Suicide: Assessment and Management

Etiology

Results from a large study of suicide attempts and suicide deaths in twins, full siblings, and half-siblings showed that suicide attempts and death were moderately heritable among both women and men and that environmental correlations were weaker. Heritability of suicide attempts was stronger in people aged between 10 and 24 than in people aged 25 and older. The genetic correlation for suicide attempt during youth and adulthood was stronger for women. The study concluded, "The genetic and environmental etiologies of suicide attempt and death are partially overlapping, exhibit modest sex differences, and shift across the life course."[7] 

Multi-ancestry and European ancestry admixture genome-wide association study meta-analyses identified several risk loci implicating genes highly expressed in brain tissue and suicide attempts. Genetic causal proportion analyses implicated attention deficit-hyperactivity disorder, smoking, risk tolerance, and pulmonary and cardiovascular health factors in the risk for suicide attempts.[8] Other individual risk factors for suicide are family history, early-life adversity, psychiatric disorders, severe mental illness, depression, personality disorders, substance misuse, and physical health problems. Environmental risk factors for suicide include lack of social support, economic factors, life events, effects of the media, and access to lethal means.[9]

Epidemiology

According to the Centers for Disease Control, 48,183 people died by suicide in the United States in 2021, an increase of 4.8% over the previous year. Suicide is the 12th leading cause of death in the United States.[10] Age-adjusted suicide rates were highest among Indigenous/Alaska Native persons, and increased significantly among those in Black and Hispanic populations in 2021; there was also a decline in the rate of suicide among White individuals. Suicide was the second leading cause of death in the United States among 10- to 14-year-olds. According to the Youth Risk Behavior Survey, 9% of high school students reported a suicide attempt in the past 12 months; rates were 4 times higher for those identifying as gay, lesbian, or bisexual.[5][11] As many as 30% to 81% of transgender and gender-nonconforming people have attempted suicide at some point in their lives.[12] 

Since 1995, gun suicides each year have accounted for more than half of all suicides in the United States in most age groups. In 2023, 55% of all suicides were by firearms.[13] Of suicide attempts using a gun, 90% are lethal.[14] According to the World Health Organization, Suicide Worldwide in 2019 Global Health Estimates, suicide rates were 2.3 times higher in males than in females. The majority of deaths by suicide (77%) occurred in low- and middle-income countries, and 58% of global suicides occurred in those younger than 50. Suicide was the third leading cause of death for females and the fourth leading cause of death for males. Although rates of suicide were higher in young men, rates of suicidal ideation were higher in young women. Globally, suicide is the fourth leading cause of death among adolescents and young adults aged 15 to 29. The most common suicide methods among young people worldwide are hanging/suffocation, followed by jumping from a height, and jumping/lying in front of a moving object. 

Pathophysiology

The pathophysiology and biological mechanisms of suicide are unclear. Studies of the serotonergic system, a focus of research on depression and suicidality, have been equivocal. Low cerebrospinal fluid concentrations of 5-hydroxyindoleacetic acid, a serotonin metabolite, have been found in violent suicide attempters and suicide attempters.[15] Study results have also shown reduced brain serotonin production and release in people with mood disorders who are at risk for suicidal behavior. Some positron emission tomography (PET) studies have shown lower serotonin receptor binding in the mesiotemporal cortex of patients with depression, yet other PET study results have reported elevated serotonin binding in depression, with higher binding predictive of suicidal ideation 1 year later.[5] 

After observing that immunotherapy and autoimmune disorders were associated with depression and suicidality in some patients, researchers proposed that inflammation may lead to suicidal behavior, although there are several confounding factors. Increased levels of proinflammatory cytokines interleukin-1β and interleukin-6 have been found in the blood, cerebrospinal fluid, and postmortem brain samples of suicidal patients.[16] In a study of 35 cases of suicide by hanging and 35 patients with non-suicidal death, neuropeptide Y levels were significantly higher in the cerebrospinal fluid of the suicide group than the control group.[17] 

Stress is a risk factor for suicidality, and a stress-diathesis model involving the hypothalamic-pituitary-adrenal (HPA) axis has been proposed in the pathophysiology of suicidal behavior. Blunted HPA axis activity has been found to precede suicidal behavior.[5] The negative internal states precipitating suicidal ideation may be related to impairments in medial and lateral prefrontal cortex regions and their connections, causing dysregulation in decision-making.[5] 

Psychological theories on the causes of suicide include the following models:

• Interpersonal theory of suicide: Based on low belongingness, burdensomeness, and acquired capabilities, such as reduced sensitivity to physical pain, no fear of death, and access to lethal means
• Integrated motivational-volitional model: Based on feeling trapped and feelings of defeat, and social humiliation
• Three-Step Theory: Based on increased hopelessness and pain, decreased connections to others and capacity to tolerate pain, and suicide capability [5][18]

However, there are no definitive biomarkers for diagnosing or predicting suicidal behavior, due to the complexity of the biological, genetic, and environmental factors involved.

History and Physical

Pathways for managing suicide risk can be conceptualized in 4 steps:

• Brief screening for suicide risk
• BSSA by a trained clinician for patients who screen positive
• Determining a course of action for patients who screen positive
• Psychiatric suicide risk assessment and formulation as needed

Brief Screening for Suicide Risk 

The purpose of a brief screening for suicide risk is to rapidly identify patients at risk of suicide. Evidence-based screening tools include the Ask Suicide-Screening Questions (ASQ), available in multiple languages; the Patient Safety Screener-3; and the Columbia-Suicide Severity Rating Scale, Screening Version, which are brief and easy to use. Depression screening alone is not adequate.[4] In February 2016, the Joint Commission issued a Sentinel Event Alert recommending that all medical patients in all medical settings (inpatient hospital units, outpatient practices, and emergency departments) be screened for suicide risk. The Joint Commission approves using the National Institute of Mental Health ASQ toolkit for all ages. 

The ASQ Suicide Risk Screening Tool

Ask the patient:

1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you ever tried to kill yourself? If yes, how? When?

• If the patient answers "no" to the first 4 questions, the screening is complete, and no intervention is necessary.
• If the patient answers "yes" to any of the questions or refuses to answer, they are considered a positive screen, and the screener asks question #5 to assess acuity.

5. Are you having thoughts of killing yourself right now? If yes, please describe.

If the answer to question #5 is "yes," the patient is considered at imminent risk and requires an immediate full mental health evaluation. The patient should be kept within sight in a safe environment and cannot leave until they have been evaluated for safety. If the answer to question #5 is "no," the patient requires a BSSA to determine if a full mental health evaluation is needed. If the patient refuses the brief assessment, this should be treated as an against medical advice discharge, and the responsible clinician should be notified.

All patients should be provided with the National Suicide Prevention Lifeline (988) and the Crisis Text Line: Text "HOME" to 741741. See the ASQ Suicide Risk Screening Tool. 

Brief Suicide Safety Assessment for Patients Who Screen Positive

Patients who screen positive should have a BSSA to clarify a patient's risk severity. This is not a full psychiatric assessment and should take 10 to 15 minutes. The BSSA can help decide the next steps. The National Institute of Mental Health ASQ Toolkit provides detailed scripts and worksheets for BSSA of youths and adults in emergency departments, inpatient medical and surgical units, and outpatient settings, as well as a patient resource list. 

The BSSA should be performed by trained mental health clinicians, physicians, nurse practitioners, or physician assistants and includes the following steps:

1. Praise the patient for discussing their thoughts.
2. Assess the patient, asking any visitors to leave the room, and review the patient's responses from the ASQ.
3. Ask about the frequency of suicidal thoughts, if the patient has a suicide plan, past suicidal behavior, symptoms, social supports, and stressors.

Determining a Course of Action/Disposition

The BSSA has 3 possible scenarios that guide the next steps in treating a patient who has revealed suicidal ideation or engaged in suicidal behavior:

• Patients at imminent risk or with acute positive screens require emergency psychiatric and safety evaluations. Healthcare professionals are obligated to ensure the patient's safety.
• Patients who are at moderate risk or need further evaluation need a prompt, comprehensive evaluation from a mental health professional and interventions such as a safety plan, lethal means safety counseling, and access to crisis resources.
• Patients at mild risk may not require further evaluation but may benefit from mental health follow-up and developing a safety plan, as well as receiving a list of resources, such as the 988 Suicide and Crisis Lifeline number.[4]  

After completing the BSSA, the clinician chooses the appropriate disposition plan:

1. Emergency psychiatric evaluation: The patient is at imminent risk for suicide with current suicidal thoughts. If inpatient, keep the patient safe, remove dangerous objects, have a 1:1 observer, and request an emergency psychiatric evaluation. If outpatient, send to the emergency department for a mental health evaluation, which should also include an assessment as to whether the patient is a danger to others.
2. Further risk evaluation is necessary: If the patient is an inpatient in a medical or surgical unit, a comprehensive mental health and safety evaluation must be requested before discharge. If the patient is an outpatient, review the safety plan and send home with a mental health referral as soon as possible, preferably within 72 hours.
3. The patient may benefit from a non-urgent mental health care follow-up: review the safety plan.
4. No further intervention is necessary at this time.
5. Provide resources to all patients (National Suicide Prevention Lifeline [988] and the Crisis Text Line: Text "HOME" to 741741).

Psychiatric Suicide Risk Assessment and Formulation

A psychiatric suicide risk assessment gathers information from various sources, including the patient, collateral contacts (friends, family, primary care or other mental health clinicians), medical records, police records, screening tools regarding suicidal ideation, historical and current risk, protective factors, and warning signs. The suicide risk formulation “systematically considers the interplay between risk and protective factors,” involving “the identification and weighing of patient-specific risk and protective factors” and “reasoning from patient-specific data to a clinical judgment about appropriate treatment and management.”[19] 

One helpful way to conceptualize the risk is in terms of the time frame and whether the risk factors are clinically modifiable. Part of medical decision-making for disposition is based on timing. A psychiatrist consulted in an emergency department setting for a patient presenting with thoughts of suicide will evaluate foreseeable risk that spans hours to days, rarely spanning weeks, and seldom months to years. This is in comparison with a psychiatrist who treats a patient with an evidence-based therapy for treatment-resistant depression. The psychiatrist may intend such treatment to mitigate longer-term suicide risk. The psychiatrist evaluates risk factors that can be changed through clinical intervention, known as dynamic risk factors. Historical risk factors for suicide, known as static risk factors, are typically demographic and are not clinically modifiable. However, certain contexts can change static risk factors into dynamic risk factors. For example, an individual who has been divorced for several years carries their divorced status as a static risk factor. However, for example, someone who learned hours ago that their spouse is divorcing them acquires a dynamic risk factor for suicide based on temporal context. The infinite variability of time frames and context of risk influences the interventions regarding the level of treatment, mitigation of modifiable risk factors, and strengthening of protective factors.

Clinical interviewing and information from other sources must be combined with clinical judgment. Such clinical judgment does not equate prediction, as prediction confers a statistical likelihood for a given clinical encounter, which is not possible when the provider is face-to-face with an individual patient. Rather, a suicide risk assessment helps determine what is foreseeable, “a common sense, probabilistic concept rather than a scientific construct. Foreseeability is the reasonable anticipation that harm or injury is likely to result from certain acts or omissions.”[19] In addition, foreseeability “must be distinguished from preventability. A suicide may have been preventable in hindsight, but was not foreseeable at the time of assessment.”[19]

The standard of care for suicide risk assessment and formulation is elusive. Mental health professionals are expected to make a reasonable assessment to foresee a substantial risk of suicide. Mental health professionals are not expected to predict suicide, given that existing prediction models are notoriously inaccurate. This is partly because suicide is a relatively rare occurrence, which reduces the predictive value of the various screening instruments and clinical algorithms.[20] A reasonable assessment and management involve due diligence in gathering data regarding current and historical factors from multiple sources (the patient, collateral sources, and records) and making and documenting a formulation along with the rationale for the risk level and the planned interventions. The risk and interventions are monitored over time, particularly during clinical change and care transitions.[21]

Components of Psychiatric Assessment of Patients Who Are Suicidal

A suicide risk assessment and formulation consists of a patient’s static and dynamic risk factors, risk-reducing protective factors, and courses of action that mitigate risk.[19] Information about risk factors is obtained by interviewing the patient, gathering collateral information, and reviewing records. The quality of the information gathered from the patient is influenced by the therapeutic alliance and the patient’s level of cooperation. When the patient is guarded or circumspect, this reduces the validity of the patient's answers and increases the risk.

Current presentation

• Thoughts, plans, or intention of suicide or self-harm
• Suicidal ideations at the worst moment of an individual’s life are a stronger predictor of death by suicide than current suicidal ideations [22]
• Suicidal behavior
• Planned method of suicide and the patient's expectation of the lethality of that method
• Accessibility of firearms
• Hopelessness, impulsivity, anhedonia, panic attacks, or anxiety
• Reasons for living and plans
• Alcohol or other substance use
• Thoughts, plans, or intentions of violence towards others

Psychiatric illnesses

• Current signs and symptoms of psychiatric disorders, including mood disorders, schizophrenia, substance use disorders, anxiety disorders, and personality disorders
• Previous psychiatric disorders, including the course of the illness, and treatment/hospitalizations

History

• Previous suicide attempts, including why, when, and how
• Aborted suicide attempts
• Other self-harming behaviors
• Medical diagnoses and treatment, including history of surgery, head trauma, and hospitalization
• Family history of mental illness, substance use, and suicide or suicide attempts

 Psychosocial situation

• Acute crises
• Chronic stressors such as relationships, domestic violence, financial status, history of sexual or physical abuse, or neglect
• Employment status
• Living situation and presence of children
• Quality of family relationships
• Cultural and religious beliefs about suicide

Strengths and vulnerabilities

• Coping skills
• Personality traits
• Past responses to stress
• Ability to reality test
• Capacity to tolerate psychological pain
• Ability to satisfy psychological needs

Protective factors

• Good social support and a social network
• Religious beliefs
• Reasons for living
• Responsibility for young children
• Problem-solving and effective coping skills
• Current engagement in treatment
• Hopefulness
• Treatment with evidence-based therapy 

Estimation of Suicide Risk

Suicide risk is related to 2 types of risk factors: static or unmodifiable risk factors and dynamic or modifiable risk factors. There are 2 types of dynamic risk factors: acute crises or changes that can be mitigated or modified by brief interventions, and longer-term conditions that are usually difficult to modify with short-term interventions, such as inpatient hospitalization and medication changes. The latter requires long-term treatment in an outpatient setting, usually with intensive psychotherapy. Examples of long-term dynamic risk factors include personality disorders, poor problem-solving skills, and substance use disorders that put a patient at a higher risk of suicide at baseline and make it more likely for the risk to increase in acute crises. 

A systematic review and meta-analysis of psychological autopsy studies examining risk factors for suicide in adults,[9] a recent review article,[23] literature reviews,[24][25] and The American Psychiatric Association Publishing Textbook of Suicide Risk Assessment and Management, https://psychiatryonline.org/doi/book/10.1176/appi.books.9781615375288, identify the following risk factors:

Static/unmodifiable risk factors

• Demographic factors, including age (some risk factors are age-stratified), male sex, white race, and less than a high school education
• Low socioeconomic status 
• Discharge from inpatient psychiatric treatment within the past week, month, and year
• Family history of mental disorders, suicide attempts, or suicide
• Loss of a parent in early childhood due to suicide
• Sexual minority status (particularly for adolescents and young adults)
• Adverse childhood experiences such as physical and emotional neglect, verbal abuse, physical abuse, sexual abuse, parental loss, parental incarceration, or living with a household member with mental illness or substance use disorder
• Previous suicide attempt—people with multiple attempts may be a different group from those who report suicidal ideations or have a single suicide attempt
• History of self-harm
• Non-suicidal self-injurious behaviors: Higher frequency and different methods confer higher risk
• Any mental disorder, including bipolar disorder, depression, anxiety, schizophrenia, substance use disorders, and eating disorders, especially with increased impairment
• Any personality disorder, especially borderline personality disorder 
  • For people with schizophrenia, depressive symptoms, positive symptoms, insight about the illness, young age, and being male confer a higher risk.
• Involvement with the criminal justice system or receiving state care in childhood
• Arrests/incarceration; a higher number of arrests increases the risk
• Military service
• Medical conditions, including epilepsy, traumatic brain injury, and chronic or terminal illness

Dynamic/clinically modifiable risk factors (short-term)

• Social isolation
• Unemployment
• New diagnosis of a chronic or terminal illness
• Access to lethal means, especially firearms
• Acute psychiatric illness
• Relationship conflict
• Legal problems
• Family-related conflict 
• Anxiety and agitation
• Hopelessness and feelings of failure
• Perceived worthlessness or burdensomeness on family/friends 
• Insomnia 
• Current thoughts of suicide: frequency, intensity, and duration
• Current plan for suicide
• Preparatory behavior for suicide 
• Current or recent alcohol or substance abuse
• Feeling trapped
• Recklessness and impulsivity
• Recent life events such as bereavement, divorce, loss of social support, financial crises, traumatic events, and other interpersonal stressors 

Suicide Risk Formulation

The suicide risk formulation is a careful synthesis by the psychiatrist or psychiatric-mental health clinician of the gathered information to determine if the acute risk is low, moderate, or high, and if the chronic risk is low or elevated. Such a formulation is needed for each initial presentation in an acute setting (emergency department or psychiatric inpatient unit intake), before discharge from a psychiatric inpatient unit, for outpatient clinic intakes, and whenever there is a significant change in a patient’s status, such as worsening mental illness, increased substance use, or stressful life events.

When documenting clinical judgments of acute or chronic risk, it is important to be as specific as possible, including describing a patient’s chronic risk as low or elevated based on their demographic features and psychiatric history. For example, a patient who has attempted suicide has an elevated chronic risk for suicide relative to an individual who has never attempted suicide; however, having an elevated chronic risk is not the same as having an elevated acute risk. A patient who has attempted suicide could have a lower acute risk if they are in intensive, weekly psychotherapy with medication management, their symptoms of psychiatric illness are in remission, and they have good social supports. Such a patient is likely to have a lower acute risk for suicide compared to an individual who has never attempted suicide but presents to the emergency department with worsening depression in the setting of no outpatient treatment, an absence of social supports, and recent job loss.

Screening instruments can serve as a starting point for a more detailed suicide risk assessment. Evidence-based screening tools include the Ask Suicide-Screening Questions, available in multiple languages; the Patient Safety Screener-3; and the Columbia-Suicide Severity Rating Scale, Screening Version, which are brief and easy to use. Depression screening alone is not adequate.[4] Some screening instruments have shown poor predictive value concerning suicide attempts and completions.[26] Simply adding risk factors and protective factors and comparing their respective quantities does not constitute a comprehensive assessment of risk. A patient may have relatively few dynamic risk factors for suicide and a plethora of protective factors; however, if this patient composed a suicide note before presenting to the emergency department, such a severe warning sign outweighs the relative number of risk and protective factors.

Even the most thorough of suicide risk assessments may not give a psychiatrist or psychiatric-mental health clinician an obvious answer to the question of safe disposition, as evaluations are specific to the person and situation with infinite permutations. Clear documentation of the clinical rationale for any decision is essential. For example, an outpatient intake of an individual who visited a gun store the week before and nearly bought a gun for the purpose of suicide evokes concern. Even in the absence of self-reported suicidal intent at the time of the evaluation, the psychiatrist may consider involuntary commitment if the patient refuses voluntary psychiatric hospitalization.

The psychiatrist or psychiatric-mental health clinician must also consider if there are reasonable steps that may be taken to mitigate risk. Suppose there are no significant additional risk factors. In that case, collateral information has been obtained, and the patient is willing to begin psychotherapy combined with medication and currently reports no suicidal intent or plan, the psychiatrist or psychiatric-mental health clinician must document that, in their clinical opinion, the motivation of the patient to undertake treatment and other protective factors sufficiently mitigate risk so that involuntary commitment is not required. Documenting the clinical rationale for the plan demonstrates that reasonable care was provided, as the clinical record clearly shows what information the clinician used to arrive at the suicide risk estimate and how the patient will be monitored.[21]

Clinical Vignette 1

Sheila is a 53-year-old woman with a history of major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder who is dropped off at the emergency department one evening by her husband on his way to work. Sheila has been more depressed over the past 2 months than normal, with intermittent thoughts of suicide. You are the psychiatrist or psychiatric-mental health clinician consulted to assess the severity of her depression and her suicide risk. Her blood alcohol level is negative, and her drug screen is negative for cannabis, opiates, cocaine, phencyclidine, benzodiazepines, and amphetamines. 

Sheila reports a history of psychotherapy and pharmacotherapy since her mid-teens. She denies any past manic or psychotic episodes, bingeing/purging/restricting, obsessive thoughts, or compulsive behavior. She says her anxiety is not worse than usual, and she denies trauma-related symptoms such as nightmares or flashbacks. Her father sexually abused Sheila as a child. Her mother was diagnosed with severe depression and was hospitalized after a suicide attempt by overdosing on prescription medications. Sheila has a master’s degree in education and works as a junior high school vice principal. She typically has a glass of wine at night, but this has increased to 3 to 4 glasses of wine every evening to help her sleep. Her last use of alcohol was yesterday evening. She occasionally uses cannabis with friends, with her last use roughly 6 months ago. She is married with 2 children in their 20s. She stated that a previous marriage ended because her ex-husband was verbally and physically abusive. In her teens and early 20s, Sheila occasionally had thoughts that life was not worth living. While an undergraduate, she once superficially cut her arm while she was intoxicated and reported that she had been more depressed leading up to this incident. This period of depression followed a suspected sexual assault when she blacked out at a party after drinking. She reports no other incidents of self-harm and no history of suicide attempts or psychiatric hospitalization.

Sheila is recently postmenopausal and has a history of hypothyroidism treated with levothyroxine. She reports that she had worsening hot flashes that interfere with her sleep. Six weeks ago, her gynecologist tapered her escitalopram from 20 mg daily to 10 mg daily and started venlafaxine extended release at 37.5 mg daily. Two weeks ago, escitalopram was discontinued, and venlafaxine was increased to 75 mg daily. She reports taking this medication as prescribed. Despite a marked improvement in hot flashes, she continued to have difficulty sleeping. Other symptoms include heightened irritability, anhedonia, increased appetite, poor concentration, and decreased energy. She finds meaning in her work and family, though she notes “fleeting” thoughts of “what’s the point of going on?” Sheila denied current thoughts of suicide, any recent or present suicide plan or intention, or any suicide preparations. She feels guilty about feeling sad when her family and colleagues are so supportive of her. She reports taking a few sick days from work due to fatigue, but has not had any significant problems at work. Her affect is constricted. There is no psychomotor retardation. Sheila denies auditory or visual hallucinations and does not appear paranoid or delusional.

She tells you that while she has not been doing well lately, she believes her husband was “overreacting” when he brought her to the emergency department. You call her husband to obtain collateral information. He reports that she has been increasingly tearful and “sleeps all day.” He said Sheila had agreed to see a psychiatrist again; for the past few years, her antidepressant medication had been managed by her primary care clinician and gynecologist. You asked him about various lethal means at home, and he says that he keeps a handgun in the nightstand drawer and has rifles and shotguns in a gun safe. He is not sure if his wife knows the passcode to the safe, but the nightstand drawer does not have a lock. He said he brought her to the emergency department after discovering her web browser open to a search of whether families receive life insurance benefits after the suicide of an insured person. The husband agreed to place all firearms in the gun safe and change the passcode. You broach the idea of inpatient treatment with Sheila; she wishes to go home and follow up with her previous psychiatrist.

As the psychiatrist or psychiatric-mental health nurse practitioner, you consider Sheila's static/unmodifiable/ chronic risk factors for suicide, which are the following:

• Psychiatric diagnoses of major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder
• Sexual and physical abuse starting in childhood
• Family history of psychiatric illness and suicide attempt
• Cannabis use and increasing alcohol use
• Self-harm behavior that may have been a suicide attempt
• White race
• Divorced
• Chronic medical illness (hypothyroidism)

You consider her dynamic/clinically modifiable/acute risk factors for suicide, which include these:

• Acute severe major depressive episode
• Insomnia
• Hopelessness
• Self-reported occasional thoughts of suicide without intent, plan, or preparation, yet preparatory behavior based on collateral information
• Increased alcohol intake
• Access to lethal means

 You consider her protective/risk-reducing factors for suicide, which include the following:

• Family and social support
• Treatment engagement and compliance with medication
• Sense of family responsibility
• Decreased availability of lethal means after the patient's husband agrees to lock up all guns

You consider to what degree her risk factors for suicide are mitigated by her protective factors for suicide, and what risk-reducing potential interventions are available. You addressed access to lethal means by having her husband agree to lock up all guns and change the combination to the gun safe. Insomnia can be alleviated by medications, which may decrease her alcohol use. Sheila is compliant with medication and wants to see her previous psychiatrist soon; however, even if venlafaxine extended release was increased to treat her severe depressive symptoms and augmentation with lithium was initiated, the onset of therapeutic effects is judged to be too long given her degree of depression and the presence of preparatory behavior. The preparatory behavior evident in her online searches about life insurance and suicide is the most compelling risk factor, especially as the patient was not forthcoming about this. Sheila is guarded, reducing the validity of her answers and increasing the risk. You decide that she is at higher acute risk for suicide, and the safest course of action is involuntary commitment for inpatient psychiatric treatment. You also order a thyroid function panel.

Clinical Vignette 2

A 36-year-old man is brought to the emergency department by ambulance at 3 am with thoughts of suicide after using cocaine. His medical record indicates a longstanding history of cocaine use disorder with a pattern of becoming suicidal after use. Previously, when the patient was admitted for inpatient psychiatric treatment, he demanded discharge after a day. You gently wake him up and try to interview him, but he raises his fist and screams and curses that you are in his space and need to get out.

Agitation is a safety risk for the patient, staff, and environment. Before evaluating the patient further, the psychiatrist or psychiatric-mental health clinician should ensure the environment is safe. Clinicians should maintain a calm demeanor, keep a safe distance, and ensure they can exit the room without interference. Other staff should be nearby. Before completing the history and physical examination, clinicians may need to implement nonpharmacological interventions (eg, verbal de-escalation, environmental modification, psychoeducation), pharmacologic treatment, or physical restraints.

Clinical Vignette 3

A 25-year-old man comes to an outpatient appointment with his wife, who is concerned that he may have obsessive-compulsive disorder because he always checks before he drives to see if the car turn signals and headlights are working. This checking routine does not take an inordinate amount of time, causes him no distress, and does not result in him being late. In fact, if he is running late for work, he skips his usual checks. A full psychiatric evaluation reveals no past or present symptoms indicating a psychiatric diagnosis. 

In this instance, documenting a separate risk formulation stating the individual has static risk factors of being white and male, documenting the absence of dynamic risk factors, and outlining protective factors may be unnecessary. A complete psychiatric assessment for a new patient includes assessing current thoughts or plans of suicide (as well as assessing if the patient is a danger to others), any history of suicidal thoughts or attempts, access to weapons, and a social history that explores any financial, legal, or relationship difficulties that would increase risk. Psychiatrists or psychiatric-mental health clinicians working in a private practice may have different formats for documenting risk than clinicians working for an institution; however, a complete psychiatric assessment includes assessing and documenting whether a patient poses a danger to themselves.

Evaluation

Screening tests for suicidality are detailed above. Substance use, especially alcohol use, is a risk factor for suicide, and there should be a low threshold for obtaining toxicology testing as clinically appropriate.[27] No laboratory, radiographic, or other tests are required to evaluate suicidality; such tests should be obtained as clinically appropriate.

Treatment / Management

Once a clinician determines the risk level, further management involves the following components:

• Determining disposition and level of care
• Brief interventions in the acute setting
• Longer-term interventions and continued treatment

Disposition and the Level of Care

In considering disposition and the appropriate level of care, it is important to consider:

• Least restrictive environment: The least restrictive environment or setting involves balancing the principles of beneficence and non-maleficence with patient autonomy. When a high-risk individual who is an imminent danger to themselves is unwilling to agree to voluntary admission, the clinician must ensure the patient’s safety by involuntary admission to an inpatient psychiatric unit or by an involuntary hold in an emergency department.[28]
• Available resources: Patients who are an imminent danger to themselves may be held in the emergency department until an inpatient psychiatric placement is available or securely transported to another facility that has an available bed on an inpatient psychiatric unit.
• Inpatient psychiatric hospitalization is the standard of care for patients with high suicide risk. However, the relationship between hospitalization and future suicidal behaviors is poorly understood. A recent study on patients seen at the Veterans Health Administration used machine learning on observational data, and the results found that hospitalization was associated with reduced suicide attempt risk only among individuals who had attempted suicide in the prior day, underscoring the importance of individualized treatment approaches. The study's results also noted that suicide risk is only one of many reasons for a patient to be hospitalized for psychiatric treatment.[29]
• The "safety contract" or no-suicide agreement has been shown to produce worse outcomes than no intervention.[30]
(B3)

The options of either hospitalizing people or sending them home do not address other aspects of suicide risk. People hospitalized for brief periods may still be at elevated risk after discharge. Sending an individual home with a future appointment is not always sufficient, as many patients fail to attend their scheduled appointments. Suicide risk is drastically increased in the 3-month period after discharge from a psychiatric facility and for a year after emergency department visits.[31][32] (A1)

Brief Interventions in Acute Settings

Brief interventions address treatment engagement, access to means, psychological and physical problems, suicidal ideation, and suicide attempts. The focus is on immediate suicide risk reduction and transition to ongoing mental health treatment. Brief interventions are associated with improved patient outcomes, including reductions in suicide deaths and non-fatal attempts, and increased follow-up care.[33][34][35](A1)

The most common components of brief acute care suicide prevention interventions include the following:

• Care coordination includes communication between the clinical team referring the patient for mental health care and the team receiving the patient for follow-up care. Aspects of care coordination also include scheduling an outpatient appointment for mental health care, scheduling a mobile crisis team evaluation, and collaborating with the patient's family to decrease barriers to attending appointments.
• Safety planning intervention components include the following: identifying personal warning signs of suicidality; determining internal coping strategies; identifying family, friends, and social outlets that can distract from suicidal thoughts; identifying individuals who can provide support during a crisis; listing mental health and urgent care services to contact during a crisis; and lethal means counseling to make the environment safer, including securely locking up or removing firearms. The goal is to reduce suicidal behavior by establishing coping strategies and a support network.[36][37][38][39] Engaging the patient actively and collaboratively in this process is essential; discussing ways to continue engaging with the plan and involving social supports and outpatient clinicians is also essential.[40] 
• Brief follow-up contacts include telephone calls, postcards, letters, and handwritten notes, either as a single contact or multiple contacts. Trained counselors respond to patients' responses with supportive statements or facilitate mental health treatment.
• Brief therapeutic interventions, eg, with brief telephone calls or single in-person encounters, aimed at preventing patients from engaging in suicidal behaviors and encouraging ongoing mental health treatment.
(A1)

Lethal means restriction is one of the most significant evidence-based methods that reduces suicidal behaviors.[6][41][42] In the United States, lethal means restriction primarily focuses on firearm safety, given the high lethality and the rate of suicide deaths by firearms compared with other high-income countries.[43] There are 2 aspects to lethal means restriction of firearms: counselling delivered in clinical settings that focuses on personal gun safety, often recruiting people from the patients’ social network to facilitate the removal of firearms; and legislative means such as state Extreme Risk Protection Order Laws allowing the removal of firearms from individuals who are assessed to be at a high risk of harm to themselves or others. While the latter is effective,[44] the former method mobilizes the patient's agency and social support. Additional consideration should be given to the relationship between Black, Indigenous, and People of Color and law enforcement. Coordination with a patient’s family in lethal means restriction rather than involving law enforcement may prevent potentially traumatic encounters. (A1)

Addressing other means when counselling about lethal means restriction is also important. While there is always a concern that the individual will substitute other means for the ones initially decided on, most often they do not—and even when they do, the secondary means identified may be less lethal and lead to fewer deaths. Priority should be given to other lethal methods by preventing jumping from heights by creating physical barriers and regulating hazardous agents such as pesticides.[45] 

Evidence-Based Psychotherapies for Longer-Term Treatments 

Various types of psychotherapy are efficacious in decreasing suicidal ideation and self-harm:

• Cognitive behavioral therapy teaches problem-solving and adaptive coping skills while addressing cognitive distortions leading to suicidal feelings and urges.[5]
• Dialectical behavior therapy develops emotional regulation, distress tolerance, and interpersonal effectiveness skills.[5][6][46]
• Mentalisation-based therapy teaches patients to conceptualize their behavior regarding thoughts and emotions.[5]
• Psychodynamic psychotherapies for borderline personality disorder have been found to prevent suicidal or self-harm behavior in most controlled studies.[47]
• Emotion-regulation psychotherapy is based on dialectical behavior therapy, acceptance and commitment therapy, and emotion-focused psychotherapy.
• Interpersonal Therapy for Borderline Personality Disorder.[48]
• Dynamic deconstructive psychotherapy has been shown to be beneficial.[49][50][51]
• Brief intervention and contact: This World Health Organization protocol has been shown to reduce suicidal behaviours post-intervention.[52]
• Substance use treatment/programs that target both mental and substance use disorders have been shown to be beneficial. Subsequent suicide attempts are reduced after interventions targeting alcohol and opioid use.[5]
(A1)

Evidence-Based Somatic Treatments

Medications and somatic treatments that have been found to have protective effects against the risk of suicide include the following:

• Lithium significantly reduces the risk of suicide compared to placebo or no intervention and is especially effective for individuals with bipolar disorder. Antiepileptic mood stabilizers were associated with a higher risk of suicide when compared to lithium.[53][54]
• Clozapine reduces the risk of suicide for individuals with psychotic disorders.[53][54]
• Antidepressants are associated with the reduction or resolution of suicidal ideation in most cases. There is a Food and Drug Administration (FDA) warning regarding using antidepressants in young people; however, there are multiple discrepancies in the research. Antidepressants are associated with a reduced suicidality risk in psychiatric patients.[5][53][55]
• Ketamine/esketamine both have anti-suicidal effects for patients with depression and suicidality, but the efficacy is transient, lasting no longer than a week; a limitation is the lack of literature demonstrating a reduction in suicide completion.[53][56]
• Electroconvulsive therapy (ECT) may reduce suicide risk among hospitalized individuals who are severely depressed, particularly older adults and patients with psychotic features.[57][58] However, some meta-analyses showed that the association between ECT and a lower risk of suicide did not achieve statistical significance.[54]
• Repetitive transcranial magnetic stimulation may reduce suicidal ideation.[6][46][59][60]
• Methadone and buprenorphine reduce rates of suicide in people with substance use disorders.[61]
(A1)

Differential Diagnosis

Differential diagnoses in suicide include the following:

• Obsessive-compulsive disorder: Some obsessional themes involve violent or suicidal content. Suicidal obsessions are unwanted and intrusive thoughts of suicide that are recurrent and persistent and cause marked anxiety and distress. These thoughts are not consistent with one's sense of self and are experienced as ego-dystonic. Individuals can have obsessional thoughts about suicide while retaining a strong desire to live and tend to experience distress in their affective response to the content of their obsessions. Individuals with obsessional thoughts of suicide tend to avoid people, places, and objects associated with suicide. Differentiating suicidal ideation from obsessional thoughts of suicide can be challenging for the clinician. (https://doi.org/10.1016/j.cbpra.2022.09.002)
• Posttraumatic stress disorder: Individuals may contemplate suicide as an escape from flashbacks.[62]
• Alcohol use disorder: Individuals may not be able to resist suicidal thoughts when disinhibited while intoxicated.[62]
• Mourning: Individuals may think of suicide as a way to "join" the recently deceased, particularly if they were close or significant.  https://https://www.researchgate.net/publication/344428740_Suicidal_Risk_Definition_Contexts_Differential_Diagnosis_Neural_Correlates_and_Clinical_Strategies/publication/344428740_Suicidal_Risk_Definition_Contexts_Differential_Diagnosis_Neural_Correlates_and_Clinical_Strategies
• Malingering: Individuals may present themselves as ill or impaired, but falsify their symptoms for external incentives. The individual should be observed for a marked discrepancy between their symptoms and the objective findings and observations.

Pertinent Studies and Ongoing Trials

Electronic health records screening for suicidality using artificial intelligence, internet-based screening, and smartphone passive monitoring to identify high-risk patients is understudied, but it also raises privacy concerns. Machine learning has been applied to the prediction of suicidal behavior and large electronic health records data sets, but has a low positive predictive value due to the low base rate of suicidal behavior in the population.[5][63] Studies assessing neuroinflammation using the neutrophil-to-lymphocyte ratio, the platelet-to-lymphocyte ratio, and the monocyte-to-lymphocyte ratio as indicators of systemic inflammation related to suicidality highlight the need for further research in this area.[64]

Prognosis

Even though it is very difficult to predict suicidal behavior, it is possible to reduce the risk of suicide. Healthcare systems must integrate medical and psychiatric care to build cultures of safety and prevention in a supportive organizational environment. Assessments of suicide risk must engage with the patient as an individual, obtain their own perspective and narrative, and elicit their reasons to live. Understanding the patient's environment and stressors and helping them develop a plan for when life seems not worth living is crucial in suicidal prevention. The prognosis is improved if help is offered in time.[65]

Complications

Contingency-Based Suicidality

One challenging clinical situation in the emergency department or the inpatient psychiatry unit is a patient with contingency-based suicidality. These are patients who come to the hospital repeatedly, usually for psychosocial issues such as homelessness and lack of social supports, or for chronic medical or substance use problems. Their situation lies at the intersection of a lack of adaptive problem-solving skills and systemic problems of limited access to social services and resources.

According to Jackson and Riggall, these situations are challenging for clinicians because “pressure is created by current treatment standards that creates a burden to take responsibility or agency for that which the therapist ultimately has no control over” (2024, p 35, https://www.upstate.edu/psych/pdf/group-ddp-final-5-7-24.pdf). Under these circumstances, it is especially important to perform a detailed suicide risk assessment and carefully document the dynamic and static risk factors, protective factors, and any acute crises, as well as the plans for their management.

According to Bundy et al (2014), in "Discharging Your Patients Who Display Contingency-Based Suicidality: 6 Steps," (https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/e1_0114CP_PRLS_Bundy_FINAL.pdf), contingency-based suicidal ideation can be managed by:

• Step 1: Define and document the situation, clinical dilemma, or impasse.
• Step 2: Assess and document current suicide risk, including chronic/static and dynamic risk factors, protective factors, acute stressors (or lack of acute stressors), and access to lethal means. Interpret any contingency-based suicidal statements.
• Step 3: Document how dynamic risk factors have been addressed or modified and how protective factors have been reinforced during the treatment. Outline a plan for addressing dynamic risk factors and protective factors.
• Step 4: Document the rationale for why further management in an acute setting would not be beneficial. This may include the patient’s lack of participation in the care offered, the inability to improve, or how continued care interferes with more effective means to address risk factors and would be counterproductive to treatment and the patient’s identified goals.
• Step 5: Document your discussion with the patient of the rationale for discharge, the patient's understanding of the discussion, and the absence of any factors that would impair their decision-making, such as severe psychosis, cognitive impairment, or intoxication. The discussion and documentation should reiterate the ongoing treatment plan and the patient's responsibility for their decisions. 
• Step 6: Consult with a colleague, document the discussion, and ask them to document the consultation.

Patients who make contingency-based threats of suicide may have presented to emergency settings multiple times for chronic financial reasons, substance use, or lack of housing. A careful medical record review helps the clinician assess chronic suicidality and identify changes in dynamic risk factors. Obtaining collateral information is also necessary.

Clinical Vignette

A 62-year-old man arrives at the emergency department in the evening, reporting thoughts of suicide. Earlier the same day, he was discharged from the inpatient psychiatric unit after being treated for suicidal thoughts in the setting of severe alcohol use disorder. He has outpatient psychiatric and substance use follow-up appointments scheduled for tomorrow. Before you speak with him, you watch him unobserved. He is sitting up on the stretcher, smiling and joking with the nurses, asking for coffee and a turkey sandwich. He says playfully to the nurse, “Where have you been all my life?” When you approach him and introduce yourself, he appears somnolent, with the bedsheets pulled over his head. He acts as though he cannot wake up to meet with you. You speak with one of the nurses and are told that the patient has mentioned that there are a couple of women patients on the unit that he’d like to see again.  

Before discharging this patient, it is essential to document that the patient has various static risk factors for suicide that are demographic and are not clinically modifiable. His dynamic risk factors and how they are mitigated must also be clearly stated. Importantly, obtain a toxicology screen to assess him for current substance use and check with his family for collateral information. His dynamic risk factors of substance use and recent discharge from a psychiatric unit are mitigated by close outpatient follow-up. Documenting his incongruent affect and statements made to nurses, which suggest his presentation to the emergency department is motivated by external gain, is crucial. Such reasoning must be explicit in the clinician's documentation because the patient may threaten suicide if told that he is going to be discharged.