Knowing how to identify and categorize dynamic and static risk factors for suicide is essential for health care professionals — those within mental health care who are developing effective intervention plans for at-risk patients and providers outside of that specialty who nonetheless are often the first to screen their patients for suicide risk.
To effectively treat those at risk of suicide, it is also important to understand and be able to use available simple screening tools; learn how to deploy short- and long-term care; understand the role of inpatient and outpatient treatment; approach patients with non-judgmental empathy; and document when caring for suicidal patients.
Understanding the difference between dynamic and static risk factors for suicide
There are many ways of distinguishing risk factors for suicide, but one of the most common separates them into two groups: dynamic and static.
As Dr. Randon S. Welton described in Psychiatry, “Static factors are based on the actuarial facts of who commits suicide.” These are “variables that the provider would be unable to change,” including race, gender, age, the patient’s personal history of suicide attempts, and whether suicide runs in their family. He notes that some of these static factors — namely a history of a suicide attempt — present problems of “stability; once someone has attempted suicide, this risk factor will be positive every day for the rest of their lives. It does correctly denote that this person is at higher risk than the general population, but it does not help the provider make decisions regarding the patient sitting in his or her office on a particular day.”
Dynamic factors for suicide are, as the name implies, modifiable. This category of risk factors includes mental health diagnoses, social support, substance use or abuse, psychiatric symptoms, “emotional turmoil,” and suicidality.
Dynamic risk factors can exacerbate suicide risk in individuals with existing static risk factors and because of that, both types of risk factors are meant to be understood in tandem. Dr. Welton explains, “Considering the dynamic risk factors in light of the static risk factors will more finely focus the clinician's assessment and will help shape the interventions.”
Evaluation and screening tools used to assess the patient
Clinicians can play a critical role in identifying suicidality in patients and helping connect them with the treatment they need. There are several different options for evaluating whether a patient is experiencing suicidal thoughts or is at risk of suicide, including various kinds of questionnaires and screening tools specifically tailored to pediatric patients at risk of suicide.
Routine suicidal risk screenings can be conducted for all patients using common, accessible tools like the following:
Columbia Suicide Severity Rating Scale (C-SSRS)
An evidence-based questionnaire that assesses for the presence and severity of suicidal ideation and behavior as well as suicidal plans or attempts both across a patient’s lifetime and within the last three months. Also known as the Columbia Protocol, it is widely used or recommended by organizations including the FDA, the WHO, the NIH, the CDC, and others.
Patient Health Questionnaire (PHQ-9)
A short questionnaire completed by the patient to gauge suicidality and depressive symptoms (based on DSM-IV depression diagnostic criteria) as well as their degree of severity. The PHQ-9 also includes a follow-up screener meant to assess the extent to which depressive symptoms have affected the patient’s functioning.
Ask Suicide-Screening Questions (ASQ)
A four-question tool created by the NIMH for screening of suicide risk in both youth and adult patients. The ASQ is part of a prevention strategy built on “an evidence-based clinical pathway” to identify at-risk patients and manage those who screen positive with a referral to a full evaluation or outpatient care if necessary.
In addition to using these tools, a comprehensive evaluation of suicide risk should include a detailed clinical interview and a review of the patient’s medical and psychiatric history, including assessing family history of suicide to identify any static risk factors.
There is increasing evidence that frequent screening, especially of patients in at-risk groups such as veterans, can “identify missed chances to save lives.”
Recognizing how physicians are perceived by the patient
A strong physician-patient relationship is foundational in the prevention and management of suicide risk. There are many socioeconomic, individual, and cultural conditions that can come into play to affect this relationship and determine whether or not a patient feels safe and comfortable confiding in a health care provider.
It has been shown that patient satisfaction and success depends on establishing trust and demonstrating empathy. Patients who perceive their physicians as judgmental or dismissive may be less likely to seek help, and many at risk of suicide may be reticent to obtain mental health care and therefore are much more likely to be screened by a family physician if at all. A 2003 report in American Family Physician noted that half of people “who commit suicide saw a physician in the preceding month,” emphasizing the opportunity that general practitioners have to screen for suicide and intervene when patients are at risk.
Unfortunately, there still remains a gap between those who have suicidal ideation or plans and those who tell their doctors about these feelings. There are a number of different reasons patients cited for withholding this information from their doctor in a 2018 study by Julie Richards et al. published in Psychiatric Services, ranging from not feeling suicidal at the moment, to fearing the repercussions of disclosing suicidality (e.g., stigma, loss of autonomy, confidentiality) to not knowing how to enunciate complex emotional feelings:
“One participant said, ‘I guess just, like, I’m really bad with words it seems like, and when I get anxious, I get fumbled. So, I just try to avoid talking as much, especially with stuff that’s gonna make me emotional and stuff.’ One participant described feelings of embarrassment and stigma around disclosing suicidal thoughts: ‘It’s really embarrassing, you know what I mean? Especially in my world, where no one would expect me to do that. I just was so embarrassed. And I hate when they put it on record and it doesn’t look good and it looks like I’m crazy. I just didn’t wanna deal with that.’”
Some patients also express doubt at the prospects for the outcome of their treatment: “Everybody just freaks out and wants to get you [hospitalized], and acts like you’re a danger, and that doesn’t really make me feel better. I don’t like that as soon as I say that that they want me to be monitored or so closely watched. I don’t want my privileges taken away or anything.” Said another, “I don’t feel they would have done anything.”
The burden of establishing a strong relationship with the patient is on the clinician — not just so patients open up about suicidal thoughts or plans, but so they also follow through with the appropriate treatment recommendations. Because of this, it's crucial for health care providers to establish a therapeutic alliance with their patients, be aware of their own personal biases/stereotypes, and use empathetic and non-judgmental language.
