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.
Try two board-style Suicidality Assessment questions
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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?
AMale sex and adolescent age
BA detailed plan with lethal means
CFamily history of mood disorder
DA breakup with a partner last month
ERecent decline in academic grades
Reveal answer & full explanation
Correct answer: B — A detailed plan with lethal means
AMale sex and adolescent age
BA detailed plan with lethal means✓
CFamily history of mood disorder
DA breakup with a partner last month
ERecent 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.
Male sex and adolescent age — adolescent boys die by suicide at higher rates than girls, largely through more lethal methods, but sex and age are fixed demographic factors that do not set tonight's acuity; this is the demographic-over-lethality trap.
Question 2PsychiatryMedium
A 52-year-old man with major depressive disorder says he sometimes wishes he would not wake up in the morning. He denies a specific method or timeline. He has lived alone since his divorce 6 months ago and drinks 4 beers most evenings. He is calm, cooperative, and agrees to return in 1 week. Which additional history finding would most strongly indicate high near-term risk for suicide?
AHe lost his father to suicide when he was a teenager
BHe gave away his fishing boat and rewrote his will last week
CHe believes his adult children would be better off without him
DHe states that life has felt not worth living for months
EHe has been sleeping only 3 hours a night for the past month
Reveal answer & full explanation
Correct answer: B — He gave away his fishing boat and rewrote his will last week
AHe lost his father to suicide when he was a teenager
BHe gave away his fishing boat and rewrote his will last week✓
CHe believes his adult children would be better off without him
DHe states that life has felt not worth living for months
EHe has been sleeping only 3 hours a night for the past month
Why He gave away his fishing boat and rewrote his will last week is correct
Suicide risk stratification by interview follows a hierarchy: passive death wish, active ideation, ideation with a method, ideation with plan and intent, and finally preparatory behavior.
Preparatory acts - putting affairs in order, giving away valued possessions, writing a note, rehearsing, or acquiring means - mark the transition from thought to action and are the most alarming historical finding in a patient who otherwise looks calm.
Apparent calm after such acts can reflect the relief of having decided rather than clinical improvement, which is why the clinician must ask about them explicitly rather than rely on affect.
He gave away his fishing boat and rewrote his will last week — preparatory behavior, the strongest near-term signal here, and it mandates same-day risk management with means restriction and consideration of a higher level of care.
Why the others are wrong
He states that life has felt not worth living for months — a passive death wish, the lowest rung of the hierarchy and chronic rather than acute.
He has been sleeping only 3 hours a night for the past month — severe insomnia, a genuine and modifiable acute risk factor, but one that raises risk broadly rather than signaling imminent action.
He believes his adult children would be better off without him — perceived burdensomeness, an interpersonal-theory risk factor that predicts ideation more than imminent behavior.
He lost his father to suicide when he was a teenager — a family history of suicide is a genuine static risk factor that raises lifetime risk, but it is fixed and remote in time and cannot signal the imminent transition from thought to action that preparatory behavior does.
His male sex, recent divorce, social isolation, and nightly alcohol use raise baseline risk, which is exactly why the preparatory finding is decisive. Joint Commission and SAMHSA guidance direct clinicians to ask directly about ideation, plan, intent, preparatory acts, and access to lethal means at every risk assessment.
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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; use an involuntary hold if a patient at imminent risk refuses admission. Chronic suicidal ideation (e.g., BPD) is usually managed outpatient with DBT, but an acute-on-chronic crisis such as a recent medically serious attempt typically warrants brief admission
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)
IV ketamine (off-label) — rapid, short-term reduction in suicidal ideation in MDD (VA/DoD 2024); esketamine nasal spray is approved to treat depressive symptoms in adults with MDD with acute suicidal ideation or behavior, but it has not been shown to reduce suicidal ideation or prevent suicide and does not replace hospitalization
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.
A positive suicide screen, even for passive ideation only, calls for a brief suicide safety assessment by a trained clinician during the same visit, with safety planning and close follow-up (NIMH ASQ pathway); routine follow-up weeks later undertriages risk.
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 or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.