Suicide Risk Assessment — Viva

Q1: First principles — what are you assessing, and how? (3 min)

Examiner: A junior doctor tells you she is worried that asking a depressed patient about suicide will "put the idea in his head." Correct her, and then take me through the structured suicide risk assessment.

Expected answer:

• Correct the myth. Asking about suicide does not increase risk; the evidence is the opposite. Direct, non-judgemental enquiry provides relief, opens the conversation, and is the core of the assessment. Failure to ask is the error.
• The structured interview sequence:
  1. Engage — privacy, time, sitting at the patient's level, a normalising opener ("I ask all my patients about this").
  2. Ask directly about thoughts that life isn't worth living, and about active ideation.
  3. Characterise the ideation — frequency, intensity, duration, controllability (can the patient dismiss the thought, or does it feel intrusive and compelling?).
  4. Elicit the plan — method, time, place, rehearsal, preparations; specificity scales with danger.
  5. Estimate intent — how likely is the patient to act? What has stopped them so far?
  6. Identify preparatory acts — giving away possessions, writing a will/note, saying goodbye, obtaining the means.
  7. Assess access to means — firearms, medication hoards, pesticides, ligature points.
  8. Weigh protective factors — reasons for living, dependants, faith, social support, engagement.
  9. Obtain collateral — family, carers, GP, prior records.
  10. Examine the mental state — hopelessness, agitation, severe insomnia, anhedonia, persecutory delusions, command hallucinations.
  11. Formulate and document a stratified risk level with explicit reasoning and a safety plan.

Follow-up: Distinguish for me passive ideation, active ideation, plan, intent, attempt, and NSSI. Passive = wish to be dead without intent to act; active = thoughts of ending one's life; plan = specifics of method/time/place; intent = subjective conviction of acting; attempt = self-directed potentially injurious behaviour with some intent to die; NSSI = deliberate tissue damage without intent to die (function is affect regulation).

Q2: Risk factors — and the ones that matter most (3 min)

Examiner: A colleague says "depressed women are the highest-risk group for suicide." Reconcile that with the epidemiology, and tell me which single factor most strongly predicts completed suicide.

Expected answer:

• The gender paradox. Women make more attempts; men complete roughly 3 to 4 times more — driven by men's use of more lethal methods (firearms, hanging) and lower help-seeking. So depressed women are NOT the highest-risk group for completed suicide; isolated middle-aged and older men are.
• The single strongest individual predictor is a previous suicide attempt (5 to 10-fold increased risk, lifelong).
• Other high-yield risk factors: psychiatric disorder (depression in ~60 percent of suicides; schizophrenia lifetime risk 5 to 10 percent; bipolar, substance use, borderline PD), hopelessness (predicts suicide better than depressive severity — Beck), recent loss/crisis, unemployment, isolation, access to lethal means, family history of suicide, recent psychiatric discharge, and the deceptive "calm."
• Protective factors — social support, responsibility for children, religious/cultural prohibition, engagement with services, reasons for living.

Follow-up: Why does a previous attempt predict so strongly, biologically? In Joiner's interpersonal theory, the 'acquired capability for suicide' grows through repeated exposure to painful and provocative events — including prior attempts. The patient has already crossed the instinctive barrier of fear and pain, making a future act psychologically and physiologically easier. This also explains why means restriction works: with capability already present, removing the means removes the opportunity.

Q3: Formulation and disposition (3 min)

Examiner: A 40-year-old divorced man with three prior attempts was discharged from psychiatry 9 days ago, lives alone, and tonight describes active ideation with a plan to use a firearm he keeps at home, with clear intent. He asks to go home. What is your disposition, and on what reasoning?

Expected answer:

• HIGH risk. The triad of active ideation + specific plan + intent, combined with access to lethal means (firearm), previous attempts (the strongest predictor), recent discharge (the highest-risk window), and a male living alone. Ambivalence ("I probably won't") does NOT downgrade risk when a plan and means coexist.
• Urgent psychiatric admission, involuntary under the Mental Health Act / Mental Healthcare Act 2017 if he refuses — the duty of care overrides autonomous refusal when risk is imminent.
• Immediate measures: one-to-one constant observation; secure the firearm (family/police); remove medications and ligature points; obtain collateral; review and intensify treatment of the underlying disorder; no no-suicide contract (no protective value).
• Never discharge on the basis of "I probably won't act."

Follow-up: He says he has capacity and demands to leave against advice. What now? Assess capacity formally (understand, retain, use, weigh, communicate). If he lacks capacity, or if — even with capacity — the risk of death is imminent and serious, you may detain him under the Mental Health Act (UK) / MHCA 2017 (India). Document the capacity assessment, the risk formulation, and the legal basis. Capacity is decision-specific and time-specific — revisit it.

Q4: The drugs that save lives (3 min)

Examiner: Name the two medications with the best evidence for reducing suicide, the population for each, and the trials that support them.

Expected answer:

1. Lithium in mood disorders (depression and bipolar). Cipriani et al.'s updated systematic review and meta-analysis (BMJ, 2013) pooled randomised data and showed lithium reduced suicide and all-cause mortality versus placebo and several active comparators. The effect likely combines mood stabilisation, reduced impulsivity, and serotonergic effects.
2. Clozapine in schizophrenia — the only antipsychotic with a proven anti-suicide effect. The InterSePT trial (Meltzer et al., Archives of General Psychiatry, 2003) randomised nearly 1,000 schizophrenia patients with suicidality to clozapine or olanzapine and showed clozapine superior on a composite suicide-prevention outcome with fewer attempts and rescue interventions.

Follow-up: Two non-pharmacological interventions with trial evidence? Dialectical behaviour therapy (DBT) reduces repeat self-harm in borderline personality disorder; cognitive-behavioural therapy for suicide prevention (CBT-SP) reduces repeat attempts; brief follow-up contact / 'caring letters' after discharge reduce subsequent suicide mortality (WHO SUPRE-MISS agenda); and means restriction at population scale (firearm legislation, paracetamol pack-size limits, bridge barriers, pesticide bans) is among the most effective interventions of all.

Q5: Controversies, the law, and the post-attempt patient (3 min)

Examiner: NICE NG225 (2022) moved away from risk-stratification tools for self-harm. Why, and what replaced them? Then tell me how attempted suicide is treated under Indian law.

Expected answer:

• Why NICE moved away from tools like SAD PERSONS: no risk-assessment tool or clinician judgement achieves a clinically useful positive predictive value for individual suicide (systematic reviews, e.g. Saab et al., and methodological critiques by Large and colleagues). A low score creates false reassurance and a high score does not reliably predict. Scales can STRUCTURE an assessment and standardise documentation, but they should not GATE discharge.
• What replaced them: a comprehensive psychosocial assessment, co-developed safety planning (Stanley-Brown), specific psychological interventions (CBT-informed, DBT-informed where appropriate), and continuity of care with a named clinician and prompt follow-up — a shift from "predict and stratify" to "needs assessment and compassionate continuity."
• Indian law — Mental Healthcare Act 2017: attempted suicide is decriminalised. A person who attempts suicide is presumed to be under severe stress and entitled to rehabilitation by the state, not prosecution under Section 309 IPC. The presumption applies regardless of whether a mental illness is diagnosed. The Act is rights-based and decouples care from the criminal-justice gateway.

Follow-up — the post-attempt patient: a farmer is brought in unconscious after organophosphate ingestion. First steps? ABCDE first; organophosphate poisoning is a leading means of suicide in rural Asia. Resuscitate with atropine (for muscarinic effects — secretions, bronchospasm, bradycardia) PLUS pralidoxime (a cholinesterase reactivator for the nicotinic effects — fasciculations, weakness). Secure the airway, oxygenate, treat seizures with benzodiazepines. Then — and only after medical stabilisation — psychiatric assessment; never discharge a post-attempt patient without psych review.