[All instructions (in RED) and text not applicable to the research should be deleted when the form is modified for use on a particular study.]

This is an example template assessment and can be used as is by editing the highlighted text OR you may design something similar in nature.

This briefassessment can beused in conjunction with other scales (e.g., SCID—Depression, Hamilton Depression Scale, PHQ-9, etc.) that already have suicide questions. Thus, this assessmentis designed to probe the participant for further information, determine the best action plan, and to document both the assessment and the steps taken.

SUICIDAL RISK ASSESSMENT

Only complete if the participant has answered the PHQ-9 suicide item with a score of 1-3, indicating thoughts about hurting themselves (active suicidal ideation) or thoughts that life is not worth living or that they would be better off dead (passive suicidal ideation) at least several days over the past two weeks..

1.Can you tell me more about that? [Probe: What specifically have you been thinking about? How frequently do you have these thoughts? How long do they stay on your mind? If thoughts about hurting self: What makes you want to hurt yourself?]

For participants who report thoughts about hurting themselves (active suicidal ideation), continue with the remainder of the assessment. Otherwise, go to Action Plan.

2.Right now, how strong is your wish to die?

None...... 0

Weak...... 1

Strong ...... 2

Don't Know...... 7

Refused ...... 8

3.In the past month, have you made any plans or considered a method that you might use to harm yourself?

No ...... 0

Yes ...... 1

Don't Know...... 7

Refused ...... 8

4.How much do you really intend to make a suicide attempt right now?

Not at all ...... 0

Uncertain, not sure ...... 1

Certain ...... 2

Don't Know...... 7

Refused ...... 8

SUICIDE RISK ACTION PLAN

LEVEL OF SUICIDE RISK / ACTION PLAN
None
(PHQ-9 suicide item=0) / Nothing
Mild Risk
  • Passive suicidal ideation only
(No mention of thoughts of actively hurting oneself in question #1)
OR
  • No or weak wish to die
(Question #2 = 0 or 1
AND Question #3 and #4 = 0) / Nothing
Return to interview.
Intermediate Risk: Reportable
  • Strong wish to die
(Question #2 = 2)
BUT
  • No plan to harm self
(Question #3 = 0)
AND/OR
  • No or uncertain intention to make suicide attempt
(Question #4 = 0 or 1) / Let participant know that we will contact the social worker/psychiatrist/psychologistto inform them of the participant’s suicidal thoughts/plans. Interviewer will notify social worker immediately upon the end of the interview.
High Risk: Urgent
  • Strong wish to die
(Question #2 = 2)
AND
  • Plan to harm self
(Question #3 = 1)
AND
  • Intention to make suicide attempt
(Question #4 = 2) / In person: Explain to the participant that this isthe standard procedure for handling such situations is to call 911. If necessary, you may need to accompany the participant to the emergency room.
Phone screen: Keep participant on phone and tell them that you are going to get someone to call 911. From your office, signal a co-worker and ask that they call 911 and explain the situation. Stay on the phone with the participant until help arrives.