What is the appropriate management for a patient who admits to self-injury with a plan?

Management of Self-Injury with a Plan

When a patient admits to self-injury with a plan, immediately conduct a comprehensive risk stratification to determine if psychiatric hospitalization is required, focusing on specific high-risk indicators that mandate admission rather than outpatient management. 1

Immediate Risk Assessment Questions

High-Risk Indicators Requiring Psychiatric Admission

Ask the following to determine if inpatient hospitalization is mandatory 2, 1:

• Does the patient continue to endorse a desire to die or maintain suicidal intent? Persistent wish to die mandates admission 1
• Can the patient engage meaningfully in safety planning discussions? Inability to participate indicates high risk 2, 1
• What is the patient's current emotional state? Severe agitation or hopelessness requires inpatient care 2, 1
• Does the patient have adequate support and monitoring? Lack of support system or inability to ensure monitoring necessitates admission 2, 1
• What was the lethality of the attempt or plan? High-lethality attempts or clear expectation of death require hospitalization 2, 1
• Is there active substance use or impulsivity? These significantly increase risk 1

Mental Status Examination Components

Conduct a focused assessment evaluating 2, 1:

• Appearance and behavior - Document level of distress and cooperation 2
• Thought process and content - Specifically assess for hallucinations, delusions, and ongoing suicidal thoughts 2, 1
• Mood and affect - Quantify hopelessness, as this is a critical predictor 1
• Insight and judgment - Evaluate the patient's understanding of their situation 2
• Intended course of action - Ask what they plan to do if symptoms worsen 1

Collateral Information

Interview the patient and caregivers both together and separately, as patients frequently minimize symptom severity or intention 2. Obtain information from family members or others who witnessed the event or know the patient's recent state of mind 2.

Safety Planning for Discharge-Appropriate Patients

If the patient does NOT meet criteria for psychiatric admission, implement a structured safety plan that includes 2, 1:

Six Essential Components

1. Warning signs and triggers - Identify specific thoughts, images, moods, situations, or behaviors that precede suicidal thoughts 2, 1

2. Internal coping strategies - List activities the patient can do independently without contacting others (e.g., exercise, listening to music, taking a walk) 2

3. Social supports for distraction - Identify specific people and places that provide healthy distraction from suicidal thoughts 2, 1

4. Emergency contacts - Document specific individuals the patient can contact during crisis, with phone numbers 2, 1

5. Professional resources - Provide clear instructions on how and when to access emergency services, including crisis hotlines and emergency department information 2, 1

6. Means restriction plan - This is the most critical component 2, 1

Mandatory Means Restriction Counseling

Means restriction is essential and potentially the most effective suicide prevention intervention, as many suicide attempts are impulsive (24% occur within 5 minutes of decision, 48% within 20 minutes) 2. Address the following 2, 1:

Firearms

• Remove ALL firearms from the home immediately - This is non-negotiable 1
• If families resist permanent removal, negotiate temporary relocation to relatives, friends, or law enforcement 2
• Never rely on locked storage alone - Parents consistently underestimate children's ability to access locked firearms, and simply having a gun in the home doubles youth suicide risk 2
• If families insist on keeping firearms, require unloaded storage in tamper-proof safes with separately locked ammunition 2

Medications and Other Means

• Lock up ALL medications, including over-the-counter drugs 2, 1
• Secure knives and other sharp objects 2
• Restrict access to potentially toxic substances (pesticides, cleaning products) 2
• Assess access to means in homes of friends and relatives 2

Alcohol and Substances

• Restrict alcohol access given high rates of intoxication in suicide attempts 2
• Refer for substance abuse treatment if indicated 2

Critical Pitfalls to Avoid

Do NOT use "no-suicide contracts" - These have no proven efficacy in preventing suicide and may impair therapeutic engagement 1. They create a false sense of security and encourage patients to be dishonest 1.

Do NOT use coercive language such as "you can't leave until you say you're not suicidal" - This undermines therapeutic alliance and encourages deceit 1.

Do NOT discharge without confirmed psychiatric follow-up - Schedule appointments before the patient leaves and verify means restriction has occurred 1.

Do NOT perform routine laboratory or neuroimaging studies unless there are specific clinical indicators (altered mental status, unexplained vital sign abnormalities, new-onset psychiatric symptoms) 2. Routine testing is low-yield and costly 2.

Follow-Up Care Structure

Arrange immediate mental health follow-up 1:

• Same-day or next-day appointment with a mental health professional 1
• Consider partial hospitalization, intensive outpatient services, or in-home crisis stabilization if available 2
• Maintain regular contact (telephone, home visits, letters) with patients who have recent self-harm 2
• The greatest risk of reattempting suicide is in the months immediately following an initial attempt 2

Safety planning interventions have demonstrated effectiveness in reducing suicidal behavior, with meta-analysis showing reduced risk compared to treatment as usual 2. One study showed significant reductions in hospitalizations and increases in crisis call utilization after safety plan implementation 3.