The Samaritans are one of the most well-known suicide prevention organizations, helping individuals in distress via telephone, email and even through postal mail, over 5 million times a year (Pollack et. al. 2008) The Samaritans teach their volunteers the skills of active listening and the value of self-determination, and therefore most Samaritan organizations use no caller ID and only intervene in calls with suicidal individuals when they ask the person to do so.
Vining (1995) describes a simple suicide risk assessment tool used by at least one Samaritans branch in the past. Since that article was published 10 years ago, the Samaritans have moved to a standardized training known as Samaritans Initial Training (SIT) and are in the process of updating their suicide risk assessment training. A 2002 risk assessment presentation trained individuals on this particular assessment though.
Just to be clear: The Samaritans do not currently use or teach this tool.
A 2008 evaluation of the Samaritans (Pollack, et. al, p.56) service noted calls were coded on a 7 point scale, ranging from -3 to +3, where -3 indicated an abusive caller, fantasizer, and +3 being a suicide attempt in progress or imminent, and the levels in between being various levels of emotional distress.
Suicide Risk Assessment Tool
Part I. Chief Indicator of Immediate Risk
Imminent Sudden Death (Firearm, Hanging, Jumping) – 8
Imminent Slow Method of Suicide (Overdose, Cutting) – 7
Future Sudden Death Planned – 6
Future Slow Method of Suicide Planned – 5
Planning Suicide “Gamble” – 4
Planning Suicidal Gesture – 3
Definite Suicidal Thoughts – 2
Toying Vaguely with Idea of Suicide – 1
No Suicidal Thoughts – 0
Part II. Additional Risk Factors
Previous Suicidal Acts or Gestures – 4
Recent Broken Relationships / Isolation / Rejection – 3 (each)
No Hope / Loss of Faith – 3 (each)
Depressive Illness – 2
Dependence on Alcohol / Drugs – 2
Possession of Means of Suicide – 2
Putting Affairs in Order – 2
Finally the score on these two sets of items are scored based on the following criteria:
Score of 8+ or greater on Part I. or more than 20 in total = Imminent Risk
14-19 = High Risk
6-11 = Moderate Risk
1-5 = Low Risk
My Thoughts on the Tool
I wonder whether the depth of the suicide plan is really the best predictor of a later suicide attempt. Someone who believes that overdosing, if they believe it will kill them, is no less likely to attempt suicide than someone who plans to jump off a building. One may even argue that the suicide risk is lower with someone who plans to jump because they have less access to tall buildings than they do to medication.
The ambiguous wording in some of these items may also hamper reliability of the scale. A suicide gamble appears to be ambivalence regarding an actual suicide attempt, despite intent being present (for instance an overdose with the intent of dying), where a suicidal gesture lacks intent – the person merely wishes to express emotional pain but has no intent to die.
The fuzziness of “definite suicide thoughts” and “toying with the idea of suicide” is also problematic in evaluating use of the tool.
I question the predictive value of some of these risk factors, particularly given their contradiction with the AAS Consensus List of Suicide Risk Factors.
Certainly previous suicide attempts are well-correlated to an increase in baseline risk for suicide death (Suominen, et. al., 2004) but it is less clear whether “suicide gestures” (where a lack of intent is present) increase risk of dying by suicide.
Relationship breakdown (Wyder, Ward & De Leo, 2009), isolation (Roma, et. al., 2003) and rejection by parents or peers (Donath, et. al., 2014; Fotti, Katz, Afifi & Cox, 2006) show some predictive validity in determining suicide risk, and the presence of strong social support is a protective factor that reduces suicide risk. (Compton, Thompson & Kaslow, 2005)
Hopelessness has been well established as a risk factor to suicide attempts (Beck et. al., 1990), as has alcohol and drug use (Tondo, et. al., 1999).
On the other hand, someone who is intoxicated may attempt suicide where they would not have otherwise, in the absence of a dependence on drugs or alcohol. Will someone who is actively intoxicated be scored these two points? If so, I would argue given the impact of alcohol on impulsiveness and judgement that being actively intoxicated is a high-risk factor for a later suicide attempt.
Redesigning this Suicide Risk Assessment Tool
I can see why the tool was attractive; it provides a simple framework that can be performed on the phone by trained paraprofessionals like crisis line volunteers. On the other hand, if the risk factors that are being assessed are not empirically related to suicide risk, they run the risk of underestimating lethality.
Taking a look at the existing tool, a number of themes exist in the elements covered:
Presence of Suicide Plan
Imminent Sudden Death (Firearm, Hanging, Jumping)
Imminent Slow Method of Suicide (Overdose, Cutting)
Future Sudden Death Planned
Future Slow Method of Suicide Planned
Presence of Suicide Ideation (Suicidal Thoughts)
Planning Suicide “Gamble”
Planning Suicidal Gesture
Definite Suicidal Thoughts
Toying Vaguely with Idea of Suicide
Historical / Stable Risk Factors
Previous Suicidal Acts or Gestures
Dependence on Alcohol / Drugs
Acute Risk Factors
Recent Broken Relationships / Isolation / Rejection
Possession of Means of Suicide
No Hope / Loss of Faith
Immediate Warning Signs
Putting Affairs in Order
Historical vs. Dynamic
These categories indiscriminately cover both suicide risk factors and warning signs, as well as modifiable factors and non-modifiable factors. It’s important that a suicide risk assessment tool only assess those factors likely to be relevant to a suicide attempt.
Chief Indicator of Immediate Risk
I suggest collapsing the first four items under “Chief Indicator of Immediate Risk” referring to the suicide plan into one item, “Presence of Suicide Plan”, which I would score two points. Then I would include a self-reported timeline differentiating between 1 hour, 24 hours, one week, one month, or one year, in decreasing order of significance.
Next, I would remove “Planning Suicide Gamble” and “Planning Suicidal Gesture” entirely as these items are too vague as to be useful. I would collapse “Definite Suicidal Thoughts” and “Toying Vaguely with the Idea of Suicide” into one item, “Presence of Suicidal Thoughts.”
Additional Risk Factors
TI would begin by renaming “Previous Suicidal Acts or Gestures” to “Previous Suicide Attempts.” Suicidal gestures without intent are not predictive of death by suicide. (Nock & Kessler, 2006)
I would rename “Depressive Illness” to “Presence of Mental Illness.” While depression is the most common mental illness leading to suicide, other mental illnesses have also shown likelihood to die, with complex psychiatric history – defined as 3 or more diagnoses having the highest risk of suicide attempt. (Nock & Kessler, 2006)
I would rename “Dependence on Alcohol / Drugs” to “Presence of Substance Abuse”, and add “Currently Intoxicated” as a warning sign. Alcohol and drug abuse has been associated with later unplanned suicide attempts (Borges, Walter & Kessler, 2000), which agrees with (Kaplan, et. al., 2012) who notes a large portion of suicide attempts or deaths involve intoxication.
“Possession of Means of Suicide” is helpful as an acute risk factor and does not need changing.
“Recent Broken Relationships / Isolation / Rejection” can be kept, but perhaps changed to “Presence of Precipitating Event” with these items listed as examples. A precipitating event viewed as overwhelming by the individual commonly precedes a suicide attempt. (Maltsberger, et. al., 2003)
“No Hope / Loss of Faith” appear to cover the same factor, hopelessness. Hopelessness, as noted above, is predictive of later suicide attempts but I feel these items should be collapsed into one so as to avoid over-emphasis on this score.
Finally, “Putting Affairs in Order” is a noted warning sign of imminent suicidal behaviour but one that is elusive to study. I suggest renaming this to “Preparatory Behaviour” to cover the wide variety of preparatory behaviours (obtaining means, ensuring solitude, preventing rescue, and so on.)
One factor missing from the historical risk factors that correlates strongly with later suicide attempts is history of sexual abuse and/or rape. (Nock & Kessler, 2006)
New Suicide Risk Assessment Tool
Part I. Chief Indicator of Imminent Risk
Presence of Suicidal Thoughts 1
Presence of Suicide Plan 2
If present, is there a timeline for attempt?
Within several hours 6
Within one day 5
Within one week 4
Within one month 3
Within one year 2
Additional Risk Factors
Historical / Stable
Previous Suicide Attempts 4
Presence of Mental Illness 3
(3 or more?) 2
Presence of Substance Abuse 2
Previous Sexual Abuse / Rape 2
Acute / Dynamic
Possession of Means of Suicide 2
Recent Precipitating Event (Recent Broken Relationships / Isolation / Rejection) 2
Preparatory Behaviour (Putting Affairs in Order / Obtaining Lethal Means / Steps to Avoid Rescue) 3
Currently Intoxicated 3
Scoring the New Suicide Risk Assessment Tool
The existing score system can still be used to score the updated tool. It should take no more time to use or score this tool that and it would the previous one, and now each item is empirically associated with future suicide attempts.
Score of 8+ or greater than 20 in total = Imminent Risk
14-19 = High Risk
6-11 = Moderate Risk
1-5 = Low Risk
Beck, A.T., Brown, G., Berchick, R.J., Stewart, B.L., Steer, R.A. (1990). Relationship Between Hopelessness and Ultimate Suicide: A Replication with Psychiatric Outpatients. American Journal of Psychiatry. 147(2).
Borges, G., Walters, E.E., Kessler, R.C. (2000) Associations of substance use, abuse, and dependence with subsequent suicidal behaviour. American Journal of Epidemiology. 151(8). 781-789
Compton, M.T., Thompson, N.J., Kaslow, N.J. (2005) Social environment factors associated with suicide attempt among low-income African Americans: The protective role of family relationships and social support. Journal of Social Psychiatry and Psychiatric Epidemiology. 40:175–185. doi: 10.1007/s00127-005-0865-6.
Donath, C., Graessel, E., Baier, D., Bleich, S., Hillemacher, T., (2014) Is parenting style a predictor of suicide attempts in a representative sample of adolescents?. BMC Pediatrics. doi: 10.1186/1471-2431-14-113
Fotti, S.A., Katz, L.Y., Afifi, T.O., Cox, B.J. (2006) The associations between peer and parental relationships and suicidal behaviours in early adolescents. Canadian Journal of Psychiatry. 51(11):698-703.
Kaplan, M.S., McFarland, B.H., Huguet, N., Conner, K., Caetano, R., Giesbrecht, N., Nolte, K.B. (2012) Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System. Journal of Injury Prevention. doi:10.1136/injuryprev-2012-040317
Maltsberger, J.T., Hendin, H., Haas, A.P., Lipschitz, A. (2003) Determination of Precipitating Events in the Suicide of Psychiatric Patients. Journal of Suicide and Life Threatening Behavior.
Nock, M.K., Kessler, R.C. (2006) Prevalence of and Risk Factors for Suicide Attempts Versus Suicide Gestures: Analysis of the National Comorbidity Survey. Journal of Abnormal Psychology. 115(3). 616-623. doi: 10.1037/0021-843X.115.3.616
Pollack, K., Armstrong, S., Coveney, C., Moore, J. (2008) An Evaluation of Samaritans Telephone and Email Emotional Support Service. Nottingham University. Accessed May 10, 2015.
Roma, P., Pompili, M., Lester, D., Girardi, P., Ferracuti, S. (2013) Incremental conditions of isolation as a predictor of suicide in prisoners. Forensic Science International. 233(1-3)e:1-2. doi: 10.1016/j.forsciint.2013.08.016
Suominen K., Isometsa E., Suokas J., Haukka, J., Achte, K., Lonngvist, J. (2004) Completed suicide after a suicide attempt: a 37-year follow-up study. American Journal of Psychiatry. 161:563-564.
Vining, R.M. Assessing risk of suicide: Samaritans’ scoring system helps develop judgment (1995) British Medical Journal.
Wyder, M., WArd, P., De Leo, D. (2008) Separation as a suicide risk factor. Journal of Affective Disorders. 116(3) 208-213. doi: 10.1016/j.jad.2008.11.007