1. Introduction
Suicide is a widespread and serious public health problem, with important consequences for individuals, families, and society. According to the World Health Organization, more than 700,000 people die by suicide every year globally [
1]. The mental health care services play a central role in preventing suicide [
2]. In Norway, in the period 1970 to 1990, the risk of suicide doubled and then fell again. The increase was most dramatic for young men in the age group 15–24 years. In 2023, the suicide rate was 12.9 per 100,000 inhabitants, 21 percent lower than in 1990. There has been a slight but significant increase in age-standardized suicide rates between 2010 and 2019 [
3]. Suicide methods have changed over time. Among men, hanging and suffocation are the most common methods, and poisoning is among women [
3,
4]. The prevalence of suicide is fairly similar in Norway, Sweden, and Denmark (around 11 per 100,000), but Finland still has a significantly higher prevalence than the other Nordic countries (almost 20 per 100,000). The incidence of suicide in Norway is somewhat higher than in Europe. Deaths by suicide in the EU have decreased by 13% in a decade [
5]. Cultural factors may also play a role in suicide rates, and the indigenous Sami population has had a higher suicide rate than the rest of the Norwegian population, possibly linked to the Sami people’s struggle to preserve their culture, loss of identity, and a social contagion effect [
6].
There is an ongoing debate about the health workers’ role and the utility of suicide screening (brief procedures to identify who might be at risk), suicide risk assessment (more in-depth assessments of the nature and severity of risk), and suicide prevention [
7,
8]. According to current recommendations and guidelines, health workers should implement screening procedures involving standardized tools in order to map their patients’ risk of suicide [
9]. A standardized procedure for suicide risk assessment would also involve a standardized tool and include elements such as taking the patient’s prior medical history, assessing the patient’s current mental status, and focusing on risk factors, including prior attempts and substance abuse [
10,
11].
There are some guidelines that recommend suicide risk assessments, including those from the National Institute for Health and Care Excellence (NICE) [
12], the European Psychiatric Association (EPA) [
13], the American Psychiatric Association (APA) [
14], and the Norwegian Directorate of Health [
15]. The NICE guidelines and the EPA guidelines recommend performing suicide risk assessments with caution and emphasize that it is difficult to predict suicides [
12,
13]. The guidelines from the APA suggest that the goal of the suicide risk assessment is to estimate an overall level of suicide risk [
14]. The aim of the Norwegian guidelines has been to prevent suicides through standardized and frequent suicide risk assessments by mental health practitioners [
15].
The target for the EPA is to halve the number of suicides in the next 5 years by preventing, detecting early, and treating completely psychiatric disorders—depression in particular [
16]. The APA recommends early contacts with providers, effective mental health care, easy access to a variety of clinical interventions, connections to individuals, family, community, and social institutions, and a strong sense of cultural identity [
17]. The NICE guidelines present five quality statements covering multi-agency suicide prevention partnerships to reduce access to methods of suicide, a local media plan that identifies how they will encourage journalists and editors to follow best practices, involving family, carers, or friends, and bereaved or affected individuals are given information and offered tailored support [
18].
Some have been critical of the ‘one size fits all’ approach that they believe such guidelines represent [
19]. One point that is made is that the guidelines recommend standardized suicide risk assessments that are excessively biomedically oriented and that do not sufficiently take contextual, psychosocial, and individual factors into consideration [
20]. Some propose a fundamentally different approach and suggest dropping standardized risk assessment procedures altogether and instead highlighting genuine and empathetic listening, the expression of compassion, and embedding the exploration of risk factors and protective factors in the interaction [
21].
Cohen et al. [
22] surveyed 90 health workers and found that few relied on standardized risk measures. They also found that the health workers did not know how to improve suicide risk assessment. A recent review found that doctors who believe that suicide can be prevented more frequently perform screenings and thorough risk assessments [
23].
According to a study by Espeland et al. [
7], health workers thought that the emphasis on standardized suicide risk assessment compromised other aspects of suicide prevention, including the therapeutic relationship. A Swedish study found that social workers emphasized relationships, past experiences, and professional discretion when working with suicidal clients [
24]. Similarly, a Canadian phenomenological study involving psychologists found that the clinicians emphasized the importance of clinical intuition in this context [
25].
Thus, it can be difficult to predict suicide, and this uncertainty can be a challenge for health workers. Previous research suggests that working with suicidal patients can be anxiety-provoking [
25,
26].
Understanding health workers’ perspectives is important for understanding how clinicians think about this topic and their attitudes toward and adherence to current guidelines. These findings can also have implications for future directions in guideline development and suicide-prevention policy. Still, very few studies have investigated health workers’ opinions of suicide risk assessments. Prior research on factors of general importance to attitudes of clinicians in mental health care has suggested that gender, profession, experience, and workplace are factors that can be relevant [
27,
28], but there is a gap in the literature that addresses these factors with respect to attitudes toward suicide risk assessment in Norway. The aim of the present study is to investigate the health workers’ perceptions and attitudes toward suicide risk assessments.
3. Results
Table 2 displays the mean scores and median scores of the responses to all 18 questions. Analyses of age group and years of clinical experience showed no significant differences on any of the questionnaire items and are therefore not reported in detail. The highest agreement with the questionnaire statements was found for the item ‘It is important to identify risk factors for suicide (e.g., prior attempts and substance abuse)’, with a mean score of 3.78, followed by the item ‘Most suicides can be prevented’, which had a mean score of 3.71. There was also very high overall agreement with the statements ‘There is no certain way to find out who will commit suicide’ (mean score 3.63), ‘Even if you know who will commit suicide, it is impossible to know when it will occur’ (mean score 3.62), and ‘National guidelines for suicide prevention in mental health care have received criticism for relying too heavily on suicide risk assessments. This critique is warranted.’ (mean score 3.40).
The respondents were most critical of the following statements: ‘Talking with patients about suicide ideation can increase the risk of suicide’ (mean score 1.24) and ‘For suicide risk assessment, it is sufficient to ask the patient about suicide thoughts or plans’ (mean score 1.66).
The Friedman test revealed that the questions about national guidelines, utility of risk factors, and prevention of suicide had significantly higher scores than the other questions,
X2 (17) = 890.0,
p = 0.001. A pairwise comparison with adjusted p-values found that the item regarding national guidelines (item 14,
Table 2) was significantly higher than the item regarding the utility of risk factors (item 4,
Table 2) (
p = 0.02,
r = 0.020) and the item regarding the prevention of suicide (item 3,
Table 2) (
p = 0.017,
r = 0.018).
Table 3 highlights the differences in responses between the participants of different professions with respect to their opinions about the Norwegian guidelines. To the item ‘The national guidelines for suicide prevention in mental health care have received criticism for relying too heavily on suicide risk assessments. This critique is warranted.’ (Item 14,
Table 2), doctors were most in agreement (mean score 3.67), followed by psychologists (mean score 3.57), nurses (mean score 3.15), and social workers (mean score 2.97). The Kruskal–Wallis test revealed a significant difference between the different professions on this question regarding their perception of the Norwegian guidelines (H (3) = 29.48,
p = 0.001). A pairwise comparison with adjusted p-values showed a significant difference between social workers and psychologists (
p = 0.001,
r = 0.46) and between social workers and doctors (
p = 0.001,
r = 0.49).
Table 4 demonstrates the relationship between the respondents’ workplace and how they perceived the Norwegian guidelines on suicide prevention. Respondents from the University Hospital of North Norway were most critical (mean score 3.54), followed by respondents from Innlandet Hospital Trust (mean score 3.44) and Helgeland Hospital (mean score 2.96). The Kruskal–Wallis test showed a significant difference between perception of the Norwegian guidelines at the different hospitals (H (2) = 18.14,
p = 0.001). A pairwise comparison with adjusted p-values showed a significant difference between Helgeland Hospital and Innlandet Hospital Trust (
p = 0.001,
r = 0.33) and between University Hospital of North-Norway and Helgeland Hospital (
p = 0.001,
r = 0.43).
Table 5 highlights differences in perceptions regarding risk factors for suicide at different hospitals, with respondents at Innlandet Hospital Trust most in agreement (mean score 3.82) with the idea that it is important to identify risk factors, followed by respondents working at the University Hospital of North Norway (mean score 3.79), and lastly those working at Helgeland Hospital (mean score 3.63). These differences were statistically significant (H (2) = 8.28,
p = 0.016).
Table 6 shows how respondents at the different workplaces perceived standardized questions. Those working at Innlandet Hospital Trust were most negative (mean score 3.17), followed by respondents from the University Hospital of North Norway (mean score 2.91) and Helgeland Hospital (mean score 2.63). The differences were statistically significant (H (2) = 7.93,
p = 0.019).
4. Discussion
The aim of the present survey was to investigate health workers’ perceptions of suicide risk assessments. We found that health workers in general perceived the criticism of the Norwegian guidelines (from 2008) for suicide prevention as warranted (i.e., these guidelines rely too heavily on standardized suicide risk assessments). This is in agreement with previous studies [
7,
22]. However, it should be noted that the guidelines have very recently been updated [
30] and that the most recent version, to a larger extent, emphasizes the importance of treatment and prevention. It is still emphasized that clinicians should assess suicide risk but do so in the context of treatment and individual needs [
30].
Our respondents generally viewed suicide as partly preventable and considered risk factors clinically meaningful, which is in line with previous research [
31]. There seems to be an agreement that suicide can be prevented and that risk factors are relevant. However, the clinical utility of risk factors and prevention at an individual level is debated [
32].
In our study, the respondents working at Innlandet Hospital Trust were significantly less skeptical of the Norwegian guidelines compared to the respondents at the other hospitals. Psychologists and doctors were also significantly more skeptical of the guidelines than other professions. In addition, we also found that there were significant differences between hospitals regarding the utility of detecting risk factors and that standardized questions can affect listening skills.
These significant differences can be attributed to several likely explanations. First, there may be cultural differences between hospitals and also between professions. Such cultural differences between hospitals and professions have also been identified in other domains, for instance, regarding attitudes toward coercion [
27]. The professional environment may affect health workers’ attitudes toward suicide risk assessments. This could be due to ‘social proof’ [
33], i.e., that health workers tend to use other health workers as a reference for their behavior and attitudes. For instance, if a majority of the health workers perceive standardized suicide risk assessment as useful, this may affect their colleagues in the same direction.
Second, there may be differences in training, and psychologists and doctors rely more on the therapeutic relationship with the patient and are less focused on standardized procedures. Psychologists and doctors may rely more on their ‘clinical intuition’. Several studies have found that psychologists emphasized clinical intuition when working with suicide assessments [
25,
34].
Some health workers seem to perceive standardized suicide risk assessments as too mechanical and may underestimate the patients’ individual needs. In addition, some health workers view standardized suicide risk assessment as a form of self-protection, i.e., allowing the clinician to ‘hide behind’ or reduce their own anxiety about making mistakes by relying on standardized procedures [
34]. Consequently, the critics of standardized suicide risk assessments recommend a ‘relational approach’ to suicide prevention [
7]. Within the context of a psychiatric setting, a relational approach may rely on psychodynamic psychotherapy, focusing on experience, meaning, context, and issues such as attachment patterns, relational difficulties, and transference [
35,
36].
According to recommendations from NICE [
12], a suicide risk assessment should not be used to predict future suicide or to determine the need for treatment or who should be discharged. Rather, it is recommended to use the assessment to focus on the patient’s needs and identify how to assist their psychological and physiological safety [
12].
Current evidence suggests that suicide prevention and suicide risk assessment are highly complex tasks, involving a variety of quantitative and qualitative factors [
37]. This complexity must be considered when attempting to prevent and assess suicide risk. The optimal suicide risk assessment strategy is still uncertain [
38].
4.1. Future Perspectives, Practice, and Policy Implications
The new guidelines that have been developed in Norway should be carefully evaluated to study whether they improve the detection rate and possible prevention of suicides. Clinicians and leadership should place more emphasis on giving appropriate treatment and less on avoiding criticism from the authorities.
Future studies should investigate each profession with a larger sample and further explore health workers’ concerns about standardized suicide risk assessments, drawing on different methodologies. It would also be interesting to investigate alternatives to standardized suicide risk assessments.
4.2. Limitations
The present study has some limitations that need to be addressed. One limitation is that there may be a ‘selection bias’ in our sample, i.e., health workers who favor suicide prevention and suicide risk assessments may be most motivated to answer the survey, including possible social desirability bias. Another shortcoming is that we do not have information about the response rate, i.e., the exact number of health workers who declined participation. The electronic survey we applied could not provide us with this information, and we have also relied on a relatively small and heterogeneous sample. Unfortunately, the questionnaire and the measures we used were not validated. We were not able to control for confounding variables such as prior exposure to patient suicide, years of post-graduate training, and departmental policies. Nor did we obtain any information about the potential influence of personal experiences, personality traits, or cultural factors, which may influence attitudes. We also acknowledge that the findings are exploratory and hypothesis-generating, rather than confirming stable attitudinal patterns. Future research would benefit from drawing on a mixed-methods approach in order to obtain more in-depth information about factors that influence attitudes.