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 level | Indicators | Disposition |
|---|---|---|
| High | Active intent + plan + means OR recent attempt; psychosis with command AH; severe agitation | Inpatient admission; means restriction |
| Moderate | Active SI without plan, OR plan without intent; significant risk factors | Intensive outpatient/PHP; safety plan; close follow-up <1 wk |
| Low | Passive ideation; protective factors strong | Outpatient with safety plan, means counseling, follow-up |
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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