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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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.
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
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)
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)
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants.