← Diagnosis and Management Guides
Suicide Risk Assessment
Key considerations: Active suicidal ideation with plan and means, Recent suicide attempt, Self-harm with medical injury
Cannot miss
- Active suicidal ideation with plan and means
- Recent suicide attempt
- Self-harm with medical injury
Likely diagnoses
- Suicidal ideation in context of MDD
- Substance-related suicidality
- Psychotic-driven suicidality
- Personality disorder crisis
Red flags
- Specific plan and means
- Recent attempt
- Psychosis with command hallucinations
- Hopelessness
- Recent discharge from psychiatric facility
Workup
- history: Columbia Suicide Severity Rating Scale (C-SSRS); Prior attempts, means access, protective factors, precipitants; Substance use, psychiatric history, recent losses; exam: Mental status exam, evidence of self-harm, intoxication; labs: Toxicology screen, BAL, BMP, acetaminophen/salicylate levels if ingestion; imaging: As indicated by injury; bedside: 1:1 observation, remove dangerous items
Management
- immediate: Ensure patient safety: 1:1 observation, remove sharps/ligature risk; Treat any medical injuries; Treat underlying psychiatric condition; general: Safety planning (not safety contracting); Means restriction counseling; Psychiatric evaluation for disposition; Consider voluntary vs involuntary admission
Disposition
- admit: Active SI with plan/intent, recent attempt, psychosis, inability to safety plan; discharge: Only with psychiatry clearance, safety plan in place, lethal means restricted, outpatient follow-up within 72hr; consults: Psychiatry for all patients with suicidal ideation
Clinical pearls
- Safety plans are evidence-based; safety contracts (no-harm contracts) are NOT — they provide false reassurance
- Prior attempt is the single strongest risk factor for completed suicide
- Ask directly about suicidal thoughts — it does not increase risk
Source and review
- APA Suicide Risk Assessment Guidelines 2023. Last reviewed: 2024-11-01