What is the appropriate assessment and management workup for a patient presenting with suicidal ideation?

Suicidal Ideation Workup

Immediately assess suicide risk through direct questioning about current suicidal thoughts, intent, specific plans, access to lethal means (especially firearms), and willingness to engage in safety planning—these factors determine whether the patient requires emergency psychiatric hospitalization or can be managed as an outpatient. 1, 2

Initial Risk Stratification

Screening Tools

• Use the Columbia Suicide Severity Rating Scale Screener for detecting suicidal thoughts in both general and high-risk populations 1
• The PHQ-9 item 9 serves as a validated universal screening instrument; higher scores predict increased risk of suicide attempts and death within one year 1

Critical Assessment Domains

Current Suicidal Ideation and Intent:

• Directly ask about active or passive thoughts of suicide or death 2
• Inquire about specific plans and intended course of action if symptoms worsen 2
• Assess access to lethal means, particularly firearms and medications 1, 2
• Determine if the patient still wants to die after initial assessment—this is a high-risk indicator 3, 1

Psychiatric Symptoms:

• Severe hopelessness is a critical high-risk indicator 1
• Assess severity of depression including anhedonia, sleep disturbance, worthlessness, and concentration problems 1
• Evaluate for agitation or severe anxiety, which signal elevated risk 1
• Screen for manic, hypomanic, or mixed mood states 1
• Identify psychotic features including command hallucinations or delusional guilt 2
• High impulsivity, especially with mood disorders, markedly raises suicide risk 1

Historical Risk Factors:

• A lifetime history of suicide attempts dramatically increases future risk, particularly in males 1
• Document recent self-directed violence 2
• Identify comorbid substance use disorders, which substantially elevate risk 1
• Assess for childhood sexual or physical abuse 1
• Note LGBTQ+ identification, which is associated with higher risk 1

Protective and Social Factors:

• Evaluate quality and responsiveness of family and social support 1, 2
• Assess family willingness to engage in safety planning and monitoring 1
• Document reasons for living and therapeutic alliance 2
• Review psychosocial stressors 2

Disposition Decision-Making

HIGH-RISK: Immediate Psychiatric Hospitalization Required

Hospitalize immediately (involuntarily if necessary) when ANY of these indicators are present: 3, 1, 2

• Persistent desire to die after initial assessment 1
• Continuous agitation or severe hopelessness 1
• Inability to participate in safety planning 2
• Inadequate or unsupportive family/social support system 1, 2
• Active substance use disorder or current intoxication 1
• Serious depression with psychotic features (command hallucinations, delusional guilt) 1, 2
• High impulsivity combined with dysphoric mood in bipolar disorder, major depression, or psychosis 1
• Family unwillingness to commit to treatment or monitoring 1
• Previous high-lethality suicide attempts 2

MODERATE-RISK: Outpatient Management Possible

Outpatient management is appropriate ONLY when ALL of these conditions are met: 1

• Responsive, supportive family capable of close monitoring 1
• Predominantly passive suicidal thoughts without intent or plan 1
• Availability of a reliable person who can intervene if mood deteriorates 1
• Expressed genuine desire to receive help 1

Even in moderate-risk cases, arrange close follow-up and timely mental health evaluation because risk can change rapidly 1

Immediate Safety Interventions

Lethal Means Restriction (MANDATORY)

• Remove ALL firearms from the home—adolescents and adults can access even locked guns 1, 2
• Secure ALL medications (prescription and over-the-counter) to prevent unauthorized use 1, 2
• Counsel family on removing other potential methods (ropes, sharp objects, toxic substances) 2

Safety Planning

Develop a collaborative crisis response plan that includes: 3, 2

• Semi-structured interview regarding recent suicidal ideation and history 3
• Collaborative identification of clear warning signs of crisis (behavioral, cognitive, affective, physical) 3
• Identification of self-management skills and distraction techniques 3
• List of social supports (friends, family members) the patient can contact 3
• Review of crisis resources including medical providers, professionals, and suicide lifeline 3
• Specific steps for crisis management and follow-up appointments 3, 2

Important caveat: "No-harm contracts" have NOT been shown to prevent suicidal behavior; refusal to engage in safety planning is an ominous sign warranting higher-level intervention 1

Evidence-Based Treatment Interventions

Psychotherapy (First-Line)

Cognitive-behavioral therapy (CBT) specifically focused on suicide prevention reduces suicide attempts by approximately 50% in patients with recent suicidal behavior 3, 1, 2

• CBT should include behavioral activation, cognitive restructuring, problem-solving skills, and relapse prevention 2
• Most patients attend fewer than 12 sessions 3
• This is the strongest evidence-based intervention and should be initiated promptly 2

Dialectical behavior therapy (DBT): Evidence is insufficient to recommend for or against DBT for reducing suicide attempts or ideation 3

Problem-solving therapy is helpful for patients at risk for suicide, particularly those with traumatic brain injury 3

Pharmacotherapy

For Major Depressive Disorder with Severe Suicidal Ideation:

• Ketamine infusion produces rapid (within 24 hours) short-term reduction of suicidal thoughts lasting up to one week 3, 1, 2
• 60% of patients report no suicidal ideation at 7 days post-infusion 3
• Use as adjunctive treatment, not monotherapy 3, 2

For Schizophrenia or Schizoaffective Disorder:

• Clozapine reduces suicide attempts in patients with suicidal ideation or history of attempts 3, 1, 2
• Note: The required monitoring program may be a barrier but also provides beneficial surveillance 3

For Mood Disorders:

• Evidence is insufficient to recommend for or against lithium specifically for suicide risk reduction 3
• However, lithium maintenance therapy has been associated with fewer suicidal behaviors in cohort studies 3

Aggressive treatment of underlying psychiatric disorders is critical for decreasing both short-term and long-term suicide risk 1

Follow-Up and Ongoing Monitoring

Post-Discharge Care

Send periodic caring communications (postal mail or text messages) for 12 months following hospitalization to reduce the risk of suicide attempts 3, 2

• Research shows that repeated communication for at least 12 months has positive effects 3
• A single postcard does not influence outcomes 3

Self-guided digital interventions (apps or web-based programs with CBT-based therapeutic content) are suggested for short-term reduction of suicidal ideation 3, 2

Follow-up structure should include: 2

• Closely-spaced appointments with flexibility for crisis visits 2
• Verification of means restriction and psychiatric follow-up 2
• Collaborative care models that maintain regular contact improve outcomes 1

Special Populations

Children and Adolescents

High-risk adolescent suicide attempters include: 3

• Older (16-19 years) males 3
• Those with current mental disorder or disordered mental state (depression, mania, hypomania, mixed states) 3
• Comorbid substance abuse, irritability, agitation, or psychosis 3
• Prior suicide attempts 3
• Use of methods other than ingestion or superficial cutting 3
• Those who still want to die 3

Assessment must draw from multiple sources: child/adolescent, parents/guardians, school reports, and other individuals close to the child 3

Never use the term "gesture" to describe any self-destructive action—it minimizes potential risk for future suicidal behavior 3