Intended for healthcare professionals

Practice Uncertainties

Can we usefully stratify patients according to suicide risk?

BMJ 2017; 359 doi: (Published 17 October 2017) Cite this as: BMJ 2017;359:j4627
  1. Matthew Michael Large, conjoint professor1,
  2. Christopher James Ryan, clinical associate professor2,
  3. Gregory Carter, conjoint professor3,
  4. Nav Kapur, professor4
  1. 1School of Psychiatry, University of New South Wales, NSW, Australia
  2. 2Discipline of Psychiatry, Westmead Clinical School and Sydney Health Ethics, University of Sydney, Australia
  3. 3Centre for Brain and Mental Health, Faculty of Health and Medicine, University of Newcastle,
  4. 4Centre for Suicide Prevention, Manchester Academic Health. Science Centre, University of Manchester, & Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
  1. Correspondence to: M M Large mmclarge{at}

What you need to know

  • Despite the ubiquity of advice to use suicide risk assessment in clinical practice, there is no evidence that these assessments can usefully guide decision making

  • All patients presenting with a mental health problem require a thorough and sympathetic assessment with the aim of negotiating an individualised treatment plan

  • All patients with suicidal thoughts or behaviours should be offered evidence based therapies for the treatable problems associated with suicide, such as substance misuse disorder and depression

  • The overwhelming majority of people who might be viewed as at high risk of suicide will not die by suicide, and about half of all suicides will occur among people who would be viewed as low risk

In the UK, one in five adults has considered suicide at some time, and one in 15 has attempted suicide.1 Half of those who attempt suicide seek help afterwards—a quarter from a GP, a quarter from a hospital or specialist medical or psychiatric service.1 Suicidal patients; patients who present to health services with suicidal ideas, self harm, or suicide attempts; and patients who present as significantly distressed or mentally ill can be challenging to manage. Doctors are often advised to use suicide risk assessment to help them decide management plans. A wide variety of risk factors have been implicated in the stratification of potentially suicidal patients.2 This stratification is often expressed in terms of high, medium, or low-risk.34 In practice, doctors commonly give the greatest importance to suicidal ideation.56 In some specialist mental health settings these judgments are aided by local risk assessment forms composed of lists of clinical and demographic factors, while other centres use risk strata derived from validated questionnaires or scales.7 However, there is little consensus over their use and virtually no evidence that any of the …

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