How do I document and manage a patient with no current risk factors for suicidal ideation (SI) or intent?

From the Guidelines

To document and manage a patient with no current risk factors for suicidal ideation or intent, conduct a basic suicide risk assessment during routine visits, documenting "No suicidal ideation, plan, or intent reported" in their chart, as recommended by the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines 1. When assessing a patient with no current risk factors for suicidal ideation or intent, it is essential to consider the importance of evaluating suicide risk, despite the lack of current risk factors. According to the 2016 study on suicide and suicide attempts in adolescents, an absence of factors that indicate high risk does not necessarily mean the patient is at low risk 1.

Key Considerations

• Ask direct questions like "Have you had thoughts of harming yourself?" and document both the questions asked and the patient's responses.
• Note protective factors such as strong social support, religious beliefs, or future-oriented goals.
• For ongoing management, continue periodic screening at regular visits, especially during major life changes or when starting medications with potential psychiatric side effects.
• Educate patients about warning signs of depression and provide resources like the National Suicide Prevention Lifeline (988).

Documentation and Management

The documentation of a basic suicide risk assessment protects both the patient and provider by establishing that suicide risk was appropriately evaluated, even when no risk factors were present. This approach creates a baseline assessment that helps identify changes in future visits while normalizing mental health discussions. As noted in the 2019 study, evaluation of suicide risk is a critical function of both mental health and primary care providers, and using several means to evaluate risk, such as self-reported measures and clinical interviews, is recommended 1.

From the FDA Drug Label

1. 1 Suicidal Thoughts and Behaviors in Pediatric and Young Adult Patients

In pooled analyses of placebo-controlled trials of antidepressant drugs (SSRIs and other antidepressant classes) that included approximately 77,000 adult patients and over 4,400 pediatric patients, the incidence of suicidal thoughts and behaviors in pediatric and young adult patients was greater in antidepressant-treated patients than in placebo-treated patients. Monitor all antidepressant-treated patients for clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy and at times of dosage changes Counsel family members or caregivers of patients to monitor for changes in behavior and to alert the healthcare provider.

• Documentation of seriousness of intent: Since the patient has no current risk factors for suicidal ideation (SI) or intent, document the patient's current mental status, including the absence of suicidal thoughts or behaviors.
• Duty to protect and warn: Although the patient is not currently at risk, continue to monitor for changes in behavior and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy and at times of dosage changes.
• Actions taken: Counsel the patient and their family members or caregivers to monitor for changes in behavior and to alert the healthcare provider if any concerns arise 2.

From the Research

Documenting Seriousness of Intent and Duty to Protect

When a patient has no current risk factors for suicidal ideation (SI) or intent, it is essential to document the seriousness of intent and thinking regarding duty to protect and warn, as well as actions taken. The following points should be considered:

• Assess the patient's mental status and document any changes or concerns 3
• Evaluate the patient's risk factors, including history of suicidal behavior, depression, and anxiety 4, 5
• Consider the patient's age, sex, and other demographic factors that may impact their risk of suicidality 5
• Document any previous suicidal ideation or attempts, as well as any non-suicidal self-injury (NSSI) 5

Managing a Patient with No Current Risk Factors

To manage a patient with no current risk factors for SI or intent, the following steps can be taken:

• Monitor the patient's mental status and adjust their treatment plan as needed 3
• Provide education and support to the patient and their family members 6
• Consider the use of selective serotonin reuptake inhibitors (SSRIs) or other medications to reduce the risk of suicidality 4, 5
• Develop a safety plan with the patient, including strategies for managing suicidal thoughts and behaviors 7

Actions Taken

The following actions should be taken when documenting and managing a patient with no current risk factors for SI or intent:

• Document all assessments, interventions, and patient interactions in the patient's medical record 3
• Communicate with other healthcare providers and family members as needed to ensure the patient's safety 7
• Review and update the patient's treatment plan regularly to ensure it remains effective and relevant 6
• Consider consulting with a mental health specialist or other experts as needed to ensure the patient receives comprehensive care 5