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Abstract
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Suicide-related deaths in India have shown a consistent rise in the last few years, from 9.9 per one lakh population in 2017 to 12.4 per one lakh population in 2022.1 Notably, this phenomenon is nested in the background of a global waning in suicide rates in the last few decades, albeit before 2016.2 Further, time trends in India show a consistently high rate of suicide among students, a rise in suicides attributed to substance use, and a change in preferred suicide means, with deaths due to hanging recording a steady rise.3 These observations, coupled with the continuing socioeconomic impact of the pandemic, provoke concern and call for action to identify factors underlying suicidal behaviors.
From a clinical perspective, a cornerstone of suicide prevention is the practice of suicide risk assessment and risk stratification. Suicide risk assessment is a highly structured process involving four main elements: assessment of risk factors; protective factors; specific suicide inquiry involving assessment of suicidal ideation, planning, and intent; and finally, assessment of evidence-based warning signs in suicide. This process is individualized and leads to stratified judgments about the level of suicide risk that inform subsequent management.4
A key drawback of extant suicide risk assessment models is their reliance on chronic, longer-term risk factors to make judgments about the level of acute risk. This approach has issues because long-term risk factors for suicide, such as lifetime suicidal ideation, past suicide attempt history, and mental disorders, have not shown a satisfactory predictive ability for near-term individual suicidal behaviors.5 One possible reason for this may be the static nature of these risk factors; because of this, they are more indicative of a chronic than acute risk of suicide. This biplanar distinction of suicide risk into chronic and acute risk, though infrequently done, has important clinical implications for practice.4
A second, and potentially more significant, drawback is the excessive reliance on verbalized or elicited suicidal ideation (SI) as a gateway question for further assessments of suicide risk: if the patient denies SI when asked, it is recorded, and this line of questioning is abandoned. Such an approach is potentially tricky because self-reported ideation may be transient and inconsistent or never reported due to the client's desire to conceal SI. Besides, cross-sectionally elicited SI has shown an inadequate predictive ability for near-term suicide behaviors.6 Significantly, a retrospective chart review aimed at identifying dynamic risk factors among suicide decedents found that about two-thirds of them denied SI when last asked by a practitioner; half of these patients died within two days of the assessment.7 These observations question the dependence on SI in risk assessment and highlight the need for a better understanding of drivers of individual progression from chronic to acute suicide risk. ...
Language: en |