Suicide factors: UNSAFE or SAFER?
The presence of disorder-specific risk and protective factors for suicide must be identified during suicide risk assessment
The basic function of a suicide assessment is to identify fixed and modifiable risk factors for suicide and existing or amendable protective factors.1 Epidemiologic studies have defined a range of suicide risk and protective factors for the general population.2 Other research has delineated suicide risk and protective factors for individuals with specific psychiatric disorders.3 The presence of disorder-specific risk and protective factors for suicide must be identified during suicide risk assessment.
Lack of support from family, peers, or the community is a critical concern. Noncompliance with treatment may be associated with onset of suicidality. Help-seeking is impeded by stigma associated with suicide and shame for past attempts. History of physical, sexual, or psychological abuse is tied to subsequent suicidal behavior. Alcohol abuse plays a role in suicide. Many patients who attempt suicide have backgrounds involving suicide loss or attempts by family members. Recurring psychiatric symptoms—particularly depression, anxiety, and panic—can trigger suicidality. Symptom relapse may lead to hospitalization, which is followed by a high-risk period after discharge.
These suicide risk factors can be summarized by the mnemonic UNSAFE:
Unconnected—no support; sense of not belonging or being a burden
Nonadherence—unmanaged mental illness or co-occurring disorders
Stigma/shame related to past attempts or suicidal behavior
Abuse history and/or alcohol misuse; prior attempt
Family history of suicide or suicide attempts
Exacerbations—worsened mental illness, hospitalizations
The presence of a personal crisis or safety self-help plan shows patient insight. Maintaining prescribed treatment indicates a patient’s likelihood of complying with clinical and self-care measures to avert future suicidality. Accessible support from family, peers, and the community demonstrates social integration. The recovery concept promotes these factors as well as wellness and resilience. Awareness of the warning signs of suicide and personal risk factors and precipitants is essential for self-help and help-seeking.
Protective factors for suicide can be summarized by the mnemonic SAFER:
Self-help skills, personal crisis/suicide prevention plan
Adherence to treatment plan
Family and community support
Education about risk factors, warning signs, and triggers for suicide
Recovery and resilience
In our emergency psychiatric facility the UNSAFE and SAFE mnemonics are posted next to the desk of the on-duty psychiatrist. Crisis center staff use these mnemonics to screen patients during psychiatric evaluations. Allied therapists use them during in-patient psychoeducation about suicidality. Peer specialists use them to help patients prepare personal safety plans.
The authors report no financial relationship with any company whose products are mentioned in this article or with manufactures of competing products.
These mnemonics were developed by Tony Salvatore in consultation with Rocio Nell, MD, CPE.
1. Simon R, Shuman DW. The standard of care in suicide risk assessment: an elusive concept. CNS Spectr. 2006;11(6):442-445.
2. Goldsmith SK, Pellmar TC, Kleinman AM, et al. eds. Reducing suicide: a national imperative. Washington, DC: The National Academies Press; 2002.
3. Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry. 1997;170(3):205-228.