Psychiatry/Behavioral · PANCE / PANRE

Suicidality Assessment

Structured evaluation of suicidal ideation, intent, plan, access to means, and protective factors with safety planning.

Also known as: suicide risk, suicidal ideation, self-harm, suicidality

Overview

A clinical evaluation of risk for self-directed violence — including ideation, intent, plan, behaviors, and the context of risk and protective factors — used to inform disposition, safety planning, and treatment. Suicidality is a clinical phenomenon (not a diagnosis) that spans many psychiatric and medical conditions.

Epidemiology

Suicide is a leading cause of death in US adolescents and young adults; rates rising over the past two decades. Males die by suicide at ~4x the rate of females; females attempt more frequently. Firearm injuries account for ~half of US suicide deaths.

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Risk factors

  • Prior suicide attempt (strongest predictor)
  • Psychiatric disorders: MDD, bipolar, schizophrenia, BPD, PTSD, AUD/SUD
  • Recent psychiatric hospitalization (first weeks after discharge especially)
  • Access to lethal means (firearms, large medication supplies)
  • Male sex, older age, white or Native American race in US data
  • Social isolation, recent loss, financial/legal stress
  • Chronic medical illness, chronic pain
  • Family history of suicide
  • LGBTQ+ youth (minority stress)
  • Active intent, plan, preparation, rehearsal, or non-suicidal self-injury

Pathophysiology

Multifactorial. Diathesis-stress model: trait vulnerability (impulsivity, serotonergic dysregulation, HPA-axis dysfunction) plus acute stressors (psychiatric exacerbation, interpersonal loss, intoxication) converge on transient suicidal crises.

Clinical presentation

Symptoms

  • Direct statements: thoughts of death, wanting to die, plan, intent, preparation
  • Indirect: giving away possessions, saying goodbye, hopelessness, withdrawal
  • Recent behaviors: research about methods, acquiring means, rehearsing
  • Warning signs: increased agitation, sleeplessness, sudden calm after distress (possible decision)

Signs / physical exam

  • Wounds or scars suggesting self-injury
  • Toxidromes from overdose
  • Affect: hopelessness, constriction of thought, anhedonia
  • Validated screens: Columbia Suicide Severity Rating Scale (C-SSRS), Ask Suicide-Screening Questions (ASQ), PHQ-9 item 9

Differential diagnosis

  • Suicidal ideation vs intent — Passive thoughts ('I'd be better off dead') differ from active intent with plan and means; both warrant evaluation
  • Non-suicidal self-injury (NSSI) — Self-injury without suicidal intent — often for affect regulation; still elevates suicide risk longitudinally
  • Homicidal-suicidal ideation — Combined risk; mandatory reporting/duty-to-warn in some jurisdictions
  • Delusional / psychotic motivation — Command hallucinations, religious delusions, severe MDD with psychosis — high risk and often requires inpatient admission
  • Substance-induced ideation — Reassess after intoxication resolves and acute withdrawal managed

Diagnostic workup

Diagnostic criteria

Not a DSM-5-TR diagnosis; assessment focuses on ideation (passive vs active), intent, plan, access to means, preparatory behaviors, attempt history, and balance of risk and protective factors. Use structured instruments (C-SSRS, ASQ) and collateral information; document risk stratification and rationale.

Labs

  • If recent attempt: toxicology, acetaminophen/salicylate level, CBC, CMP, ECG, pregnancy test, blood alcohol
  • Targeted workup for medical contributors (delirium, encephalopathy)

Imaging

  • Head CT if altered mental status or trauma

Diagnostic algorithm

Risk levelIndicatorsDisposition
HighActive intent + plan + means OR recent attempt; psychosis with command AH; severe agitationInpatient admission; means restriction
ModerateActive SI without plan, OR plan without intent; significant risk factorsIntensive outpatient/PHP; safety plan; close follow-up <1 wk
LowPassive ideation; protective factors strongOutpatient with safety plan, means counseling, follow-up
Suicide risk stratification and disposition framework (clinical judgment overrides any single algorithm).

Treatment

First-line

  • Safety planning intervention (Stanley-Brown) — collaborative written plan with warning signs, internal coping, social distractions, people to contact, professional resources, and means restriction
  • Lethal means counseling — particular emphasis on firearm storage (gun lock, off-site storage) and limiting medication supply during high-risk periods
  • Treat underlying psychiatric and medical illness — antidepressants for MDD (monitor for early activation), lithium for bipolar (anti-suicide effect), clozapine for schizophrenia (anti-suicide effect)
  • Hospitalize if active intent with plan and means, recent attempt, inability to maintain safety, command hallucinations, or severe symptoms with limited supports
  • Provide 988 Suicide and Crisis Lifeline and local emergency resources

Second-line / adjunct

  • Cognitive therapy for suicide prevention (CT-SP), dialectical behavior therapy (DBT) for chronic suicidality, collaborative assessment and management of suicidality (CAMS)
  • Caring contacts — brief follow-up communications after ED/inpatient discharge reduce attempts
  • Ketamine/esketamine — rapid (hours to days) reduction in suicidal ideation; bridge while antidepressant takes effect
  • ECT for severe MDD with active suicidality, catatonia, or psychosis

Complications

  • Death by suicide
  • Severe injury, disability from attempts
  • Trauma to family, providers, community
  • Repeat attempts (highest risk in days-weeks after prior attempt)

PANCE pearls

  • Asking about suicide does NOT plant the idea — this is myth. Ask directly and document.
  • First 30 days post-discharge from psychiatric hospitalization are highest-risk — schedule follow-up within 7 days and provide caring contacts.
  • Lethal means counseling is one of the most evidence-based suicide prevention interventions; specifically address firearms and medication storage with patient and family.
  • Lithium and clozapine are the only psychotropics with demonstrated suicide-reduction effects.
  • FDA black box warning: antidepressants increase suicidal ideation in patients <25 in initial weeks — monitor closely but do not withhold treatment for depression.

References

  • VA/DoD 2024 — VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide (2024)
  • Joint Commission NPSG — Joint Commission National Patient Safety Goal 15.01.01: Suicide risk reduction
  • Stanley-Brown SPI — Stanley B, Brown GK. Safety Planning Intervention. Cogn Behav Pract 2012
  • C-SSRS — Posner K et al. The Columbia-Suicide Severity Rating Scale. Am J Psychiatry 2011

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