Diagnosing Suicidal Ideation: Clinical Criteria and Assessment Framework
Suicidal ideation is diagnosed through a comprehensive psychiatric evaluation that systematically assesses current thoughts of death or suicide, intent, plan, access to means, mental state, and underlying psychiatric disorders—not through laboratory tests or imaging studies. 1, 2
Core Diagnostic Elements
Direct Assessment of Suicidal Thoughts
The diagnosis requires direct questioning about:
- Active or passive thoughts of suicide or death - Ask specifically whether the patient thinks about suicide and how often 1
- Intent - Determine if the patient wants to die or act on suicidal thoughts 1
- Specific plan - Assess whether the patient has formulated a method for suicide 3, 4
- Access to means - Document availability of firearms, medications, or other lethal methods 1, 2
- Timeline - Establish the patient's intended course of action if symptoms worsen 1, 2
Distinguishing Passive from Active Ideation
Passive suicidal ideation involves death wishes without intent or specific plans (e.g., "I wish I wouldn't wake up," "others would be better off without me") 5. Active suicidal ideation includes formulated plans and intent to act 5. This distinction is critical but passive ideation should never be dismissed as unimportant, as it may represent the only way a patient can ask for help 5.
Mental Status Examination Requirements
Document the following psychiatric findings: 1, 2
- Mood state - Depression, mania, hypomania, mixed states, or severe anxiety 1
- Hopelessness - This is a critical risk factor that must be documented 1, 2
- Thought content - Recurring thoughts of death, worthlessness, guilt 1
- Psychotic symptoms - Delusions, hallucinations, or command hallucinations 1
- Agitation or irritability - These increase immediate risk 1
- Cognitive function - Concentration, decision-making capacity 1
Essential Risk Factor Documentation
Psychiatric History
The diagnosis requires assessment of: 1, 2
- Current psychiatric disorders - Particularly mood disorders, substance abuse, psychotic disorders 1, 6, 7
- Previous suicide attempts - This greatly increases risk, especially in males 1
- Comorbid substance abuse - Especially when combined with mood disorders 1, 7
- Impulsivity - Associated with higher risk 1, 7
Psychosocial Stressors
Document specific precipitants: 1
- Family conflict, romantic relationship breakup, bullying 1
- Academic difficulties, legal troubles, disciplinary actions 1
- Financial, housing, or occupational problems 1
- Recent losses or humiliation 1
Trauma and Abuse History
Systematically assess: 1
- History of childhood sexual or physical abuse 1, 7
- Exposure to violence or combat 1
- Sexual victimization 1, 7
Demographic Risk Factors
Note high-risk characteristics: 1, 2
- Male sex (5 times higher completion rate) 1
- Age 16-19 years or older adults 1, 2
- LGBTQ+ youth 1
- American Indian/Alaska Native ethnicity 1
- Living alone or lack of social support 1
Information Sources
Assessment information must be drawn from multiple sources: 1
- Direct interview with the patient 1
- Parents or guardians (for adolescents) 1
- School reports 1
- Other individuals close to the patient 1
Medical Evaluation Parameters
The focused medical assessment should include: 1
- Vital signs, general appearance, nutritional status 1
- Current medications and side effects 1
- Neurological examination for coordination, gait, involuntary movements 1
- History of head injuries or neurological disorders 1
Routine laboratory testing and brain imaging are NOT indicated unless specific findings on history or physical examination suggest medical causes 1. The current evidence shows that routine diagnostic testing in psychiatric patients is low yield and unlikely to affect management 1.
Critical Pitfalls to Avoid
Do not rely on suicide screening scales alone - Structured questionnaires have limited predictive value and should never replace thorough clinical assessment 1, 2
Never use "no-suicide contracts" as a basis for diagnosis or disposition - These have no proven efficacy and may impair therapeutic engagement 2
Avoid coercive communications - Statements like "you can't leave until you say you're not suicidal" encourage deceit and undermine the therapeutic alliance 2
Do not minimize "gestures" - This term is misleading because seemingly minor attempts can precede completed suicide 1
Never discharge patients with active psychosis, agitation, or threatening behavior without psychiatric evaluation 1
Documentation Requirements
Your assessment must document: 2