It is impossible to predict accurately which patients will make serious suicide attempts, but a thorough assessment taking into account major risk factors is critical in suicide prevention efforts. The assessment should be conducted within the context of a positive therapeutic relationship established using a supportive, empathetic approach. Key areas to evaluate are past suicide attempts by the patient or close family or friends, access to lethal means, medication non-compliance, severity of depression, intensity of command hallucinations (e.g., voices telling the patient to kill himself, telling the patient he is worthless, telling the patient he would be better off dead) and the patient’s ability to resist those voices, and severe paranoid delusions that frighten the patient (e.g., warning of terrible torture, warning of being captured, jailed).
The assessment should also include areas that can be leveraged to prevent suicide including supports, personal goals, future plans, and a sense of hope. Vulnerable periods that should trigger suicide assessment in the population with SMI include illness onset, just before hospital discharge or soon after, or the occurrence of a recent adverse life event (e.g., interpersonal conflict, anniversary of a major loss). SAMHSA has some good suicide assessment tools here.