taking overdose of drugs than men. transgender individuals are at particularly high risk. prolonged stress lasting 3 to 5 years, such clinical depression co-morbid with other conditions, can be a major factor in these cases. ethnicity and culture in the united states white persons and native americans have the highest suicide rates, black persons have intermediate rates, and hispanic persons have the lowest rates of suicide. however, native american males in the 15-24 age group have a dramatically higher suicide rate than any other group. a similar pattern is seen in australia, where aboriginal people, especially young aboriginal men, have a much higher rate of suicide than white australians, a difference which is attributed to social marginalization, trans-generational trauma, and high rates of alcoholism. a link may be identified between depression and stress, and suicide. sexual orientation there is evidence of elevated risk of suicide among non-heterosexual individuals (e.g. homosexual or bisexual individuals), especially among adolescents. biographical and historical factors the literature on this subject consistently shows that a family history of suicide in first-degree relatives, adverse childhood experiences (parental loss and emotional, physical and sexual abuse), and adverse life situations (unemployment, isolation and acute psychosocial stressors) are associated with suicide risk. recent life events can act as precipitants. significant interpersonal loss and family instability, such as bereavement, poor relationship with family, domestic partner violence, separation, and divorce have all been identified as risk factors. financial stress, unemployment, and a drop in socioeconomic