depression, risk assessment, suicide
A Sankaranarayanan. Suicide Risk Assessment Made Easy. The Internet Journal of Mental Health. 2007 Volume 5 Number 2.
Nearly two-thirds of patients present to the emergency department before committing suicide; however risk assessments often tend to be done poorly or inadequately in emergency settings. A mnemonic is presented that can aid in easy recall of essential factors to be considered in suicide risk assessment.
Suicide risk assessment is an important component of a Mental Status Examination and is an integral part of any mental health assessment undertaken in an emergency setting. Research has consistently shown that up to 69% of suicidal patients present to emergency departments shortly before their death ( 1 ) and a proportion of these patients have occult suicidality ( 2 ). The quality of recording of risk assessments in the emergency department after deliberate self harm tends to be poor ( 3 ). These points only emphasise the need for a thorough risk assessment. Below is a mnemonic that captures all the important risk factors for suicide and that will help ensure a comprehensive risk screen.
The mnemonic is: “MAN THIS ISN’T FAIR.”
M=MENTAL STATUS (AT RISK) (depression, anxiety, agitation, guilt, shame, delusions)
A=ATTEMPTS (in the past and exploring the lethality if any)
N=NO POSITIVE FACTORS (e.g., family, peer supports, reasons to live)
T=TRIGGER (recent significant psycho-social stressors, psychotic experience that precipitates suicidal thoughts)
I=IDEAS and INTENT (exploring details of plans if any, confidence level to carry through on intent)
I=ILLNESS (Medical- e.g., chronic physical or pain)
S=SUICIDE IN THE FAMILY
F=FINAL ARRANGEMENTS (final good bye; leaving a will)
A=ACCESS TO MEANS (e.g., firearms)
I=ISOLATION (social isolation, lack of supports)
R=RECENT PSYCHIATRIC HOSPITALISATION
As a mnemonic, MAN THIS ISN’T FAIR is easy to remember as it reflects the content of the mnemonic. It is also a thorough checklist of all the important risk factors, including a trigger question to identify positive factors. While a serious issue such as suicide risk assessment cannot be trivialized, it is often difficult to remember all the pertinent risk indicators in a busy emergency setting. Previous literature has highlighted the importance of mnemonics in medical education ( 4 ). The mnemonic described here is not so much to gauge severity as the SAD PERSONS scale ( 5 ) purports to do, as it is to remember the important clinical aspects to cover during a suicide risk assessment. This mnemonic has been well received in local teaching sessions and I hope students and educators will find this mnemonic useful as a teaching aid.
Anoop Sankaranarayanan, MD FRANZCP
Anoop Sankaranarayanan MD FRANZCP
Senior Staff Specialist Psychiatrist and Clinical Director
Hunter Valley Mental Health Services
Conjoint Senior Lecturer, University of Newcastle
Area Director of Clinical Training, Hospitalist Program, HNEAHS
Maitland, NSW 2320
Mobile: 0408 273 665
Phone: (02) 4939 2455 / 4939 2123
Fax: (02) 4939 2082