What is the next step in management after treating a patient's wounds for a failed suicide attempt?

Management After Treating Wounds from a Failed Suicide Attempt

After medically stabilizing a patient following a suicide attempt, immediately conduct a comprehensive psychiatric risk assessment to determine the appropriate level of care—either inpatient psychiatric hospitalization for high-risk patients or structured outpatient follow-up with safety planning for lower-risk patients. 1

Immediate Psychiatric Risk Assessment

Once the patient is medically stable, perform a thorough psychiatric evaluation that includes:

• Mental status examination assessing mood, anxiety level, thought content (including ongoing suicidal ideation, hallucinations, delusions), thought process, perception, and cognition 2
• Current suicidal intent and planning—specifically ask if the patient still wishes to die and whether they have formulated any plans 1, 2
• Assessment of hopelessness, which is a critical predictor of future suicide risk 2
• Access to lethal means, particularly firearms, medications, pesticides, and other toxic substances in the home 1, 2
• Substance use history and current intoxication, as this significantly increases risk 2, 3
• Previous suicide attempts, especially those using high-lethality methods 2, 3
• Psychiatric diagnoses, particularly depression, schizophrenia, bipolar disorder, and borderline personality disorder 2, 3

Determining Level of Care: Inpatient vs. Outpatient

High-risk patients requiring inpatient psychiatric admission include those who: 1, 4

• Continue to endorse a persistent desire to die despite intervention
• Remain severely agitated, hopeless, or cannot engage in safety planning discussions
• Made a high-lethality attempt with clear expectation of death
• Have inadequate support systems or cannot be adequately monitored at home
• Present with psychotic symptoms (delusions, hallucinations)
• Have comorbid substance abuse with current intoxication or withdrawal
• Display high impulsivity with dysphoric mood
• Are male adolescents aged 16-19 or older adults (highest risk demographics) 2, 4

Lower-risk patients eligible for outpatient management must meet ALL of the following criteria: 1, 2

• No active suicidal intent or specific plan after comprehensive evaluation
• Able to engage meaningfully in safety planning discussions
• Adequate outpatient support structure with responsible adult supervision
• Agreement from a responsible adult to remove all lethal means from the home
• Willingness to attend immediate follow-up appointments

Safety Planning for Patients Not Requiring Hospitalization

Develop a collaborative crisis response plan that includes: 1

1. Warning signs and triggers—specific behavioral, cognitive, affective, or physical signs that indicate crisis recurrence 1
2. Self-management coping strategies—concrete steps the patient can take independently to distract from stressors or reduce distress 1
3. Healthy distraction activities—specific activities that could suppress suicidal thoughts 1
4. Social support contacts—names and phone numbers of friends and family members the patient feels comfortable contacting 1
5. Professional crisis resources—contact information for mental health providers, emergency services, and the National Suicide Prevention Lifeline (988) 1
6. Scheduled follow-up appointments—definite, closely-spaced appointments within days of discharge 1, 5

Lethal Means Restriction Counseling

Means restriction is a critical component of discharge planning because: 1

• 24% of suicide attempts occur within 0-5 minutes of deciding, 24% within 5-19 minutes, and 23% within 20 minutes to 1 hour—most attempts are highly impulsive 1
• Case-fatality rates vary dramatically: 85% for firearms, 2% for ingestions, 1% for cutting 1
• Patients typically misjudge the lethality of their chosen method 1

Specific counseling must include: 1

• Firearms: Temporarily relocate all firearms to relatives, friends, or law enforcement; if families refuse removal, insist on locking all firearms unloaded in tamper-proof safes with ammunition stored separately 1
• Medications: Lock up all prescription and over-the-counter medications 1
• Other means: Secure knives, remove pesticides (particularly relevant in agricultural settings), and restrict alcohol access 1, 6
• Extended environment: Address access to lethal means in homes of friends and family members the patient may visit 1

Evidence-Based Psychotherapeutic Interventions

Initiate or arrange for cognitive-behavioral therapy (CBT) focused on suicide prevention, as this reduces the risk of post-treatment suicide attempts by half compared to treatment as usual 1, 5, 4

For patients with borderline personality disorder, dialectical behavior therapy (DBT) is superior to standard therapy, reducing both suicidal ideation and repetition of self-directed violence 1, 5

Problem-solving therapy, a specific type of CBT aimed at improving coping with stressful life experiences, has demonstrated effectiveness for at-risk patients 1

Follow-Up Care and Ongoing Contact

Schedule definite, closely-spaced follow-up appointments before discharge—the greatest risk of reattempting suicide occurs in the months immediately after an initial attempt 1, 5

Implement periodic caring communications (postcards, letters, phone calls) for at least 12 months, as repeated contact reduces rates of suicide death, attempts, and ideation 1

Maintain flexibility in arranging urgent appointments if a crisis arises between scheduled visits 5

Ensure coordinated care between emergency department, inpatient services (if applicable), outpatient mental health providers, and primary care 7, 6

Pharmacological Considerations for Underlying Psychiatric Conditions

For major depression with suicidal ideation: Start SSRI antidepressants combined with CBT, as treatment decreases suicide risk among depressed patients 4

For treatment-resistant cases with acute suicidal ideation: Consider ketamine infusion (0.5 mg/kg single dose), which provides rapid improvement in suicidal ideation within 24 hours, lasting at least 1 week 4

For bipolar depression: Lithium maintenance therapy reduces suicidal behaviors and deaths 4

For schizophrenia with suicidal ideation: Clozapine reduces suicidal behaviors 4

Critical Pitfalls to Avoid

Do not rely on "no-suicide contracts"—these have no proven efficacy in preventing suicide and may impair therapeutic engagement 1, 2

Do not use coercive communications such as "you can't leave until you say you're not suicidal," as this encourages deceit and undermines the therapeutic alliance 2

Do not discharge patients with ongoing agitation, threatening violence, delusions, or hallucinations without psychiatric evaluation 2

Do not rely solely on structured suicide risk scales—these have limited predictive value and must be combined with comprehensive clinical assessment 2, 4

Documentation Requirements

Document the following in the medical record: 2

• Comprehensive psychiatric evaluation findings
• Specific risk factors identified and protective factors present
• Estimate of suicide risk level with rationale
• Treatment plan selected with justification for level of care decision
• Safety plan components discussed
• Lethal means restriction counseling provided
• Follow-up arrangements confirmed
• Responsible adult's agreement to supervise and remove lethal means