Clinical Insights

The Effects of Suicide Ideation

Assessments on Urges
to Self-Harm and Suicide
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Rahel Eynan1, Yvonne Bergmans2, Jesmin Antony2,

This document is copyrighted by the American Psychological Association or one of its allied publishers.

John R. Cutcliffe3, Henry G. Harder4, Munazzah Ambreen5,

Ken Balderson2, and Paul S. Links1
1
Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada,
2
St. Michael’s Hospital, Toronto, Ontario, Canada, 3University of Ottawa, Ottawa, Ontario, Canada,
4
University of Northern British Columbia, Canada,
5
The Hospital for Sick Children, Toronto, Ontario, Canada

Abstract. Background: Participants’ safety is the primary concern when conducting research with suicidal or potentially suicidal participants.
The presence of suicide risk is often an exclusion criterion for research participants. Subsequently, few studies have examined the effects of
research assessments on study participants’ suicidality. Aims: The purpose of this research was to examine the patterns of postassessment
changes in self-harm and suicide urges of study participants who were recently discharged from an inpatient psychiatric service. Method:
Study participants (N = 120) were recruited from patients with a lifetime history of suicidal behavior admitted with current suicidal ideation
or suicide attempt to an inpatient psychiatric service and/or a crisis stabilization unit. Participants were assessed for suicidal ideation with the
Suicide Ideation Scale at 1, 3, and 6 months following their discharge from hospital. The risk assessment protocol was administered at the start
and at the end of each of the study follow-up assessments. Results: Changes in self-harm and suicide urges following study assessments were
small, infrequent, and were most likely to reflect a decrease in suicidality. Similarly, participants rarely reported worsening self-control over
suicidal urges, and when they did, the effect was minimal. By the end of the 6-month follow-up period, increases in self-harm and suicidal
urges postassessment were not seen. Conclusion: The inclusion of suicidal participants in research interviews rarely increased suicide risk.
Research involving suicidal individuals is possible when study protocols are well planned and executed by trained assessors and clinicians who
are able to identify participants at risk and provide intervention if necessary. The few participants that required intervention had high levels of
suicide ideation and behavior at baseline and almost all reported symptoms of posttraumatic stress disorder. Further study is needed to better
characterize this subgroup of participants.

Keywords: suicide, suicide risk assessment, suicidal ideation, suicide urges, self-harm urges

Suicide is a public health problem with extensive social,
emotional, and economic consequences. According to the
World Health Organization (WHO), it is one of the leading
causes of premature death worldwide (WHO, 2011) and
claims the lives of approximately one million individuals
annually.
As a serious public health problem, suicide research
is imperative, yet there are fewer empirical studies on sui-
cide than on numerous less common causes of death (Mis-
hara & Weisstub, 2005). There is a paucity of information
about the efficacy of treatments for individuals with the
highest-risk psychiatric disorders and actively suicidal in-
dividuals (Vincent, 2003). Generally, intervention studies
targeting mental disorders often excluded individuals with
a history of suicide attempts or those perceived to be at
current or future risk for suicide (Pearson, Stanley, King,
& Fisher, 2001). While researchers agree that empirical
investigations are needed to better understand suicide and
to help develop effective prevention and treatment proto-
cols (Fisher, Pearson, Kim, & Reynolds, 2002; Lakeman
& FitzGerald, 2009; Oquendo, Stanley, Ellis, & Mann,
2004; Pearson et al., 2001), there is a hesitancy among re-
searchers to include individuals who are at high risk for
suicide in research studies. Despite the fact that suicide re-
search aims at examining the presence of the vulnerability
manifested in suicide risk, the perceived burden of moni-
toring and managing suicidal crises, the ethical and legal
implications, and the potential consequences are often the
rationales cited for the exclusion of high-risk participants
(Jobes, Bryan, & Neal-Walden, 2009; Lakeman & Fitz-
Gerald, 2009; Pearson et al., 2001). Concomitantly, there
is a ubiquitous perception among researchers, health-care
professionals, and the public (Feldman et al., 2007; Meer-
wijk et al., 2010) that talking about suicide elevates the

© 2013 Hogrefe Publishing Crisis 2014; Vol. 35(2):123–131

DOI: 10.1027/0227-5910/a000233
 124 R. Eynan et al.: Effects of Suicide Ideation Assessments
suicide risk and may result in the individual’s attempt to
end their life (Lakeman & FitzGerald, 2009).
Alternatively, there are a number of studies that con-
tend that while some participants may feel distressed
when asked about suicidal ideation and suicidal behavior,
it does not contribute to an intensification in suicide risk
nor does it result in long-term distress (Biddle et al., 2012;
Deeley & Love, 2010; Hahn & Marks, 1996; Henderson &
Jorm, 1990; Jacomb et al., 1999; Parslow, Jorm, O’Toole,
Marshall, & Grayson, 2001). While even a small rate of
increase in distress or depressive symptoms may be seen
as a cause for concern, Reynolds, Lindenboim, Comtois,
Murray, and Linehan (2006) reported that for 63 high-risk
chronically suicidal women with borderline personality
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disorder (BPD), distress and suicidality varied independ-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ently. Any reported elevation in suicide risk tended to be
small, with low-level interventions such as validating feel-
ings or providing emergency number cards being sufficient
for nearly all participants in their study.
Several studies have reported that after screening for
suicidal ideation over time, participants with depression
do not report an elevation in their ideation at follow-up
interviews (Crawford et al., 2011; Cukrowicz, Smith, &
Poindexter, 2010; Gould et al., 2005; Mathias et al., 2012;
Smith, Poindexter, & Cukrowicz, 2010). Furthermore, al-
though a small number of participants found the 4-week
postattempt interview difficult and upsetting, self-reported
distress declined significantly for participants who had
made a medically serious suicide attempt as well as those
who had not made a near-lethal attempt 4 weeks earlier in
Rivlin, Marzano, Hawton, and Fazel’s (2012) case-control
study.
Overall, there still remains a need for definitive re-
search to indicate whether to include or not include sui-
cidal individuals in research. Similar to the Reynolds et al.
(2006) study, the purpose of this study was twofold: (1) to
examine the effects of research assessment interviews on
the self-harm and suicide urges of study participants who
were recently discharged from an inpatient psychiatric ser-
vice after being admitted with a current suicide attempt or
a current suicide ideation with a lifetime history of suicidal
behavior and (2) to describe the frequency in which clini-
cal interventions were used to reduce suicide risk.
Method
The examination of the postassessment changes in par-
ticipants’ urges to self-harm and suicide is part of a larger
prospective cohort study that examined the occurrence of
postdischarge suicidal ideation and behavior in a high-risk
cohort of recently discharged patients. The participants
were followed up prospectively for evidence of suicidal
ideation and behaviour at 1, 3, and 6 months following
discharge from an inpatient psychiatric service or short-
stay crisis stabilization unit (CSU). The prospective cohort
study was carried out between May 2007 and December
2009 and utilized a concurrent quantitative–qualitative
methods design. The findings from the quantitative and
Crisis 2014; Vol. 35(2):123–131
qualitative studies were published separately elsewhere
(Cutcliffe et al., 2012; Links et al., 2012). Herein we only
report on the postassessment changes in participants’ self-
harm and suicide urge ratings.
All patients admitted to St. Michael’s Hospital inpa-
tient service with a lifetime history of suicidal behavior
and current suicidal ideation based on self-report or chart
documentation were eligible for the study. Participants
were recruited from among consecutive patients admitted
to the inpatient psychiatric service or to the short-stay (72
hr) CSU for a current suicide attempt or for current sui-
cidal ideation with some level of intent to die. The his-
tory of suicide attempts was based on self-report or chart
documentation. A suicide attempt was defined as “a po-
tentially self-injurious behaviour with a nonfatal outcome,
for which there is evidence (either explicit or implicit) that
the person intended at some (nonzero) level to kill himself/
herself” (O’Carroll et al., 1996).
Baseline assessments were conducted during the par-
ticipants’ hospital admission after obtaining permission
from their inpatient physician and a signature of informed
consent. Assessment of psychopathological predictive fac-
tors, that is, diagnosis, depression, hopelessness, impul-
sivity, alexithymia, problem-solving deficits (described in
detail elsewhere; Links et al., 2012), and the participant’s
suicidal ideation were administered while in hospital or
shortly after discharge. The study received research ethics
approval from the hospital’s Research Ethics Board.
Suicidal Ideation at Baseline
Baseline suicidal ideation was assessed during the partici-
pants’ index hospital stay with the Scale for Suicide Idea-
tion (SSI; Beck, Kovacs, & Weissman, 1979). The SSI is a
21-item, interviewer-administered rating scale that meas-
ures the current intensity of patients’ specific attitudes,
behaviors, and plans to die by suicide on the day of the
interview and during the preceding week. This scale has
demonstrated internal consistency, inter-rater reliability,
and concurrent validity (Beck et al., 1979) as well as ad-
equate predictive validity significantly predicting eventual
suicide (Brown, Beck, Steer, & Grisham, 2000).
Suicidal Ideation at Follow-Up
To assess for evidence of suicidal ideation and behavior
after hospital discharge, the SSI (Beck et al., 1979) was
administered at the 1-, 3-, and 6-month follow-up inter-
views. At the 6-month follow-up appointment, participants
were asked to report on any self-injury events without in-
tent to die or suicide attempts with intent to die during the
6 months of postindex hospital discharge using the clini-
cian-administered Lifetime Parasuicide Count (Linehan &
Comtois, 1996).
© 2013 Hogrefe Publishing
 R. Eynan et al.: Effects of Suicide Ideation Assessments 125

Suicide Risk Assessment
Participants were assessed for suicide risk using a mod-
ified Washington Risk Assessment Protocol (UWRAP;
Linehan, Comtois, & Murray, 2000). The 6-item UWRAP
Face Sheet and the Debriefing Form were reduced to a
3-item risk assessment that was administered at the start
and at the end of each follow-up research assessment in-
terview conducted at 1, 3, and 6 months. Participants were
asked to self-rate their self-harm and suicide urges using
the following questions:
1. Please rate your urges to self-harm on a scale of 0–7
(none to severe).
2. Please rate your urge to suicide on a scale of 0–7 (none
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Fisher’s exact test, t test, or Wilcoxon rank-sum test. A
95% (p < .05) significance level was adopted. All statisti-
cal analyses were conducted using the Statistical Package
for the Social Sciences (SPSS, Version 15 for Windows).
Results
Sample Description
A total of 152 patients admitted to the inpatient psychiatric
service met study criteria and were referred to the study
coordinator. Of those, 120 (78.9%) consented to partici-

to severe).
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3. Please rate your sense of control over any self-harm or
suicide urges using a scale of 0–7 (out of control to in
control).
A participant was considered to be at moderate or high risk
requiring suicide risk intervention if he or she rated their
urges to self-harm or urges to suicide as 4 or higher and in-
dicated they were uncertain of their ability to control their
urges. If the score was below 4 but the research associate
had reasons to be concerned about the participant’s ability
to control their urges not to self-harm or attempt suicide,
clinical judgment prevailed.
Statistical Analyses
Descriptive statistics (mean, standard deviation, quartiles)
were calculated to characterize the patients at baseline
with respect to demographics (i.e., age, sex, race/ethnicity,
marital status), psychopathologic risk factors, and psychi-
atric comorbidities, overall and by group. Comparisons
between groups at baseline were conducted using a χ2 test,
pate in the study. By the end of the study, eight (5.3%) par-
ticipants withdrew from the study and nine (6%) were lost
to follow-up. There were nearly equal numbers of male
(63; 52.5%) and female (57; 47.5%) participants, and the
mean age was 37.5 years (SD = 11.1). The vast majority
of participants (98; 81.9%) were admitted to hospital for
a current suicide attempt; 22 (18.3%) were admitted for
suicide ideation. Only 27 (22.5%) participants were admit-
ted to inpatient services for their first-time suicide attempt,
while the majority of participants (93; 78.5%) had a medi-
an number of 2 previous attempts (interquartile range = 2)
over their lifetime.
The most common current psychiatric diagnoses
among study participants were affective disorders (con-
firmed by the Structured Clinical Interview for DSM-IV
Axis I Disorders [SCID-I]). On the basis of DSM-IV cri-
teria, 99 (90%) study participants met criteria for major
depressive episode or bipolar disorder, while 12(10.9%)
met criteria for schizophrenic disorders. Two thirds (74;
67%) of the study participants met criteria for Axis II dis-
orders (confirmed by SCID-II), and borderline personality
disorder (BPD) was diagnosed in 36 (31.9%) of the par-
ticipants.

Table 1. Changes in self-reported ratings of suicidality and control over period of assessment
Preassessment Postassessment Patterns of changes
ratings ratings Increase Decrease No change
Measure/Time Mean (SD) Mean (SD)  n % n % n %
Month 1 (n = 99)
Urges to self-harm 1.31 (1.7) 1.13 (1.7)* –0.18 3 3.0 16 16.2 80 80.8
Urges to suicide 1.36 (1.8) 1.14 (1.6)* –0.22 2 2.0 14 14.1 83 83.8
Sense of control 6.06 (1.2) 6.19 (1.2) +0.13 12 12.1 4 4.0 83 83.8
Month 1 (n = 95)
Urges to self-harm 1.06 (1.5) 1.01 (1.5) –0.05 6 6.1 6 6.1 83 87.4
Urges to suicide 1.08 (1.6) 1.06 (1.6) –0.02 7 7.4 7 7.4 81 85.3
Sense of control 6.03 (1.3) 6.17 (1.3) +0.14 11 9.2 3 3.2 81 85.3
Month 6 (n = 96)
Urges to self-harm .74 (1.3) .70 (1.2)* –0.04 0 0 4 3.3 92 95.8
Urges to suicide .91 (1.5) .85 (1.5)* –0.06 0 0 5 5.2 91 94.8
Sense of control 6.36 (1.1) 6.42 (1.1) +0.06 7 7.3 2 2.1 87 90.6
Notes: *Based on paired sample t-test p < .05.

© 2013 Hogrefe Publishing Crisis 2014; Vol. 35(2):123–131

 126 R. Eynan et al.: Effects of Suicide Ideation Assessments

Suicidal Ideation
At baseline (n = 119), SSI scores ranged from 10 to 31,
with a mean score of 23.6 and a standard deviation of
3.8. As indicated in Table 1, over the course of the study
the SSI mean score significantly decreased from the ob-
served baseline score, MBase = 23.6 (SD = 3.8) vs. M1 = 7.9
(SD = 9.0) p < .0001; MBase = 23.6 (SD = 3.8) vs. M3 = 6.6
(SD = 7.8), p < .0001; MBase = 23.6 (SD = 3.8) vs. M6 = 5.7
(SD = 7.8), p < .0001 at 1, 3, and 6 months, respectively. Of
note, a high proportion of participants reported no suicide
ideation (SSI score = 0) at the 1-month (40.0%), 3-month
(44.8%), and 6-month (48.0%) follow-up interviews.
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mean increase of 1.8 (SD = 1.1) and a median of 1. As in-
dicated in Table 2, a significant increase in the mean self-
harm urges score was reported after the 1- and 3-month
assessment interviews, 1 = +2.0; Mpre = 1.0 (SD = 1.0) vs.
Mpost = 3.0 (SD = 2.7), p = .005; 3 = +1.7; (Mpre = 2.0
(SD = 2.0) vs. Mpost = 3.7 (SD = 2.0), p = .004, respectively.
None of the participants reported an increase in self-harm
urges following the 6-month interview. Only three (3/9,
33.3%) of the participants who reported an increase in their
self-harm urges following a study interview had rated their
postassessment self-harm urges as greater than 4. Interven-
tions were offered to those participants identified as high-
risk (discussed in detail in the “Interventions” section).
During the study period, 26 participants indicated their

self-harm urges decreased following the study interview.

Changes in Urges to Self-Harm
Following Research Interview
The magnitude and the direction of change were calculated
by comparing pre- and postassessment ratings. We exam-
ined 290 research assessments conducted over a 6-month
period of study. As indicated in Table 1, throughout the
study period, only nine research interviews (9/290, 3.1%)
resulted in an increase in the urges to self-harm following
the study interview. In the vast majority of research inter-
views there was no change in the pre- and postassessment
self-harm ratings (255/290, 87.9%). A decrease in the self-
harm urges rating was reported following 26 interviews
(26/290, 9%).
Overall, as indicated in Table 1, the pre- and postas-
sessment interview self-harm ratings were at the low end
of the scale indicative of low urges to self-harm. Through-
out the study period the mean rating was below 2.0 (on an
8-point scale ranging from 0 = none to 7 = severe). Com-
parison of postassessment ratings from the first follow-up
study interview (1 month) to the last one (6 months) shows
a slight decrease occurred in the self-harm urges ratings
over the course of the study: M1 = 1.13 (SD = 1.7) vs.
M6 = 0.7 (SD = 1.2).
Nine participants indicated an increase in their self-
harm urges following the assessment interview. The over-
all increase in self-harm urges ranged from 1 to 4 with a
The overall decrease in ratings ranged from –1 to –7 and
the mean decrease was –1.7 (SD = 1.6) with a median of 1.
As indicated in Table 2, the comparison of pre- and postas-
sessment ratings of those participants who indicated a de-
crease in their self-harm urges shows a statistically signif-
icant decrease in self-harm urges following the 1-, 3-, and
6-month assessment interviews, 1 = –1.5, p = < .0001; 3
= –2.5, p = .026; 6 = –1.0, p = .046, respectively. Among
those who reported a decrease in their self-harm rating,
two (2/26, 7.7%) participants had rated their postassess-
ment self-harm urges to be greater 4.
As noted earlier, the vast majority of study participants
(87.9%) did not report any changes in their self-harm urges
following the study interviews. Their postassessment rat-
ings ranged from 0 to 7, and had a low mean score that de-
creased during the course of the study from 1.1 (SD = 1.6) to
0.66 (SD = 1.2). Thirteen (13/255, 5.5%) of the “no change”
follow-up interviews had self-harm ratings greater than 4.
Changes in Urges to Suicide Following
Research Interview
The same descriptive data were also examined for ratings
of suicide urges. As shown in Table 1, throughout the study
period, only nine research interviews (9/290, 3.1%) result-
ed in an increase in the urge to suicide following the study

Table 2. Changes in self-reported urges to self-harm or suicide after the follow-up assessment interview
Measure/Time Increase  p Decrease  p No change
Pre Post Pre Post Pre Post
Urges to self-harm
Month 1 (n = 99) 1.0 (1.0) 3.0 (2.7) +2 .1 2.4 (1.9) 0.94 (1.9) –1.46 .0001 1.1 (1.6) 1.1 (1.6)
Month 3 (n = 95) 2.0 (2.0) 3.7 (2.0) +1.7 .004 3.2 (2.1) 0.67 (0.8) –2.53 .0026 .84 (1.3) .84 (1.3)
Month 6 (n = 96) 2.5 (1.3) 1.5 (1.3) –1 .046 .66 (1.2) .66 (1.2)
Urges to suicide
Month 1 (n = 99) 1.5 (0.7) 3.0 (2.7) +2 .32 2.9 (2.0) 1.0 (1.2) –1.9 .001 1.1 (1.7) 1.1 (1.7)
Month 3 (n = 95) 1.0 (2.3) 4.0 (2.3) +3 .01 3.3 (2.2) 1.0 (1.5) –2.3 .034 .83 (1.4) .83 (1.4)
Month 6 (n = 96) 1.8(0.45) 0.8 (0.45) –1 .025 .86 (1.5) .86 (1.5)
Notes: Pre = preassessment ratings. Post = postassessment ratings.

Crisis 2014; Vol. 35(2):123–131 © 2013 Hogrefe Publishing

 R. Eynan et al.: Effects of Suicide Ideation Assessments
interview. Similar to the pattern seen with self-harm urg-
es, the vast majority of research interviews resulted in no
change in the pre- and postassessment suicide urges ratings
(255/290, 87.9%), while a decrease in suicide urges ratings
was reported following 26 study interviews (26/290, 9%).
Overall, as indicated on Table 1, the pre- and post-
assessment interview suicide urges ratings were at the
low end of the scale indicative of low urges to suicide.
Throughout the study period the mean rating was below
2.0 (8-point scale ranging from 0 = none to 7 = severe).
Comparison of the suicide urges postassessment ratings
from the first follow-up study interview (1 month) to
the last one (6 months) shows a slight decrease occurred
in the suicide urges ratings over the course of the study,
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M1 = 1.14 (SD = 1.6) vs. M6 = 0.85 (SD = 1.5). Nine par-
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ticipants indicated an increase in their suicide urges fol-
lowing the assessment interview. The overall increase in
suicide urges ranged from 1 to 4 with a mean increase of
2.0 (SD = 1.2) and a median of 2. As indicated in Table 2,
a significant increase in the mean suicide urges score was
reported after the 1- and 3-month assessment interview, at
1 month: 1 = + 2.0; Mpre = 1.5 (SD = 0.7) vs. Mpost = 3.5
(SD = 0.7, p = .32; at 3 months: 3 = +3.0; (Mpre = 1.0
(SD = 2.3) vs. Mpost = 4.0 (SD = 2.3), p = .01, respectively.
None of the participants reported an increase in suicide
urges following the 6-month interview. Of the nine partic-
ipants who had reported an increase in their suicide urges
following the assessment interviews, five (5/9, 55.6%) had
an elevated postassessment score (> 4). Interventions were
offered to those participants identified as high-risk (dis-
cussed in detail in the “Interventions” section).
During the study period, 26 participants indicated their
suicide urges decreased following the study interview. The
overall decrease in ratings ranged from –1 to –7 and the
mean decrease was –1.8 (SD = 1.7) with a median of 1.
As indicated in Table 2, the comparison of pre- and post-
assessment ratings of those participants who indicated a
decrease in their suicide urges shows a statistically signif-
icant decrease in suicide urges following the 1-, 3-, and
6-month assessment interviews, 1 = –1.9, p = < .001;
3 = –2.3, p = .034; 6 = –1.0, p = .025, respectively. Only
one participant from among those who reported a decrease
in their suicide urges (1/26, 3.9%) had rated their urges to
suicide after a follow-up interview as greater than 4.The
vast majority of study participants (87.9%) did not report
any changes in their suicide urges following the study in-
terviews. Their postassessment ratings ranged from 0 to 7,
and had a low mean score that decreased during the course
of the study from 1.1 (SD = 1.6) to 0.66 (SD = 1.2). Sixteen
(16/255, 7.8%) of the “no change” follow-up interviews
had suicide ratings greater than 4.
Changes in Self-Reported Control Over
Self-Harm and Suicide Urges Following
Assessment Interview
Following the postassessment interviews, 92.7% of the
participants rated their level of control over their self-harm
© 2013 Hogrefe Publishing
127
and suicide urges as 5 or greater (on an 8-point scale rang-
ing from 0 = out of control to 7 = in control). As indicat-
ed in Table 1, risk assessment protocols over the 6-month
study period indicated the vast majority of postassessment
interviews reflected no change in the participants’ abili-
ty to control their self-harm and suicide urges (255/290,
87.3%). An examination of the data indicates both pre- and
postassessment scores are at the high end of the scale and
are indicative of a high level of control over self-harm and
suicide urges. Over the course of the study only nine par-
ticipants (9/290, 3.1%) indicated that their sense of control
over their urges weakened after the study interview. None
of the decreases in control, however, were statistically sig-
nificant, p =.2; p = .06; p = .2, respectively. Conversely,
10.3% of study assessments (30/290) showed a greater
sense of control over participant urges following the study
interview. The increase in self-control over self-harm and
suicide urges was statistically significant at the 1-, 3-,
and 6-month study interviews, at 1 month: Mpre = 4.9
(SD = 1.4) vs. Mpost = 6.4 (SD = 0.7), p = .01; at 3 months:
Mpre = 6.2 (SD = 1.0) vs. Mpost = 6.4 (SD = 0.7), p = .01; at
6 months: Mpre = 6.6 (SD = 0.8) vs. Mpost = 6.7 (SD = 0.7),
p = .008, respectively.
Interventions
A participant was judged as a high risk for suicidal be-
havior if they rated the urge to self-harm or the urge to
suicide as 4 or greater, or based on the research associate’s
clinical judgment after administering the SSI. Eighteen
(18%) study participants required some clinical interven-
tion to lower the risk of suicidality. Nine (9%) participants
required “soft” intensity interventions (e.g., validation of
feelings, de-escalation) at one of their follow-up inter-
views (3.1%; 9/290). These interventions were provided
by the research associate, who used mood improvement
strategies and de-escalation techniques, and did not require
clinical investigator involvement.
Of 290 assessment interviews carried out throughout
the study period, 13 high-intensity interventions were in-
itiated (4.5%; 13/290) for nine study participants. Of the
nine requiring clinical intervention, two (22%) required in-
tervention at two assessment interviews (1 and 3 months;
1 and 6 months) while one study participant required in-
tervention at all three assessment interviews (1, 3, and 6
months).
Of the 13 who were referred to the emergency psychi-
atric service, five (38.5%, 5/13) were assessed by emergen-
cy psychiatry personnel and discharged home, six (46.2%,
6/13) were kept in the short-stay unit for  72 hr, and two
(15.4%, 2/13) were admitted to the psychiatric inpatient unit.
Participants who required clinical intervention report-
ed much higher suicidal ideation throughout the study
period as measured by the SSI compared to the rest of
the sample, at 1 month: M = 7.2 (SD = 8.5) vs. M = 21.2
(SD = 9.8), p = .003; at 3 months: M = 5.9 (SD = 7.1)
vs. M = 25.7 (SD = 1.5), p < .001; at 6 months: M = 4.5
(SD = 6.3) vs. M = 25.0 (SD = 3.3), p < .001 (see Table 3).
Crisis 2014; Vol. 35(2):123–131
 128 R. Eynan et al.: Effects of Suicide Ideation Assessments

Table 3. Differences in postassessment changes between participants who required intervention and the rest of the sample
Time/Measure Sample High-intensity intervention p
Pre Post Pre Post Pre Post
1 Month
Self-harm urges 1.2 (1.7) 1.0 (1.5) 3.6 (1.5) 4.2 (1.3) .002 .001
Suicide urges 1.2 (1.6) 1.0 (1.4) 4.4 (2.1) 4.4 (2.1) .001 .001
Sense of control 6.2 (1.0) 6.3 (1.0) 3.6 (1.9) 4.2 (1.6) .001 .001
Suicidal ideation 7.2 (8.5) 21.2 (9.8) .003
3 Months
Self-harm urges 1.0 (1.5) 1.0 (1.5) 3.0 (1.0) 2.3 (0.6) .016 .035
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Suicide urges 1.0 (1.6) 1.0 (1.6) 3.0 (2.7) 3.3 (2.5) .155 .232
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Sense of control 6.1 (1.2) 6.3 (1.2) 3.3 (2.3) 3.3 (2.1) .018 .004
Suicidal ideation 5.9 (7.1) 25.7 (1.5) < .001
6 Months
Self-harm urges 0.6 (1.1) 0.5 (1.0) 3.6 (1.7) 3.6 (1.7) .001 .001
Suicide urges 0.7 (1.4) 0.7 (1.3) 4.0 (1.2) 4.0 (1.2) .001 .001
Sense of control 6.5 (1.0) 6.5 (1.0) 4.4 (1.8) 4.6 (1.8) .003 .002
Suicidal ideation 4.5 (6.3) 25.0 (3.2) < .001
Notes: At 1 month: sample N = 94, intervention n = 5. At 3 months: sample N = 92, intervention n = 3. At 6 months: sample N = 91, intervention n = 5.
Pre = preassessment ratings. Post = postassessment ratings.

Factors Associated with
High-Intensity Intervention
There were no statistically significant differences between
participants who required high-intensity intervention fol-
lowing their study interview and those who did not in Axis
I or II diagnoses with the exception of posttraumatic stress
disorder (PTSD). A greater proportion of study participants
who required high-intensity intervention following their
study interview met criteria for a current PTSD episode
(n = 6/9, 66.7% vs. n = 36/110, 32.70%, p = .025).
However, there were no statistically significant differences
between participants in the subgroup who required high-
intensity intervention following their study interview and
those who did not in terms of psychopathological predic-
tive factors, that is, depression severity, hopelessness, im-
pulsivity, alexithymia, problem-solving deficits (described
in detail elsewhere; Links et al., 2012) and the reason for
the index hospital admission. The majority of study partic-
ipants in both groups (those who required high-intensity
intervention and those who did not) had previously been
admitted for recurrent suicide attempts (58.9% vs. 77.8%).
At baseline there were no statistically significant dif-
ferences in suicidal ideation, based on SSI mean scores,
between the sample and the nine participants who required
high-intensity intervention, M = 23.4 (3.8) vs. M = 24.1
(4.0), p = .8; however, participants who required high-in-
tensity intervention had a much higher score at the 1-, 3-,
and 6-month assessment interview (see Table 3). A statis-
tically significant larger proportion of study participants
who required intervention reported at least one self-harm
incident during the 6-month study period compared to the
rest of the sample (7/8, 87.5% vs. 31/89 34.8%, p < .001),
and those who required intervention engaged in a signif-
icantly greater number of self-harm behaviors, M = 0.88
(SD = 0.35) vs. M = 0.35 (SD = 0.48), p = .008.
Discussion and Conclusion
To explore the validity of the belief that suicide risk will
increase if one talks about suicide, our study examined the
effects of suicide assessment interviews on study partici-
pants’ reported self-harm and suicide urges over a 6-month
period. A total of 103 participants with suicide ideation
and/or behavior who were recently discharged from an
inpatient psychiatric service were assessed at 1, 3, and 6
months postdischarge.
The primary finding of our study is that the vast ma-
jority of suicidal participants reported no changes in self-
harm or suicide urges following assessment interviews and
in some cases even reported a decrease in postassessment
suicide risk. Only a small proportion of study participants
reported an increase in their self-harm or suicide urges fol-
lowing their assessment interview. Moreover, there was a
decline in the number of participants who reported an in-
crease in suicidality over time. By the end of the 6-month
follow-up period, none of the participants reported an in-
crease in suicide risk postassessment, comparable to the
findings of previous studies (Biddle et al., 2012; Cukrow-
icz et al., 2010; Deeley & Love, 2010; Mathias et al., 2012;
Reynolds et al., 2006).
Based on our research experiences and those report-
ed by others (Biddle et al., 2012; Deeley & Love, 2010;

Crisis 2014; Vol. 35(2):123–131 © 2013 Hogrefe Publishing

 R. Eynan et al.: Effects of Suicide Ideation Assessments
Mathias et al., 2012; Reynolds et al., 2006; Rivlin et al.,
2012), the decline in reported suicidality over time may
be due to the therapeutic and cathartic effect of the assess-
ment interviews, including both the content of the research
interview and the relationship formed between the inter-
viewer and interviewee. A second factor that may have
contributed to this decline is that with time, participants
may have become more familiar with and therefore less
reactive to the assessment interview process. In the end,
it is difficult to determine whether or to what extent the
therapeutic effect of the interview or the interviewer, habit-
uation, or postassessment diminished anxiety contributed
to the findings. Further research is required to better under-
stand the impact of these factors.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
As mentioned earlier, instances of elevated risk follow-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ing study assessments were rare in our study. When deter-
mining whether a participant was in need of risk manage-
ment intervention, four factors were considered including
the modified UWRAP self-harm and suicide ratings, the
suicide ideation assessment, the participants’ perceived
sense of self-control, and the research associate’s clinical
judgment. The use of multiple factors helped ensure that
the presence of elevated suicide risk was identified and
appropriate steps were taken. In most cases, minimal in-
tervention strategies (validation, de-escalation) were suf-
ficient to reduce potentially negative consequences. In the
few more acute cases, however, high-intensity interven-
tion was required. Similar to the study by Reynolds et al.
(2006), we found that compared to the rest of the sample,
the subgroup of participants who required intervention fol-
lowing their study assessment interviews reported elevated
self-harm and suicide urges and a lesser ability to con-
trol those urges throughout the course of the study. This
group also reported twice the number of previous suicide
attempts than reported by the rest of the sample. While the
suicide ideation scores of the nonintervention subsample
decreased significantly over the course of the 6-month
study, the scores of those participants who required inter-
vention remained unchanged from their baseline scores.
This suggests that elevated suicidal ideation and perceived
low self-control are a combination of factors that may con-
tribute to the need for intervention.
Individuals in the high-risk group did not differ from
the rest of the sample in psychopathology or Axis I or II
diagnoses, with the exception of PTSD. The majority of
participants who required intervention endorsed symp-
toms that are consistent with a PTSD diagnosis. Further
exploration is needed to assess the extent to which PTSD
acts as an indicator of elevated suicide risk.
Our findings demonstrate that suicide research involv-
ing participants with a history of suicidality can be con-
ducted safely without the fear of elevating their suicide
risk with the following provisos:
• The research associate must be well trained in being
able to identify elevated risk (i.e., through suicide as-
sessments, participant ratings, personal judgement).
• An appropriate “safety net” (Cutcliffe, 2002) protocol
must be in place and ready to be implemented prior
to recruitment of participants. This protocol has two
elements:
© 2013 Hogrefe Publishing
129
– It must outline the safety measures to be instituted
in the case of elevated risk including names and lo-
cations of individuals trained and competent in risk
assessment.
– Provide a list of available treatment resources
should the need arise for the participant subsequent
to the visit.
Cutcliffe (2002) further suggests that forewarning partici-
pants in an information letter gives them the option to not
reply to the offer of participation. Additionally, reiterating
the possibility of arousal of emotions in the consent form
allows a second and in-person opportunity for the person
to decline or defer participation.
Overall, our work has expanded on previous research
(Biddle et al., 2012; Crawford et al., 2011; Cukrowicz et
al., 2010; Deeley & Love, 2010; Gould et al., 2005; Mathias
et al., 2012; Reynolds et al., 2006; Rivlin, et al., 2012;
Smith et al., 2010) sharing limited generalizability. The
sampling and measurements in this study make it unique.
Our sample included, in almost equal numbers, both gen-
ders (male: 52.5%, female: 47.5%) recruited from among
patients who were admitted to the inpatient psychiatric ser-
vice or the CSU for a suicide attempt (59.2%) or current
suicidal ideation with a lifetime history of suicidal behav-
ior, that is, individuals at high risk of suicide. In addition,
unlike Reynolds et al. (2006), our sample was not limited
to participants who met criteria for BPD. The most com-
mon diagnosis in our study was affective disorders (90%),
with 31.9% of participants meeting criteria for BPD.
Despite our best efforts, this study did have limitations.
Based on our clinical experience, we differentiated be-
tween the urge to self-harm and the urge to attempt suicide
recognizing that these two urges represent discrete behav-
iors with distinct intents. Thus, we modified the UWRAP
(Linehan et al., 2000) and focused only on two questions;
the first enquiring about self-harm urges and the second
about suicide urges. A limitation of the study was that the
psychometric properties of this modified UWRAP scale
were not established and therefore we cannot comment on
its validity and reliability.
While we relied on this brief UWRAP scale to assess
the magnitude of change in the pre- and postassessment
ratings, participants were also rigorously assessed for their
suicidal ideation on the assessment day and the preced-
ing week regardless of their self-reported suicidal urges.
Nonetheless, we only examined the proximal effects of the
assessments and did not evaluate the distal effects in the
weeks following the interview. Given that 39.4% of our
sample engaged in self-harm and suicide attempts, there
may be a need for a longer monitoring period.
Another consideration is that data were not system-
atically collected on the time it required to provide soft-
intensity intervention or higher-level intensity interven-
tions throughout the study, and thus we cannot comment
on the extent of the burden placed on clinical and admin-
istrative management of the research. Future studies are
needed to investigate the extent to which unscheduled
interventions with highly suicidal participants burden re-
searchers.
Crisis 2014; Vol. 35(2):123–131
 130 R. Eynan et al.: Effects of Suicide Ideation Assessments
Overall, our findings provide robust evidence that in a
sample of highly suicidal individuals, inquiring about sui-
cidal ideation rarely increased self-harm and suicide urges
and may have been potentially beneficial. The few partic-
ipants who required some intervention had elevated levels
of suicide ideation and behavior at baseline and almost all
reported symptoms of PTSD. This study reinforces the
notion that research involving high-risk suicidal individu-
als is possible when study protocols are well planned and
executed by trained assessors and clinicians who are able
to identify participants at risk and provide intervention if
necessary.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Acknowledgments
This document is copyrighted by the American Psychological Association or one of its allied publishers.
The research team wishes to offer their thanks to the
Canadian Institutes for Health Research, who generous-
ly supported this research (funding reference number
MOP82835).
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Received July 10, 2012
Revision received July 31, 2013
Accepted August 6, 2013
Published online November 13, 2013
About the authors
Rahel Eynan is an adjunct assistant professor in the Department
of Psychiatry, Schulich School of Medicine & Dentistry, The
University of Western Ontario, London, Ontario Canada.
Yvonne Bergmans is a suicide intervention consultant at the Su-
icide Studies Research Unit at St. Michael’s Hospital. Yvonne is
actively involved in clinical work with suicidal clients, commu-
nity and professional education, and research. She has led the de-
velopment of the Psychosocial/Psychoeducational Intervention
for People with Recurrent Suicide Attempts (P.I.S.A).
Jesmin Antony holds a BHSc from McMaster University and an
MSc from the University of Toronto. She completed her graduate
work with the Arthur Sommer Rotenberg Chair in Suicide Stud-
ies and is currently a research coordinator with the Knowledge
Translation program at St. Michael’s Hospital.
John Cutcliffe is the CEO for Cutcliffe Consulting. He also holds
adjunct professor of nursing positions at the University of Otta-
© 2013 Hogrefe Publishing
131
wa, Canada, the University of Coimbra, Portugal, and the Uni-
versity of Malta.
Henry G. Harder is Professor and Chair of the School of Health
Sciences at the University of Northern British Columbia. He is
a registered psychologist. His research interests are in disability
issues, workplace mental health, suicide prevention, and aborigi-
nal health. He is a Canadian Institutes of Health Research-funded
scholar.
Munazzah Ambreen received her MD from Pakistan and MSc
in Human Genetics from McGill University. She is actively in-
volved in qualitative and quantitative research in mental health
and is affiliated with the Hospital for Sick Children, Toronto, and
the Centre for Addiction and Mental Health (CAMH).
Ken Balderson is the medical director of Acute Mental Health
Services at St. Michael’s Hospital, Toronto, Ontario, Canada, and
is an assistant professor in the Department of Psychiatry, Univer-
sity of Toronto.
Dr. Paul S. Links is a professor and chair of the Department of
Psychiatry, Schulich School of Medicine & Dentistry, The Uni-
versity of Western Ontario. He is also Chief of Psychiatry at
London Health Sciences Centre and St. Joseph’s Health Care,
London, Ontario. Dr. Links was holder of the Arthur Sommer
Rotenberg Chair in Suicide Studies, University of Toronto, for
three terms.
Rahel Eynan
Department of Psychiatry
Schulich School of Medicine & Dentistry
Western University
750 Base Line Road East
Suite 105-7
London, ON N6C 2R5
Canada
Tel. +1 519 685 8500 ext.74914
Fax +1 519 434 6955
E-mail rahel.eynan@lhsc.on.ca
Crisis 2014; Vol. 35(2):123–131