Suicide Risk Assessment Questions for Psychiatric Mental Health Hospital Intake
As a PMHNP conducting intake assessments for suicidal patients in a mental health hospital, you must systematically ask specific questions across multiple domains, avoiding negatively-phrased questions that bias patients toward denying suicidality.
Core Assessment Domains
1. Suicidal Ideation, Intent, and Behavior
Ask these specific questions in this order 1, 2:
- "Have you felt so upset that you wished you were not alive or wanted to die?"
- "Have you thought about killing yourself?"
- "Do you have a plan to kill yourself? If yes, what is your plan?"
- "Have you done anything to prepare to kill yourself?" (e.g., acquiring means, writing notes, giving away possessions)
- "Have you tried to kill yourself in the past year? In your lifetime?"
- "Have you done something dangerous where you could have been killed?"
- "Have you hurt yourself on purpose?"
Critical caveat: Avoid negatively-phrased questions like "No thoughts of harming yourself?" These bias patients toward denying suicidality—patients are significantly less likely to disclose when asked this way 3, 4. Instead, use positively-phrased or neutral open questions.
2. Current Suicidal Intent Assessment
For patients endorsing current ideation 1, 2:
- "What is your intended course of action if your symptoms worsen?"
- "Do you still want to die right now?"
- "What are your reasons for wanting to die?" (e.g., escape pain, revenge, reunion with deceased, command hallucinations)
- "What are your reasons for living?" (e.g., responsibility to children, religious beliefs, future plans)
- "On a scale of 0-10, how strong is your wish to die versus wish to live?"
3. Access to Lethal Means
- "Do you have access to firearms? Where are they kept?"
- "Do you have access to medications that could be lethal? Which ones and where?"
- "Do you have access to other means?" (pesticides, toxic substances, high places)
Document this and ensure family/caregivers are explicitly instructed to remove or secure these means 5.
4. Mental Status and Psychiatric Symptoms
Assess current mental state 1, 5:
Depression indicators:
- Depressed mood most of the time
- Loss of interest/pleasure in activities
- Sleep disturbance (insomnia or hypersomnia)
- Appetite/weight changes
- Psychomotor agitation or retardation
- Fatigue, loss of energy
- Worthlessness or excessive guilt
- Hopelessness about the future (critical predictor)
- Difficulty concentrating, indecisiveness
- Irritability
Mania/hypomania indicators:
- Elated, expansive, or irritable mood
- Decreased need for sleep
- Pressured speech, racing thoughts
- Grandiosity
- Distractibility
- Agitation or restlessness
- Impulsive behaviors (hypersexuality, reckless spending)
Psychotic symptoms:
- Hallucinations (especially command hallucinations to harm self)
- Delusions (especially guilt, persecution, nihilistic themes)
5. Substance Use
- Current alcohol or drug use (type, frequency, amount)
- Recent intoxication or withdrawal
- History of substance use disorders
- Warn about disinhibiting effects of alcohol/drugs on suicidal behavior 5
6. History and Risk Factors
- Number of previous attempts
- Methods used (attempts other than ingestion/superficial cutting = higher risk)
- Medical lethality of attempts
- Degree of planning involved
- Steps taken to avoid discovery
- Time since last attempt
Demographics and social factors 1, 5:
- Age (older adolescents/young adults at higher risk)
- Gender (males at higher risk for completed suicide)
- Living situation (alone, runaway, homeless = higher risk)
- Recent interpersonal losses or conflicts
- Legal or disciplinary problems
- Financial, housing, occupational stressors
- Social support availability
- Cultural factors and beliefs about suicide
7. Family and Trauma History
- Family history of suicide, suicide attempts, or psychiatric illness (especially bipolar disorder)
- History of physical, sexual, or emotional abuse
- Exposure to violence or combat
- Recent traumatic events or losses
8. Medical History
Document 1:
- Chronic pain conditions
- Terminal or disfiguring illnesses
- Recent medical diagnoses
- Current medications
Interview Technique Recommendations
Do's:
- Interview patient and collateral sources (family, prior providers) separately and together 6, 2
- Use open-ended questions when possible to elicit narrative responses 3, 4
- When using closed questions, phrase them neutrally or positively (not "You're not thinking of suicide, are you?")
- Assess throughout hospitalization, not just at intake 7
- Document inability to guarantee safety rather than asking patients to predict future behavior 4
Don'ts:
- Don't rely solely on patient self-report—always obtain collateral information 5
- Don't use coercive language ("Unless you promise not to attempt suicide, I'll keep you here") 2
- Don't ask patients to predict if they'll be suicidal or guarantee safety—they cannot reliably do this 4
- Don't tie questions to discharge ("Can you keep yourself safe overnight so we can discharge you?") 4
- Don't skip detailed questions even if patient denies suicidality on screening—44% of patients with aborted attempts initially deny them 8
Risk Stratification
Highest risk patients requiring psychiatric admission 5, 6:
- Persistent wish to die despite intervention
- Abnormal mental state (severe depression, mania, psychosis, agitation, severe anxiety)
- Recent high-lethality attempt with clear expectation of death
- Multiple prior attempts
- Active substance intoxication
- Command hallucinations to self-harm
- Inability to engage in safety planning
- Inadequate support system or supervision
- Access to lethal means that cannot be secured
Document 1:
- Estimate of suicide risk level
- Specific factors influencing risk (both increasing and protective)
- Rationale for level of care decision
This structured approach ensures comprehensive assessment while avoiding common pitfalls that lead to missed disclosures of suicidality.