Eduovisual
Behavioral Health
Suicide risk assessment and safety planning
— Suicide is a top-10 cause of death in the US; rates highest in middle-aged and elderly white men, AI/AN populations, and adolescents/young adults
— Firearms account for ~50% of completed suicides; lethal means access is the single most modifiable risk factor
— ~45% of completed suicides saw a primary care provider within 1 month of death — screening in PCP and ED settings is high-yield
— Any new or worsening depression, bipolar depression, schizophrenia, PTSD, borderline personality disorder, anorexia, or substance use disorder
— Recent psychiatric hospitalization (highest risk in first 30–90 days post-discharge)
— Acute psychosocial losses: job, relationship, legal trouble, financial crisis, recent humiliation
— Chronic pain, terminal illness, TBI, Huntington disease, MS
— New SSRI start in patients <25 (FDA black box for suicidal ideation, not completions)
— PHQ-9 item 9 as universal screen in primary care (USPSTF: screen all adults and adolescents 12+ for depression with systems to ensure follow-up)
— Positive screen → administer Columbia Suicide Severity Rating Scale (C-SSRS) or ASQ (Ask Suicide-Screening Questions) for stratification
— Screen separates ideation (passive vs active), intent, plan, and preparatory behavior
— Step 3 vignettes commonly test the outpatient clinician's next step after a positive PHQ-9, the ED disposition decision, and post-discharge follow-up cadence
— Expect questions on lethal means counseling, safety planning vs no-suicide contracts, and involuntary hold criteria
Step 3 management: Asking directly about suicide does not increase risk — this myth is a frequent distractor. Every positive depression screen requires a direct, specific suicide inquiry documented in the note, followed by structured risk stratification before disposition.
— "I want to die," "Everyone would be better off without me," "I won't be here much longer"
— Passive ideation ("I wish I wouldn't wake up") still requires full assessment — can escalate
— Indirect: giving away possessions, sudden goodbyes, finalizing wills, unexplained calm after prolonged depression (ominous — may indicate decision made)
— Sex (male — higher completion), Age (<19 or >45), Depression
— Previous attempt (strongest single predictor — 5–6× risk), Ethanol/substance use, Rational thought loss (psychosis), Social supports lacking, Organized plan, No spouse, Sickness
— Ideation: frequency, duration, controllability, passive vs active
— Plan: method, specificity, lethality, rehearsal
— Intent: subjective ("Do you intend to act?") and behavioral (preparatory acts)
— Access to means: firearms in home (ask explicitly), stockpiled medications, ropes, high places
— Prior attempts: method, lethality, medical consequences, rescue circumstances, ambivalence, regret about surviving
— Protective factors: children at home, religious objection, future-oriented plans, therapeutic alliance, sobriety
— With patient consent ideally, but HIPAA permits gathering (not disclosing) collateral in emergencies
— Speak to family/partner about firearm access, medication stockpiling, recent behavior changes
Board pearl: A patient who downplays prior attempts ("It wasn't really serious") but had medically severe consequences or took precautions against discovery is at higher, not lower, risk. Lethality of prior attempt + low rescue probability = high future risk, regardless of stated intent.
Key distinction: Non-suicidal self-injury (NSSI) — cutting, burning for affect regulation, no intent to die — is distinct from suicide attempt, but NSSI patients still have elevated long-term suicide risk and require assessment.
— Disheveled grooming, poor eye contact, psychomotor retardation (severe depression) vs agitation (mixed states, akathisia — akathisia is independently linked to suicide)
— Look for self-inflicted wounds (wrists, forearms, thighs), ligature marks, healed scars suggesting prior NSSI or attempts
— Intoxication signs: alcohol on breath, pupillary changes, ataxia — acute intoxication markedly raises near-term risk and impairs assessment reliability
— Hopelessness is the single cognitive predictor most strongly correlated with completed suicide — assess with Beck Hopelessness Scale concepts: "Can you imagine things getting better?"
— Anhedonia, anergia, guilt, worthlessness
— Watch for sudden brightening after persistent depression — may signal resolved ambivalence after deciding to act
— Command auditory hallucinations to harm self (schizophrenia, severe MDD with psychotic features) — high acuity
— Delusions of guilt, poverty, nihilism (Cotard) — elevate risk
— Ruminative, constricted thinking; inability to generate alternatives ("tunnel vision")
— Assess for delirium or dementia that could impair safety judgment
— Insight into illness and willingness to engage in treatment is itself a protective factor
— Vitals (overdose, hemodynamic compromise)
— Skin survey for wounds; neck for ligature; abdomen for ingestion tenderness
— Toxicology screen, acetaminophen/salicylate levels, ethanol, EKG (QTc — affects antidepressant choice and screens for TCA ingestion)
CCS pearl: On CCS, a suicidal patient in the ED requires immediate orders for 1:1 sitter, search/removal of belongings (belts, shoelaces, sharps), and toxicology workup before disposition decisions. Document MSE explicitly — risk stratification without MSE is incomplete.
— CBC, BMP — baseline, electrolyte derangements from ingestion or self-neglect
— LFTs — acetaminophen toxicity, chronic alcohol use
— Acetaminophen and salicylate levels in ALL intentional overdoses (occult co-ingestion is common and treatable; measure at 4 hours post-ingestion for APAP, plot on Rumack-Matthew nomogram)
— Urine drug screen (limitations: doesn't detect synthetic opioids, GHB, many benzodiazepines)
— Ethanol level — quantify, do not just qualitative
— Urine pregnancy (β-hCG) in females of reproductive age — affects pharmacology and disposition
— TSH — hypo/hyperthyroidism mimicking depression
— EKG — QTc baseline, TCA ingestion (wide QRS, terminal R in aVR), citalopram overdose
— Lithium level if on lithium — therapeutic window narrow, overdose common
— VPA, carbamazepine, digoxin, TCA levels as indicated
— Carboxyhemoglobin if suspected CO inhalation (suicide in enclosed space, vehicle exhaust)
— ABG/VBG with anion gap — toxic alcohols, salicylates, metformin
— CK, myoglobin, UA — rhabdomyolysis after prolonged down-time
— CT head if AMS, anticoagulated, fall, head trauma, suspected TBI in attempt
— CT chest/abdomen for ingestion of caustics, foreign bodies, button batteries (peds)
— CXR for aspiration after ingestion or hanging attempts
— Capacity is decision-specific and time-specific — a patient may lack capacity to refuse psychiatric admission but retain capacity for other choices
— Document the four elements: communicate choice, understand information, appreciate situation, reason about options
Board pearl: Always check acetaminophen level regardless of stated ingestion — APAP is the most common occult co-ingestant, is clinically silent for 24–48 hours, and N-acetylcysteine is highly effective if started within 8 hours. Missing this is a classic Step 3 error and a real-world cause of preventable death.
— Modern practice (per VA/DoD, Joint Commission, Zero Suicide framework) replaces rigid scales with a structured clinical judgment that integrates static and dynamic factors
— Static (chronic) risk: prior attempts, family history of suicide, chronic psychiatric illness, history of trauma/abuse, chronic medical illness, male sex
— Dynamic (acute) risk: current ideation/intent/plan, hopelessness, recent loss, intoxication, insomnia, agitation, access to means, recent discharge
— Protective factors: treatment engagement, social support, dependents, religious belief, future orientation, problem-solving ability
— High acute risk: ideation + plan + intent + means + impaired judgment → inpatient psychiatric admission (voluntary preferred; involuntary if refuses and meets criteria)
— Intermediate acute risk: active ideation without specific plan/intent, with concerning dynamic factors → intensive outpatient, partial hospitalization, or admission case-by-case; mandatory safety planning, means restriction, 24–72 hr follow-up
— Low acute risk: passive ideation, no plan/intent, robust protective factors → outpatient management with safety plan, lethal means counseling, close follow-up
— Specific ideation/plan/intent description, risk and protective factors, formulation ("In summary, this patient is at intermediate acute / chronic high risk because…"), disposition rationale, safety plan, follow-up
— No-suicide "contracts" are not evidence-based and do not reduce risk or provide legal protection — replaced by Stanley-Brown Safety Planning Intervention
— No tool reliably predicts individual suicide; the goal is risk reduction, not prediction
— Even high-risk patients on inpatient units complete suicide — vigilance is continuous
Key distinction: Risk assessment is the snapshot stratification; safety planning is the active intervention. Both are required at every encounter where suicidal ideation is identified — Step 3 stems may offer "obtained safety plan" without assessment, or vice versa, as wrong answers.
— Remove access to means in the assessment environment: belts, shoelaces, sharps, plastic bags, cords
— 1:1 continuous observation for any patient with active suicidal ideation in ED
— Treat acute medical issues (overdose, trauma) first; medical clearance before psychiatric disposition
— Inpatient psychiatric admission indicated for:
— Active intent or plan with means
— Recent attempt with ongoing intent or severe lethality
— Command hallucinations to self-harm
— Severe depression with psychosis or catatonia
— Inability to maintain safety as outpatient (no support, intoxication, severe agitation)
— Voluntary admission preferred — preserves alliance, autonomy
— Involuntary hold (varies by state — e.g., 72-hour 5150 in CA, 2PC in NY) when patient meets criteria (danger to self/others due to mental illness) and refuses voluntary care
— Stanley-Brown Safety Plan completed collaboratively (see chunk 7 detail)
— Lethal means counseling — specific firearm and medication restriction
— Follow-up within 24–72 hours (phone or in-person)
— Crisis resources: 988 Suicide & Crisis Lifeline, Crisis Text Line, local mobile crisis
— Engage family/support person with patient consent
— Treat underlying disorder (MDD, bipolar, SUD, psychosis)
— Consider augmentation: lithium (anti-suicide effect in mood disorders), clozapine (FDA-approved for schizophrenia suicide reduction), ketamine for acute ideation
Step 3 management: The single most evidence-based intervention to reduce suicide death is means restriction, particularly firearm access. A patient discharged with active depression and a firearm at home is high-risk regardless of safety plan completion — counsel for off-site storage (relative, gun shop, police), gun locks, or voluntary surrender. Document the counseling and the patient's plan.
— 1. Warning signs: personal triggers, thoughts, situations that precede crisis
— 2. Internal coping strategies: distraction, exercise, music — without contacting others
— 3. Social contacts and settings for distraction (not necessarily disclosing crisis)
— 4. People to contact for help: family/friends who know and can support
— 5. Professionals and agencies: therapist, psychiatrist, 988, ED
— 6. Means restriction plan: specific, written, named third party for firearms/meds
— Co-created with patient, written legibly, copy to patient, copy in chart, share with family if consented
— Lithium — reduces suicide and all-cause mortality in bipolar disorder and recurrent MDD; strongest anti-suicide evidence of any psychotropic; target 0.6–1.0 mEq/L; monitor TSH, Cr, levels
— Clozapine — FDA-approved to reduce suicidality in schizophrenia/schizoaffective disorder; requires ANC monitoring (REMS program)
— Ketamine/esketamine (Spravato) — rapid reduction of suicidal ideation within hours; intranasal esketamine FDA-approved for MDD with acute suicidality; observe 2 hours post-dose (sedation, BP, dissociation)
— ECT — fastest definitive treatment for severe depression with active suicidality, catatonia, psychotic depression; works within 1–2 weeks
— FDA black box: increased suicidal ideation (not completion) in patients <25, particularly first 4 weeks
— Do not withhold SSRI in young adult with MDD — untreated depression carries higher suicide risk; instead, monitor closely (weekly × 4 weeks, then biweekly)
— Avoid abrupt discontinuation; favor sertraline, fluoxetine, escitalopram for safety in overdose
— Avoid TCAs and MAOIs as first-line in suicidal patients — lethal in overdose
Board pearl: Among antidepressants, TCAs cause the most overdose deaths per prescription. If a TCA is needed, dispense in limited 1-week supplies to a suicidal patient and avoid amitriptyline/doxepin (highest lethality). SSRIs are far safer in overdose.
— Firearms (50% of US suicide deaths, 85% case fatality):
— Ask: "Are there firearms in the home or accessible to you?"
— Options in order of effectiveness: temporary off-site storage with trusted party, gun shop/range storage, law enforcement hold, voluntary disposal, in-home locking with ammunition stored separately
— Extreme Risk Protection Orders (ERPOs/red flag laws) — available in many states; allow temporary firearm removal via court order; physicians may petition in some states
— Medications:
— Limit dispensing quantities; blister packs; lock boxes
— Remove TCAs, opioids, benzodiazepines, acetaminophen stockpiles
— Family member dispenses daily doses
— Other means: secure ropes/cords, address access to bridges/heights, vehicle exhaust prevention
— 988 Suicide & Crisis Lifeline — universal US number, 24/7, with chat and text
— Mobile crisis teams — co-response with mental health professionals (not police-only)
— Crisis stabilization units / 23-hour observation — alternative to inpatient for intermediate-risk patients
— Partial hospitalization / intensive outpatient (PHP/IOP) — step-down or step-up
— Environmental: ligature-resistant fixtures, breakaway shower rods, weighted/anchored furniture, tamper-resistant outlets, no plastic bags
— Q15-minute checks at minimum; 1:1 for highest acuity
— Contraband searches on admission and after visits
— Highest inpatient suicide risk: bathrooms, bedrooms during shift change, weekend nights, time of pass/discharge
— Cognitive Therapy for Suicide Prevention (CT-SP) — 50% reduction in repeat attempts
— Dialectical Behavior Therapy (DBT) — borderline personality with self-harm
— CAMS (Collaborative Assessment and Management of Suicidality)
CCS pearl: On CCS, for a discharged ED patient with passive ideation and no plan, the order set should include: "safety plan completed and given to patient," "lethal means counseling documented," "follow-up scheduled within 48–72 hours," "988 number provided," and "outpatient psychiatry referral." Missing any of these can lower the score.
— Highest completion rates in US: men ≥75 (suicide rate 3–4× general population)
— More planning, more lethal means (firearms predominate), fewer prior attempts, fewer warnings
— Often present with physical complaints, not psychiatric — somatic depression, insomnia, weight loss
— Underdiagnosed because primary care visits focus on medical comorbidities
— Recent widowhood (highest risk in first year, particularly widowers)
— Functional decline, loss of independence, fall, new diagnosis of dementia or terminal illness
— Chronic pain (back, headache, GI)
— Social isolation, financial strain
— Polypharmacy, alcohol use, sedative-hypnotics
— Hopelessness more predictive than depression severity in elderly
— Use Geriatric Depression Scale (GDS) rather than PHQ-9 (validated for older adults, less somatic-item burden)
— SSRIs first-line: sertraline, escitalopram preferred; start low (12.5–25 mg sertraline), titrate slow
— Avoid paroxetine (anticholinergic), citalopram >20 mg (QTc), TCAs, benzodiazepines (falls, delirium)
— Monitor for SIADH/hyponatremia with SSRIs in elderly — check Na at 2–4 weeks
— Consider ECT — well-tolerated and effective in geriatric depression with suicidality
— Higher suicide risk: cancer (first year post-diagnosis, especially lung, head/neck, pancreatic), HIV, MS, Huntington, ESRD on dialysis, COPD, chronic pain, TBI
— Steroids, interferon, varenicline (boxed warning removed but still monitor), isotretinoin, levetiracetam — drug-induced mood changes
— Address pain control adequately — poorly controlled pain is a modifiable risk factor
Key distinction: Medical Aid in Dying (MAID) in states where legal is distinct from suicide — requires terminal illness with prognosis <6 months, capacity, voluntary repeated requests, and physician oversight. A patient requesting MAID still warrants assessment for treatable depression, which can mimic terminal hopelessness.
— Suicide is the 2nd leading cause of death ages 10–24
— Screen with ASQ (4 items, validated in pediatric ED) or PHQ-A
— Risk factors: bullying (in-person and cyber), LGBTQ+ identity without family support, recent breakup, academic failure, social media exposure (suicide contagion), prior NSSI, ADHD, conduct disorder
— Confidentiality limits: most states allow adolescents to consent to mental health care, but suicide risk overrides confidentiality — parents must be informed for safety planning and means restriction
— Firearm in home → ALWAYS counsel parents on storage; single greatest pediatric suicide intervention
— Fluoxetine — FDA-approved for MDD ages 8+
— Escitalopram — FDA-approved for MDD ages 12+
— Both fluoxetine and sertraline approved for pediatric OCD
— Black box warning highest relevance in this age group — monitor weekly initially
— CBT alone or in combination has the best evidence; TADS trial showed fluoxetine + CBT superior to either alone
— Suicide is a leading cause of maternal death in the first postpartum year (especially months 6–12)
— Screen with Edinburgh Postnatal Depression Scale (EPDS) — item 10 addresses self-harm
— Postpartum psychosis (rapid onset, 1–2 weeks postpartum) is a psychiatric emergency — high infanticide/suicide risk
— Sertraline preferred SSRI in pregnancy and breastfeeding (minimal milk transfer); avoid paroxetine (cardiac malformations) and valproate (neural tube defects, lowest IQ outcomes)
— ECT safe in all trimesters and postpartum; lithium pregnancy risk (Ebstein anomaly) is lower than historically taught — case-by-case
— Transgender youth have markedly elevated rates of attempts (~40% lifetime in some surveys)
— Family acceptance and gender-affirming care are protective
— Avoid invalidating language; use chosen name and pronouns in chart
Board pearl: A postpartum mother with delusions about her infant being evil or possessed has postpartum psychosis until proven otherwise — admit, do not discharge home with the baby, even if she denies intent to harm. This is a Step 3 fail-safe answer.
— Overdose: hepatotoxicity (APAP), arrhythmia (TCA, methadone, citalopram), serotonin syndrome (SSRI/MAOI/MDMA), anion gap acidosis (salicylates, toxic alcohols), aspiration pneumonia, rhabdomyolysis, compartment syndrome from prolonged immobility
— Hanging: anoxic brain injury, cervical fracture (rare in low-drop), laryngeal injury, post-hanging pulmonary edema, ARDS, carotid dissection
— Firearm: TBI with poor neurologic outcome, facial reconstruction, chronic disability
— Jumping: polytrauma, calcaneal fracture pattern, vertebral burst fractures, pelvic injury, solid organ injury
— Wrist cutting: tendon/nerve injury, infection; rarely lethal from blood loss alone (used more for NSSI)
— Carbon monoxide: anoxic brain injury, delayed neurologic sequelae (2–6 weeks), cardiac ischemia — hyperbaric O₂ for severe cases
— Recurrent attempts — 1-year reattempt rate ~15%; 10-year suicide death rate ~5% in attempters
— Worsening hopelessness post-failed attempt
— Survivor guilt, PTSD from attempt itself, identity changes
— Family/witness trauma
— Boarding in ED — psychiatric patients wait hours-days for inpatient beds; risk of clinical deterioration, elopement, in-ED suicide
— Restraint-related injury (chemical or physical) — use least restrictive
— Medication errors — abrupt discontinuation of lithium triggers manic relapse; rebound depression with abrupt SSRI stop
— Premature discharge — 30-day post-discharge suicide rate is 100× general population
— Inpatient suicide is a Joint Commission Sentinel Event — requires root cause analysis and corrective action plan
— Outpatient suicide of recently discharged patient often reviewed similarly
Step 3 management: After any failed attempt, the focus shifts from "Did they really mean it?" (irrelevant — outcome bias) to "What is the risk now, and what changes for treatment?" A medically minor attempt (small ingestion) with high intent and low rescue probability is higher risk than a medically severe attempt that was impulsive with high rescue probability.
— Hemodynamic instability, vasopressor need
— Intubated/airway concern (CNS depression, aspiration, hanging-related laryngeal edema)
— Severe acidosis, hyperkalemia, ongoing arrhythmia
— TCA overdose with widened QRS, requiring sodium bicarbonate
— Severe APAP overdose on NAC with rising LFTs/INR (transplant eval threshold: King's College criteria)
— Salicylate level >100 mg/dL or AMS requiring HD
— Lithium >4 mEq/L or AMS — hemodialysis indicated
— Severe anoxic brain injury post-hanging or CO
— TCA, methadone, citalopram, hydroxychloroquine ingestion with QTc/QRS monitoring × 24 h
— Hemodynamically stable but requires close cardiac/neuro monitoring
— Medical issues requiring admission (e.g., hepatotoxicity trending, electrolytes) with active suicidal ideation
— Continuous 1:1 observation; psychiatry consult; environmental safety (no cords, ligature points)
— All intentional overdoses and attempts (before any disposition, even if "feels better now")
— New suicidal ideation in any admitted patient
— Capacity questions related to refusal of psychiatric care
— Postpartum psychosis suspicion
— Catatonia, severe agitation, ECT consideration
— Once medically cleared → transfer to psychiatric unit
— "Medical clearance" is not a checkbox — requires stable vitals, normal mental status (no delirium), addressed acute medical issues, and a psychiatrically-appropriate environment for ongoing care
— Acceptance to receiving facility before transfer
— EMTALA compliance — cannot refuse transfer/admission for inability to pay
— Maintain 1:1 during transport
CCS pearl: On CCS, before transferring a patient from medical ED to inpatient psychiatry, your order set must include: "medical clearance documented," "labs reviewed and stable," "psychiatry consult agrees with disposition," "1:1 sitter continued during transport," and "belongings searched." Skipping medical clearance and sending an unstable patient is a major safety lapse.
— Bipolar depression carries higher lifetime suicide risk (~15% vs ~6% in unipolar)
— Screen for past hypomania/mania (MDQ) before starting antidepressant monotherapy — can trigger mania or mixed states (highest suicide risk state)
— Mixed features (depression + agitation, racing thoughts) — high suicide risk; treat with mood stabilizer
— Chronic suicidality with frequent NSSI and low-lethality attempts; lifetime completion ~10%
— Repeated brief admissions can be iatrogenically harmful — reinforce hospitalization-seeking
— Best evidence: outpatient DBT, mentalization-based therapy, transference-focused therapy
— Admit for acute change in chronic pattern, not chronic ideation alone
— ~5% lifetime suicide rate; highest risk early in illness, after psychotic episode, with insight return, with comorbid depression
— Command hallucinations elevate acute risk
— Clozapine uniquely reduces suicide
— Elevated suicide risk; comorbid depression, SUD, TBI common
— Veterans: 988 → press 1 for Veterans Crisis Line; VA safety planning standard
— Alcohol use disorder: 60–120× general population suicide risk
— Acute intoxication disinhibits and impairs judgment — reassess after sobriety before disposition decisions
— Opioid use disorder + benzodiazepine combinations — often unclear if overdose was intentional
— Anorexia nervosa has the highest mortality of any psychiatric disorder — half from suicide
— Address both medical instability (refeeding, electrolytes) and psychiatric risk
Key distinction: Chronic suicidal ideation in borderline personality (baseline) vs acute exacerbation requires careful assessment — admit for new specific plan, recent severe attempt, loss of outpatient support, comorbid acute depression, not chronic ideation alone. Over-hospitalization in BPD worsens long-term outcomes.
— Hypothyroidism — fatigue, depression, cognitive slowing; check TSH
— Hypercalcemia — depression, constipation, polyuria; check Ca, PTH
— Cushing syndrome — depression in 50%+; consider in unexplained depression with hypertension, central obesity, striae
— Addison disease — fatigue, depression, hyponatremia, hyperpigmentation
— B12/folate deficiency — depression, cognitive changes, neuropathy
— Vitamin D deficiency — modest contribution
— HIV — direct CNS effects and reactive depression
— Neurosyphilis — neuropsychiatric presentation
— Wilson disease — young adult with mood/psychotic symptoms + hepatic/neurologic findings; check ceruloplasmin
— Huntington disease — high suicide rate, particularly around diagnosis and loss of independence
— TBI — even mild TBI elevates suicide risk; screen all TBI patients
— Sleep apnea, chronic insomnia — insomnia is an independent suicide risk factor
— Corticosteroids — dose-related; mania, depression, psychosis
— Interferon-α — depression, suicidality; screen before and during
— Isotretinoin — controversial but black box; counsel and monitor
— Levetiracetam — irritability, depression in ~10%
— β-blockers — historically implicated; modest effect
— Varenicline — original boxed warning removed (EAGLES trial); still monitor
— Mefloquine — neuropsychiatric effects, contraindicated with psychiatric history
— Withdrawal states: alcohol, benzodiazepines, opioids — all increase acute suicide risk
— Akathisia from antipsychotics/SSRIs — agitated dysphoria misread as worsening depression; treat with propranolol or benztropine, reduce offending agent
— Acute confusion can manifest as agitated, paranoid, or hopeless behavior; suicide attempts during delirium are documented
— Address underlying cause (infection, metabolic, drug-induced) before attributing to primary psychiatric illness
Board pearl: A new "depression" in a previously healthy older adult with weight loss, unexplained anemia, or constitutional symptoms requires a medical workup first — occult malignancy (pancreatic cancer classically presents with depression preceding diagnosis) is a Step 3 favorite.
— Written safety plan in patient's hands at discharge (Stanley-Brown)
— Lethal means restriction documented with specific plan (firearms off-site, meds locked/dispensed)
— Caring contacts — brief follow-up letters/texts/calls for weeks-months post-discharge (Motto/Luxton evidence base)
— Bridge appointment within 7 days of discharge — ideally within 24–72 h for high-risk
— Warm handoff — direct introduction to outpatient provider, not just a phone number
— 988 and crisis resources written, with patient demonstrating knowledge of how to use
— Continue effective acute treatment (lithium, clozapine, antidepressant) — do not abruptly discontinue
— Dispense limited quantities of high-lethality medications (TCAs, lithium narrow therapeutic index)
— Address insomnia aggressively — insomnia is a modifiable suicide risk factor (CBT-I preferred over benzodiazepines)
— Treat comorbid SUD — refer to MAT (buprenorphine, naltrexone, acamprosate)
— CT-SP (Brown/Wenzel) — 10 sessions, 50% reduction in reattempts
— DBT — for BPD with chronic suicidality
— CAMS — collaborative outpatient framework
— IPT, CBT, problem-solving therapy — for underlying mood disorders
— Connect to peer support (NAMI, AA/NA, suicide attempt survivor groups)
— Address social determinants: housing, food, financial counseling
— Employer FMLA paperwork, school accommodations
— Faith community involvement if patient-aligned
— Warning signs to monitor
— How to remove/secure means
— How to use 988, mobile crisis, ED
— Self-care for caregivers — burnout is real
Step 3 management: The 30 days post-discharge is the highest-risk period — schedule the first follow-up within 7 days (ideally 48–72 h), and use caring contacts (a brief check-in text, call, or letter) — these alone reduce reattempts in RCTs. "Follow up in 4–6 weeks" is the wrong answer post-discharge.
— Day 1–3: phone or in-person contact, confirm safety plan in use, medication adherence, side effects, ideation status
— Day 7: in-person bridge visit (psychiatry or PCP), reassess C-SSRS, refine safety plan
— Day 14: PHQ-9, GAD-7, medication titration
— Day 30: comprehensive reassessment, transition to standard cadence if stable
— Every 2–4 weeks during medication initiation/titration
— Every 4–6 weeks during stabilization
— Every 3 months during maintenance
— PHQ-9 + suicide item (PHQ-9 item 9 or C-SSRS) at every visit
— Lithium: level (5–7 days after change, then q3 mo), TSH, Cr q6–12 mo, Ca q12 mo
— Valproate: level, LFTs, CBC, weight
— Clozapine: ANC weekly × 6 mo, q2 weeks × 6 mo, then monthly; metabolic monitoring; myocarditis risk first 4 weeks
— SSRIs: Na at 2–4 weeks in elderly; QTc with citalopram
— ECT: cognitive screening, anesthesia tolerance
— PHQ-9 score trajectory
— Functional measures (work, school, relationships, sleep, appetite)
— Repeat C-SSRS
— Therapy engagement and homework adherence
— Substance use status
— Worsening PHQ-9 item 9
— Increased alcohol/substance use
— Sleep disturbance
— New psychosocial stressor
— Medication non-adherence
— Treatment dropout — proactive outreach when patient misses appointment
— Anniversary reactions (loss anniversaries, prior attempt anniversaries)
— Seasonal patterns (peak completed suicides spring/early summer, not winter as myth suggests)
— Transition points: graduation, retirement, deaths, divorces
CCS pearl: On CCS for a recently discharged suicidal patient, your follow-up clock should advance in days, not weeks — "follow up in 3 days" and "telephone check-in tomorrow" beat "follow up in 1 month" every time. Re-administer PHQ-9 and C-SSRS at each visit and document.
— Suicide risk overrides confidentiality for safety — disclose to family/emergency contacts as needed to ensure safety, lethal means restriction, and follow-through
— Tarasoff duty (in most states): duty to warn/protect identifiable third parties if patient poses serious threat — applies to homicidal more than suicidal ideation, but parallel safety duty applies
— Adolescents: confidentiality is conditionally protected but suicide risk requires parental involvement
— Documentation: note what was disclosed, to whom, and the safety rationale
— Capacity is decision- and time-specific
— Patients with severe depression often retain capacity but may have impaired judgment due to hopelessness — careful assessment required
— Involuntary hold criteria (state-specific but common elements):
— Mental illness present
— Imminent danger to self or others, OR grave disability
— Less restrictive alternative not available
— Holds are time-limited (typically 72 hours); continued involuntary treatment requires judicial review
— A suicidal patient can refuse medical treatment (e.g., refuse NAC for APAP overdose) if they retain capacity — but suicidal intent itself raises capacity concerns and may justify emergency treatment under implied consent
— In practice: provide life-saving medical treatment first; address psychiatric refusal afterward
— Document capacity assessment carefully
— Firearm-related self-injury may have state-specific reporting requirements
— Suspected abuse contributing to suicidality (child, elder, vulnerable adult) — mandatory reporting
— Workplace/school threats — duty to warn may extend
— Discharge from inpatient psychiatry without scheduled outpatient follow-up = major safety lapse
— Handoff to outpatient must include: diagnoses, current meds, suicide risk formulation, safety plan, means restriction status, follow-up scheduled
— Use the post-discharge safety bundle: caring contacts, 7-day appointment, warm handoff
— Postvention: peer support, M&M review, root cause analysis
— Avoid defensive practice changes that harm other patients
— Self-care; ~50% of psychiatrists experience a patient suicide in career
Board pearl: Documentation that contains a risk formulation ("Risk is intermediate acute / chronic high because…") and an explicit rationale for disposition is the single best protection — both for patients and against malpractice claims. "Denies SI" alone in a charting note is insufficient.
— Highest US suicide rate: non-Hispanic white men age 75+
— Highest attempt rate: young women; highest completion rate: older men
— Method by sex: men → firearms; women → poisoning (but firearms rising)
— Firearms: 50% of US deaths, ~85% case fatality
— AI/AN populations: highest rates by ethnicity, particularly youth
— LGBTQ+ youth: 4× increased attempt rate; transgender youth higher still
— Veterans: ~1.5× general population; 988 → press 1
— Prior attempt (5–6× risk)
— Hopelessness (strongest cognitive predictor)
— Access to lethal means, especially firearms
— Recent discharge from psychiatric hospitalization (first 30–90 days)
— Acute intoxication at time of crisis
— Lithium — mood disorders
— Clozapine — schizophrenia (FDA-approved indication)
— Ketamine/esketamine — rapid SI reduction
— ECT — fastest for severe depression with active SI
— TCAs (amitriptyline most lethal)
— MAOIs
— Lithium (narrow therapeutic index) — but benefits often outweigh; dispense limited quantities
— Opioids, benzodiazepines (combined respiratory depression)
— PHQ-9 (screen)
— C-SSRS (stratify)
— ASQ (pediatric ED screen)
— GDS (geriatric)
— EPDS (perinatal)
— Stanley-Brown Safety Plan (intervention)
— 988 Suicide & Crisis Lifeline (resource)
— "Asking about suicide plants the idea" — FALSE
— "People who talk about it don't do it" — FALSE
— "No-suicide contracts work" — FALSE; replaced by safety planning
— "Most suicides happen in winter holidays" — FALSE; peak spring/early summer
— "Improved mood means crisis resolved" — sometimes ominous
— TJC: screen all medical/surgical inpatients with primary behavioral health complaint
— USPSTF (2023): screen adults and adolescents 12+ for depression; insufficient evidence to screen general adult population for suicide risk specifically — but act on positive depression screens
Step 3 management: Memorize the post-discharge bundle: 7-day follow-up + caring contacts + safety plan + means restriction + 988 — these together reduce 30-day reattempts in multiple RCTs and are the highest-yield "next best step" answers.
— 24F brought in after ingesting 30 acetaminophen tablets 6 hours ago, says "I just wanted the pain to stop." Vitals stable. APAP level pending.
— Best initial action: check APAP level at 4-hr mark, plot on Rumack-Matthew; if above treatment line → start NAC; obtain salicylate, ethanol, UDS; 1:1 sitter; psychiatric consult after medical stabilization; do not discharge before psychiatric eval
— 45M at annual physical, PHQ-9 = 18, item 9 = "more than half the days"
— Next step: structured suicide assessment (C-SSRS), specifically ask about plan/intent/means/firearm access; safety plan; lethal means counseling; start SSRI (sertraline/escitalopram); follow-up in 1–2 weeks; not "refer to psychiatry in 4–6 weeks alone"
— 30F discharged from inpatient psych 5 days ago after suicide attempt, calls saying she stopped her lithium because of weight gain
— Next step: same-day or next-day appointment, reassess SI with C-SSRS, address med side effect (consider alternative or adjunct), reinforce safety plan, verify firearm/med restriction; 30-day post-discharge is highest-risk window
— 16M with cuts on forearm, tells school counselor "I've thought about killing myself"; parents called to ED
— Best action: full assessment with patient and collateral with parents; firearm access query (mandatory); admit if active plan/intent or unable to ensure safety at home; fluoxetine + CBT for moderate-severe MDD; weekly follow-up initially; do not rely on confidentiality alone
— 78M widowed 4 months ago, recent weight loss, somatic complaints, lives alone with rifle for "protection"
— Best action: GDS or PHQ-9; direct SI inquiry; firearm removal with family member (highest-yield intervention); SSRI (sertraline 25 mg start); same-week follow-up; consider home visit/social work
— 28F on sertraline for "depression," now agitated, not sleeping, racing thoughts, with new suicidal ideation
— Best action: stop SSRI (likely activated mixed state in undiagnosed bipolar); admit; mood stabilizer (lithium or valproate) ± antipsychotic; reassess diagnosis with MDQ; mixed states = highest suicide risk
— Patient with active SI and plan refuses admission, has capacity for most decisions
— Best action: involuntary hold (state-specific name) — danger to self due to mental illness; document capacity assessment, less-restrictive alternatives considered
Board pearl: When stems offer "no-suicide contract" or "follow up in 4–6 weeks" as options after a positive screen or recent attempt, those are distractors. The correct answer is always structured safety plan + lethal means counseling + close follow-up (≤7 days).
Suicide risk assessment is a structured clinical formulation — not a checklist — that integrates static and dynamic risk with protective factors to guide disposition, and is paired with a Stanley-Brown safety plan, lethal means restriction (especially firearms), and close post-crisis follow-up to reduce death.
— Direct assessment: C-SSRS-style inquiry into ideation, plan, intent, means, prior attempts, hopelessness
— Means restriction: firearm and medication access counseled with a specific, named plan; documented
— Safety planning: Stanley-Brown 6-step plan, written, in patient's hands; no-suicide contracts are not acceptable substitutes
— Follow-up: 24–72 h for high-intermediate risk; ≤7 days post-discharge; caring contacts reduce reattempts
— Lithium (mood disorders)
— Clozapine (schizophrenia — FDA-approved for suicide reduction)
— Ketamine/esketamine (rapid acute ideation reduction); ECT as definitive treatment for severe depression with active SI
— Older men with firearms post-loss — highest completion rates, fewest warnings
— Postpartum mothers with new psychosis or worsening depression — suicide is a leading maternal mortality cause
— Recently discharged psychiatric patients in the first 30 days — 100× general-population risk
— Restricting access to lethal means, especially firearms — the only intervention with consistent population-level evidence to reduce suicide mortality, and the highest-yield Step 3 answer when offered alongside generic options like "schedule follow-up" or "start SSRI"
Step 3 management: When in doubt on exam — ask directly about SI, assess plan/intent/means, restrict means (firearms off-site), build a safety plan, schedule follow-up within days, and treat the underlying disorder. That sequence wins almost every suicide-risk vignette.