BACKGROUND: Instruments have been developed to facilitate suicide risk 
assessment. We aimed to evaluate the evidence for these instruments including 
assessment of risk of bias and diagnostic accuracy for suicide and suicide 
attempt.
METHODS: PubMed (NLM), PsycInfo, Embase, Cinahl and the Cochrane Library 
databases were searched until December 2014. We assessed risk of bias with 
QUADAS-2. The average sensitivity and specificity of each instrument was 
estimated and the certainty of the evidence was assessed with GRADE. We 
considered instruments with a sensitivity > 80% and a specificity > 50% to have 
sufficient diagnostic accuracy.
RESULTS: Thirty-five relevant studies were identified but 14 were considered to 
have high risk of bias, leaving 21 studies evaluating altogether 15 risk 
assessment instruments. We could carry out meta-analyses for five instruments. 
For the outcome suicide attempt SAD PERSONS Scale had a sensitivity of 15% (95% 
CI 8-24) and specificity of 97% (96-98), and the Manchester Self-Harm Rule 
(MSHR) a sensitivity of 97% (97-97) and a specificity of 20% (20-21). ReACT, 
which is a modification of MSHR, had a similar low specificity, as did the 
Sodersjukhuset Self Harm Rule. For the outcome suicide, the Beck Hopelessness 
Scale had a sensitivity of 89% (78-95) and specificity of 42% (40-43).
CONCLUSIONS: Most suicide risk assessment instruments were supported by too few 
studies to allow for evaluation of accuracy. Among those that could be 
evaluated, none fulfilled requirements for sufficient diagnostic accuracy.