Criteria to Diagnose Danger to Self
No validated criteria exist for assessing level of risk for subsequent suicide or determining level of care, but most experts agree that patients who continue to endorse a desire to die, remain agitated or severely hopeless, cannot engage in safety planning discussions, lack adequate support systems, cannot be adequately monitored, or had high-lethality suicide attempts with clear expectation of death should be considered at high risk of danger to themselves. 1
Core Assessment Domains
When evaluating a patient for danger to self, the psychiatric evaluation must systematically assess multiple domains 2:
Current Suicidal Ideation and Intent
- Direct questioning about active or passive thoughts of suicide or death 2
- Specific plans for self-harm and intended course of action if symptoms worsen 2
- Access to lethal means, particularly firearms 2
- Severity of suicidal intent and expectation of death from any recent attempt 1
Psychiatric Symptoms
- Hopelessness (one of the strongest predictors) 2
- Severity of depression 2
- Presence of psychosis, command hallucinations, or delusional guilt 2
- Level of agitation and impulsivity 2
- Comorbid substance abuse 1
Historical Factors
- Lifetime history of suicide attempts 2
- Recent self-directed violence within the past 6 months 2
- Previous high-lethality attempts 1
Protective Factors
- Reasons for living 2
- Quality of therapeutic alliance 2
- Availability of social support and confidants 2
Social Determinants
- Psychosocial stressors 2
- Lack of social support or living alone 2
- Ability to be adequately monitored or receive follow-up care 1
High-Risk Indicators Requiring Immediate Intervention
Psychiatric hospitalization is strongly indicated when the following high-risk indicators are present 2, 3:
- Persistence in endorsing a desire to die 1, 2
- Continuous agitation or severe hopelessness 1, 2
- Inability to participate in safety planning 1, 2
- Inadequate support system or inability to be monitored 1, 2
- Previous high-lethality suicide attempts (gunshot, hanging, jumping) 2, 3
- Active substance use disorder 2
- Serious depression with psychotic features 2
- Florid psychosis with severe agitation, paranoia, or command hallucinations 3
Additional Risk Stratification Factors
While no specific tool is recommended for risk stratification 1, consider these additional factors 1:
- Gender (males have higher completion rates) 1
- High levels of anger or impulsivity 1
- Recent discharge from psychiatric hospitalization (highest risk period) 1
Critical Pitfalls to Avoid
Do not rely on "no-suicide contracts" as they have not been proven effective in preventing suicide and provide false reassurance 3. This is a common error that can lead to underestimation of risk.
Do not underestimate risk based on low medical lethality of an attempt—intent matters more than actual lethality 3. A patient who took 10 aspirin tablets believing they would die is at higher risk than one who impulsively cut superficially without intent to die.
Do not accept family reassurance alone when high-risk features are present, as families often underestimate risk and overestimate their ability to supervise 3.
Structured suicide prediction tools have limited accuracy and should not be used as the sole basis for clinical decision-making 1. Clinical judgment informed by systematic assessment of the domains above is superior to relying on screening tools alone 1.
Legal Threshold for Involuntary Commitment
Involuntary hospitalization criteria typically require a mental disorder plus imminent risk of harm to self 3. Physicians can initiate psychiatric holds for brief periods when these criteria are met, and breaking confidentiality is justified when there are significant concerns about imminent harm 3.