Conference Agenda

Risk prediction has dominated suicide research for over 40 years. Compelling evidence and arguments against its effectiveness is now driving change in clinical practice. That nascent change brings both opportunities and cautions. New tools claiming to predict suicide continue to emerge and be promoted, often repeating old errors. And if we move beyond prediction, what replaces it? In the UK, narrative risk assessments are increasingly dominant, despite no evidence for benefit, and strong arguments for their harm.
This talk will draw on several recently published papers to argue the field needs a bigger shift away from risk as an organising principle. Our fixation on risk is not only ineffective but damaging. Prediction represents a rabbit hole suicide research must climb out of. Psychiatry's clinical approach to risk is out of step with the rest of medicine. It gets in the way of helping patients, perverts the role of clinicians, and serves organisations rather than patients. It fuels a culture of blame that drives defensive practice, clinician burn out and ends up serving none of us.

Structure of the talk:

1. How psychiatry's approach to risk compares with other medical settings (e.g. TIA clinic)
2. The damage caused by our current approach to risk:
   1. Time and opportunity cost
   2. Focus on documenting over changing risk
   3. Patients seen as risk-bearers, not people we can help
   4. Harm to therapeutic relationship
   5. Perceived risk level used as barrier to accessing care
   6. Risk assessment serving organisations over individuals
3. Concluding themes:

1. 1. Risk obsession reflects a wider culture of responsibility and blame that needs to be pushed against
   2. Risk thinking prioritises bureaucracy over relationships and recovery
   3. The case for refocusing on relational psychiatry

In Lithuania—a country with persistently high suicide rates—most people who die by suicide have consulted at least one physician in the year before their death, yet only about one third have had contact with a mental health professional. In countries where national suicide prevention strategies are still emerging, the role of non-psychiatric physicians in identifying suicide risk remains unclear. Therefore, it is important to understand how physicians outside psychiatry perceive their role in suicide prevention. This study explored Lithuanian physicians’ experiences with documenting suicide risk following 2023 regulations mandating the registration of suicide-related diagnoses and referrals for psychosocial assessment.

Method. Semi-structured interviews examined physicians’ experiences of providing help to patients who were at suicidal risk. Sixteen physicians from a range of specialties (family medicine, internal medicine, emergency medicine, toxicology, neurology, and anesthesiology), with varying levels of experience and working in both inpatient and outpatient settings, participated. The data were analyzed using reflexive thematic analysis.

Results. Four main themes with subthemes were identified: 1. The need to learn to talk about suicide (Both sides find it difficult to talk about suicide; Suicidality itself is complex; Knowledge and experience build confidence); 2. The decision to record the diagnosis is subjective (Duty to help the patient; Perception of seriousness; Perceived benefit or risk); 3. Procedure as a Barrier or Enabler (Knowing What to Do Depends on Exposure; The importance of clear procedures; Legal responsibility and fear of sanctions; Documenting, but not recording the diagnosis); 4. Not My Domain (A Psychiatric Matter; Referral challenges and resource gaps; Choosing not to register risk when care isn’t available).

Conclusions. Physicians face substantial challenges in identifying and documenting suicide risk. To serve effectively as gatekeepers in suicide prevention, they require clear guidelines, training, and institutional support.

The study was funded by the Institute of Hygiene, Lithuania.

Clinicians are uniquely positioned to prevent a significant proportion of lives lost to suicide. However, common clinical practice continues to rely on and support risk assessment practices that, at best, have weak empirical support and, more often, lack empirical support. This presentation will challenge these practices with research data and make corrective recommendations. Specifically, evidence will be presented to refute the following:

1. If a patient admits to having suicide ideation, they are at increased risk of dying by suicide.

2. If a patient denies suicide ideation, they may be considered to not be at acute risk of dying by suicide.

3. If a patient admits to having active suicide ideation, this should be considered an indication of greater risk of dying by suicide than if they only admitted to having passive suicide ideation.

4. Protective factors buffer (or lower) a patient's suicide risk.

5. A patient expressing suicide ideation with plans should be considred to be at greater risk than if that ideation is expressed without plans.

6. Risk assessment scales, such as the C-SSRS, are good screeners of someone at risk of dying by suicide.

7. Suicide risk factors published and promoted in national suicide prevetion strategies and by major public health organizations are reasonable in focusing clinical attention to a patient at acute risk of dying by suicide.

8. There is good evidence to support stratifying a patient's suicide risk from low to high/imminent.

Complex Assessment of Acute Suicide Risk: A Theoretical Framework Supported by Preliminary Clinical Data

Introduction

Accurate identification of acute suicide risk is a key challenge in suicide prevention. Traditional risk factor–based approaches often fail to capture the dynamic psychological processes characterizing the presuicidal mental state. This presentation introduces an integrative theoretical framework that conceptualizes acute suicide risk as a complex psychological syndrome and illustrates its clinical relevance using preliminary empirical data.

Methods

The empirical component is based on a clinical pilot study applying Hungarian adaptations of a suicide screening tool , derived from Galynker’s Suicide Crisis Syndrome (SCS) concept, and the Brief Suicide Questionnaire (BSQ) by Rihmer. . Consecutive psychiatric outpatients and inpatients (N = 99) completed a total of 150 assessments during routine clinical care. In cases of positive screening results, a detailed instrument assessing Suicide Crisis Syndrome symptoms (SCS-C) was also administered.

Results

Screening indicated acute suicide risk in over half of outpatients and approximately three quarters of inpatients, with a marked reduction following inpatient treatment. Full diagnostic criteria for Suicide Crisis Syndrome were most frequently met among patients with a positive SCS screening, particularly when combined with BSQ positivity. Severe Suicide Crisis Syndrome symptomatology was most prevalent when both screening instruments were positive. These findings suggest that acute suicide risk is multidimensional and cannot be adequately captured by the presence or absence of explicit suicidal intent alone.

Conclusions

Preliminary clinical data support a theoretical model in which acute suicide risk is conceptualized as a complex psychological state characterized by affective, cognitive, and behavioural dysregulation. Integrating syndrome-based assessment with clinical judgment may enhance time-sensitive decision-making in acute psychiatric care and contribute to more targeted suicide prevention strategies.

Background
Suicidality is a complex phenomenon that places a heavy burden on individuals and their social environment. Although suicidality is often treated as uniform in practice, research indicates that distinct forms of experienced entrapment can produce different expressions of suicidality. The recently developed suicidality differentiation model identifies four of these suicidality subtypes (i.e., perceptual disintegration, primary depressive cognition, psychosocial turmoil, inadequate coping or communication)[1, 2]. To date, this model has only been validated in living individuals assessed by crisis teams [3][de Winter et al under review]. Therefore, this study aims to replicate these suicidality subtypes in a post-mortem cohort and compare patients who died by suicide with those who were assessed by crisis teams.

Method
This study will systematically review suicide evaluation reports from 280–320 individuals who died from suicide within mental health services, generating a structured database of demographic (e.g., age, gender, education) and clinical information (e.g., psychiatric diagnoses, treatments, suicide attempts). Three to six trained healthcare professionals will then independently assess the reports using the validated SUICIDI-3 questionnaire to classify and document each case’s suicidality subtypes both categorically and dimensionally.

Results
The database will first be used to validate the suicidality differentiation model in a post-mortem cohort, with rater agreement quantified using the intraclass correlation coefficient (ICC). It also allows for in-depth research on how demographic and clinical variables influence suicidality subtypes, using multiple regression and, where appropriate, structural equation modeling (SEM). Finally, findings can be compared with patients assessed by crisis teams or suicides outside mental health services to identify differences in clinical and demographic profiles.

Conclusion
This study will validate the suicidality differentiation model in a post-mortem cohort and clarify how suicidality differs across clinical settings. The findings aim to help clinicians recognize distinct suicidality profiles and apply these insights to more targeted, patient-centered care.