From Warning Signs to Suicidal Crisis: A Scoping Review of Imminent Suicide Risk Indicators

Introduction: The assessment of imminent suicide risk is critical for informing timely and effective clinical interventions. However, most suicide risk assessment tools focus on self-reported suicidal ideation - which is not always disclosed - and long-term risk factors. While these factors reflect a general vulnerability to suicide over the lifespan, they are often insufficient for identifying acute periods of heightened risk. On the other hand, warning signs may signal the onset of a suicidal crisis, a state characterized by rapidly escalating psychological distress and an increased likelihood of suicidal behavior. Despite their clinical relevance, indicators of imminent suicide risk lack a shared definition and clearly defined temporal boundaries in the literature. The aim of this scoping review was to: 1) synthesize current knowledge on warning signs for suicide, 2) examine their relationship with the concept of suicidal crisis. Methods: A search was conducted in Scopus, PubMed, and PsycInfo databases using keywords related to acute suicide risk to identify relevant studies. Studies of any design (quantitative, qualitative, mixed-methods, and reviews) investigating indicators of imminent suicide risk were included. Only English-language publications were considered, and no date restrictions were applied. Results: 1) A comprehensive list of warning signs was synthesized from the included studies, spanning cognitive, emotional, verbal, and behavioral domains. Many of these signs can be directly observed by others (e.g. verbalizations about death, agitation, irritability, apathy, and reckless or preparatory behaviors) underscoring the importance of integrating observed or reported behavioral manifestations into clinical suicide risk assessments. 2) Several warning signs were found to overlap with symptoms commonly proposed in the clinical characterization of suicidal crises, including hyperarousal, hopelessness, and social withdrawal. The literature supports the suicidal crisis as an acute, time-limited condition that can escalate within days or even hours. Discussion: The findings of this review have significant clinical implications, particularly to improve the assessment of imminent suicide risk. The proposed list of warning signs aims to assist mental health professionals in conducting more accurate evaluations. Moreover, current research on the suicidal crisis underscores the need for the introduction of a suicide-specific diagnostic category within mental disorder classification systems.