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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Question 1PsychiatryMedium
A 16-year-old boy is brought to the emergency department after his mother read a post in which he wrote that he intends to end his life tonight. He describes when and how he would do it, and the family keeps an unlocked shotgun in the home. His girlfriend ended their relationship last month, his grades have fallen sharply this term, and his mother has bipolar disorder. He is alert and cooperative, and vital signs are normal. Which of the following is the strongest acute suicide risk factor?
  • AA breakup with a partner last month
  • BFamily history of mood disorder
  • CA detailed plan with lethal means
  • DRecent decline in academic grades
Reveal answer & full explanation
Correct answer: C — A detailed plan with lethal means
  • AA breakup with a partner last month
  • BFamily history of mood disorder
  • CA detailed plan with lethal means
  • DRecent decline in academic grades

Why A detailed plan with lethal means is correct

  • A defined plan, stated intent, and immediate access to a firearm constitute the highest-acuity risk profile.
  • Firearm access sharply raises lethality and case fatality, compressing the window for intervention.
  • This combination mandates emergency psychiatric evaluation and means restriction now.

Why the others are wrong

  • Family history of mood disorder — a parent with bipolar disorder raises lifetime risk but is a static factor that does not set tonight's acuity; this is the chronic-versus-acute trap.
  • A breakup with a partner last month — relationship loss is a precipitant but far weaker than active plan plus means; this is the stressor-over-lethality trap.
  • Recent decline in academic grades — falling grades may signal distress but do not equal imminent risk; this is the warning-sign minimization trap.
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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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