← Diagnosis and Management Guides
Suicidal Ideation
Key considerations: Active plan with intent and means, Recent suicide attempt, Command auditory hallucinations to harm self
Cannot miss
- Active plan with intent and means
- Recent suicide attempt
- Command auditory hallucinations to harm self
- Intoxication masking true severity
Likely diagnoses
- Major depressive disorder
- Bipolar disorder (depressed phase)
- Borderline personality disorder
- Substance use disorder
- Adjustment disorder
- PTSD
Red flags
- Specific plan
- Access to lethal means (firearms)
- Prior attempt (strongest predictor)
- Recent discharge from psychiatric facility
- Hopelessness
- Social isolation
- Giving away possessions
- Male >65 years
Workup
- history: C-SSRS structured interview; Current stressors and triggers; Psychiatric history and prior attempts; Substance use (active intoxication); Access to firearms and other lethal means; Protective factors: reasons for living, social support, children; exam: Mental status exam; Physical exam for self-harm injuries (arms, thighs); Signs of intoxication; Evidence of ingestion; labs: Urine drug screen; Ethanol level; Acetaminophen and salicylate levels (in case of unreported ingestion); BMP, glucose; imaging: ; bedside: C-SSRS; Safety assessment
Management
- immediate: 1:1 observation; Remove all potentially harmful items from room; Search belongings; Document C-SSRS findings; general: Safety planning (Stanley-Brown Safety Planning); Lethal means counseling (especially firearms); Treat underlying psychiatric condition; Involve family/supports with patient consent; specific: diagnosis: High Risk (Plan + Intent); steps: Involuntary hold if patient refuses voluntary admission; Psychiatric inpatient admission; Continuous 1:1 observation; Sitter until disposition finalized; diagnosis: Moderate Risk (Ideation, No Plan); steps: Psychiatric evaluation; Safety planning; Consider admission vs intensive outpatient; Crisis hotline: 988 Suicide & Crisis Lifeline; diagnosis: Low Risk (Passive Ideation); steps: Safety planning; Outpatient referral with follow-up within 48-72h; Lethal means counseling; Crisis resources provided
Disposition
- admit: Active plan with intent; Recent attempt; Command hallucinations; Unable to safety plan; No protective factors; Intoxicated — reassess when sober; discharge: Passive ideation with strong protective factors; Engaged in safety plan; Willing to follow up within 48-72h; Family/support available; Means restriction plan in place; consults: Psychiatry for all; Social work for resources and follow-up; Substance abuse counseling if indicated
Clinical pearls
- Asking about suicide does NOT increase risk — it saves lives
- Firearm access is the single most modifiable risk factor — counsel on safe storage/removal
- Follow-up within 48 hours of ED discharge reduces suicide attempts by 50%
- Prior attempt is the strongest predictor of future completed suicide
Source and review
- APA Practice Guidelines for Assessment and Treatment of Suicidal Behaviors 2023. Last reviewed: 2024-11-01