Warning signs for suicide

Research has identified the importance of both warning signs and risk factors for suicide in conducting suicide risk assessments [546, 547]. Warning signs for suicide are specific to the current state of the person (e.g., behaviours preparing for suicide), and indicate a heightened risk in the near-term (e.g., minutes, hours, or days). In contrast, risk factors are often long-lasting and increase suicide risk over time (e.g., lifetime psychiatric diagnoses, past suicide attempts) [546, 547].

Warning signs may be immediately apparent at intake or may arise during treatment. The presence of warning signs indicates that screening and information gathering regarding suicidality is required. Warning signs can be either direct, requiring immediate attention, or indirect, which are less identifiable [546–548]. Direct signs include [545, 549]:

Suicidal communication: A client threatening to hurt or kill themselves or talking about wanting to do so. Suicidal communication also includes speaking ominously, such as talking about going away, or of others being better off without them.
Seeking access to a method: A client looking for ways to kill themselves by seeking access to pills, rope, or other means.
Making plans: A client talking or writing about death, dying, or suicide, when these behaviours are out of the ordinary for the person.

Indirect warning signs are less easily identifiable, and require a heightened level of awareness, particularly as many indirect signs may also occur in AOD clients who are not suicidal [545, 546]. Any changes in normal thoughts, emotions, or behaviours can indirectly indicate that a client is in crisis [389, 548], but the most common of these changes are sleep disturbances, anxiety, agitation, and hopelessness [548]. These factors are critical in assessing level of suicide risk. The mnemonic ‘IS PATH WARM’ (see Table 31) may be useful in assisting AOD workers remember common warning signs [550], with each letter corresponding to a specific warning sign experienced or reported in the last few months [551].

Table 31: IS PATH WARM model for common suicide warning signs

Mnemonic	Warning sign	Explanation
I	Ideation	Has the client expressed a desire to kill themselves, with a method that they have access to, or can access (e.g., weapon, pills), or an intention to obtain a method for the purpose of killing themselves?
S	Substance use	Has the client recently relapsed?
P	Purposelessness	Does the client express a lack of purpose in life, or reason for living?
A	Anger	Does the client express feelings of rage, uncontrolled anger, or revenge-seeking?
T	Trapped	Does the client feel trapped in a terrible situation from which there is no escape?
H	Hopelessness	Does the client have a negative sense of self, others, and the future, with little chance of positive change?
W	Withdrawal	Does the client indicate a desire to withdraw from significant others, or have they already begun withdrawing?
A	Anxiety	Does the client feel anxious, agitated, unable to relax, and/or report disturbances in sleep?
R	Recklessness	Does the client act recklessly without thinking or considering the consequences?
M	Mood changes	Does the client report dramatic shifts in emotions?

Adapted from Juhnke et al. [551] and Deady et al. [545].

Other mnemonics that AOD workers may find useful include ‘SIMPLE STEPS’, for assessing the severity of suicide ideation [552, 553], and ‘SHORES’, for assessing protective factors [554]. These mnemonics are illustrated in Table 32 and Table 33.

Table 32: SIMPLE STEPS model for assessing severity of suicidal ideation

Mnemonic	Warning sign	Explanation
S	Suicidal	Is the person expressing suicidal ideation?
I	Ideation	What is their suicidal ideation?
M	Method	How detailed is the person’s suicidal method and is their method accessible?
P	Perpetuation	How intense is their emotional pain?
L	Loss	Have they experienced actual or perceived losses (e.g., relationships or material objects)?
E	Earlier attempts	Have there been previous suicide attempts? What did they involve? What happened afterwards?
S	Substance use	Is the person currently using substances or have they recently relapsed?
T	Trouble shooting (lack of)	Are they able to see any alternatives or options other than suicide?
E	Emotions and diagnosis	Assessment of emotional factors and diagnoses commonly associated with suicide (e.g., hopelessness, helplessness, worthlessness, loneliness, depression).
P	Protective factors (lack of)	Internal or external factors that might reduce the risk of suicide (e.g., individual resilience, family/community support).
S	Stressors and life events	Evaluation of current and previous stressors.

Table 33: SHORES model for assessing protective factors

Mnemonic	Warning sign	Explanation
S	Skills and strategies to cope	Emotional regulation, adaptive thinking, engaging in interests or hobbies.
H	Hope	Hope and goals for the future, in addition to a sense of purpose to obtain those goals.
O	Objections	Moral, cultural or spiritual beliefs that may protect against suicide.
R	Reasons to live and Restricted means	Reasons to stay alive include family or carer responsibilities (e.g., to a person’s children). Restricted means refers to reducing access to methods which might be used in suicide (e.g., medications, poisons).
E	Engaged care	Active engagement in a therapeutic relationship.
S	Support	Involvement in supportive relationships, including family, community, friends.

The risk of suicide can increase during times of significant events, stress, upheaval, or trauma. It is likely that warning signs will be more pronounced during such times. These risk factors might include [389, 545, 550]:

Relationship break-up/significant relationship problems.
Trauma.
Impending legal event.
Child custody issues.
Past history/family history of suicide or suicide attempt, or recent suicide of friend.
Loss of a loved one.
Financial crisis, job loss, employment set back.
Family conflict or breakdown.
Chronic pain or illness.
AOD relapse.
AOD intoxication.
Recent discharge from treatment service.
Social isolation.

Direct warning signs indicate a need for immediate assessment and intervention and, although the presence of indirect warning signs may not indicate acute suicide risk, there is the need for follow-up questions to determine whether suicidality is indicated. This requires a degree of judgement and skill by the AOD worker. Careful elicitation of suicidal ideation does not increase the risk of suicide [389, 538, 539]. When in doubt, it is critically important that workers ask clients directly.

As mentioned previously, it is critical that suicide risk assessment be an ongoing process and not a one-off event. Clients’ suicidality may change throughout treatment to reflect the changes in their AOD use, mental health, or personal circumstances, and there is a need for AOD workers to monitor and assess for any such changes. Whenever suicide risk is at all suspected, it is essential that AOD workers enquire as to the presence of suicidal thoughts and/or feelings. Regular assessment of suicidality and a therapeutic relationship in which a client feels they can talk openly will help clinicians gather the best possible estimate of suicide risk [555].