Assessing Suicide Risk

1. What is the clinical setting? (emergency department, inpatient psychiatric unit, outpatient clinic, primary care, crisis hotline, telehealth) — default: outpatient clinic
2. What triggered this risk assessment? (positive screen on PHQ-9 Item 9, patient disclosure, collateral concern, routine reassessment, post-attempt evaluation) — default: positive PHQ-9 Item 9
3. What screening tool was used, if any? (PHQ-9 Item 9, ASQ, C-SSRS Screener, ED-SAFE PSS-3, none) — default: PHQ-9 Item 9
4. Is there an acute precipitant? (recent loss, relationship crisis, legal trouble, substance intoxication, medication change) — default: unknown
5. Is the patient currently in a safe environment? — default: assess immediately
6. Are collateral informants available? (family, partner, therapist, case manager, police) — default: none confirmed
7. Does the patient have a prior documented safety plan? — default: unknown
8. What is the patient's current level of cooperation with assessment? — default: cooperative

Documents to Request

• Prior suicide risk assessments and safety plans
• C-SSRS prior administration records (if repeat assessment)
• Emergency department records for prior attempts or presentations
• Current medication list (especially recent changes)
• PDMP query results (for assessment of access to lethal means)
• Prior psychiatric hospitalization discharge summaries
• Outpatient therapist and prescriber notes from past 90 days
• Any existing advance directives or crisis plans

Step 1: Universal Screening and Triage

Begin with a validated screening instrument. The Columbia Suicide Severity Rating Scale (C-SSRS) Screener includes two categories of questions:

Suicidal Ideation Questions (past month):

1. Have you wished you were dead or wished you could go to sleep and not wake up? (passive ideation)
2. Have you actually had any thoughts of killing yourself? (active ideation, non-specific)
3. Have you been thinking about how you might do this? (active ideation with method)
4. Have you had these thoughts and had some intention of acting on them? (active ideation with intent)
5. Have you started to work out or worked out the details of how to kill yourself, and did you intend to carry out this plan? (active ideation with plan and intent)

Suicidal Behavior (lifetime and past 3 months):

• Actual attempt, interrupted attempt, aborted attempt, preparatory acts or behavior

Any "yes" response to Questions 1-2 requires further assessment. Any "yes" to Questions 3-5 or suicidal behavior requires immediate full risk evaluation and safety intervention.

Step 2: Comprehensive Risk Factor Assessment

Systematically evaluate and document each category:

Static Risk Factors (historical, non-modifiable)

• Prior suicide attempts (strongest single predictor) — document number, methods, lethality, medical intervention required
• Family history of suicide or attempts
• History of non-suicidal self-injury
• Adverse childhood experiences (abuse, neglect, household dysfunction)
• Demographic factors (male sex, older age, White or American Indian/Alaska Native race, unmarried status, veteran status)
• Chronic medical illness, especially conditions causing pain or functional limitation
• History of psychiatric hospitalization

Dynamic Risk Factors (current, modifiable)

• Current suicidal ideation — severity, frequency, duration, controllability
• Hopelessness (Beck Hopelessness Scale if time permits)
• Current psychiatric symptoms (depression severity, psychotic symptoms, agitation, insomnia, anhedonia)
• Substance use or intoxication (acute alcohol or stimulant use markedly elevates risk)
• Recent psychosocial stressors (job loss, divorce, bereavement, legal problems, financial crisis)
• Access to lethal means (firearms in the home are the single most important means restriction target)
• Social isolation and perceived burdensomeness (Interpersonal Theory of Suicide — Joiner)
• Recent discharge from psychiatric hospitalization (highest risk period: first 7 days post-discharge)
• Non-adherence with treatment

Warning Signs (acute, imminent risk indicators)

• Expressed intent to die
• Giving away possessions
• Saying goodbye to loved ones
• Searching for methods online
• Acquiring means (purchasing firearm, stockpiling medications)
• Sudden calmness after period of agitation (may indicate decision has been made)
• Increasing substance use

Step 3: Protective Factor Assessment

Document protective factors with the same rigor as risk factors:

• Reasons for living (document specifically — children, partner, pets, faith, future goals)
• Social connectedness and support system (identify specific people)
• Engagement with treatment and therapeutic alliance
• Religious or moral objections to suicide
• Problem-solving ability and coping skills
• Employment and sense of purpose
• Restricted access to lethal means
• Pregnancy or responsibility for dependents
• Fear of death or dying
• Cultural or familial expectations

Step 4: Risk Level Determination and Clinical Reasoning

Integrate all data into a risk-level determination. Document the clinical reasoning explicitly:

Low Risk: Modifiable risk factors present but manageable, strong protective factors, no current ideation or passive ideation only, engaged in treatment, no access to lethal means. Disposition: outpatient management with safety plan.

Moderate Risk: Active ideation without specific plan or intent, multiple risk factors, some protective factors, ambivalence about living. Disposition: intensified outpatient treatment (increased session frequency, medication adjustment), safety plan with means restriction, close follow-up within 48-72 hours.

High Risk: Active ideation with plan or intent, few protective factors, recent attempt, access to lethal means, acute agitation or intoxication, psychotic symptoms. Disposition: emergency psychiatric evaluation, consider voluntary or involuntary hospitalization.

Imminent Risk: Active ideation with plan, intent, and available means; preparatory behaviors; patient unable to contract for safety. Disposition: immediate psychiatric hospitalization, continuous observation, involuntary hold if patient refuses voluntary admission.

Step 5: Safety Planning and Intervention

For all patients at any risk level above none, create or update a Safety Plan using the Stanley-Brown Safety Planning Intervention:

1. Warning signs — personal triggers that indicate a crisis is developing
2. Internal coping strategies — things the patient can do alone to distract (exercise, music, breathing techniques)
3. People and social settings for distraction — contacts who can help take mind off problems (names and numbers)
4. People to contact for help — family or friends who can provide support (names and numbers)
5. Professionals and agencies to contact — therapist, psychiatrist, crisis line (988 Suicide & Crisis Lifeline), emergency services
6. Making the environment safe — lethal means restriction plan (firearms stored off-site, medication secured, sharps removed)

Document the safety plan in the medical record. Provide the patient with a written or digital copy. Identify a collateral contact who can assist with means restriction.

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the C-SSRS or equivalent screening tool fully documented with responses to each item?
2. Are both static and dynamic risk factors comprehensively listed with clinical specifics?
3. Are protective factors documented with the same specificity as risk factors?
4. Does the risk-level determination include explicit clinical reasoning linking factors to the conclusion?
5. Is the safety plan specific and personalized (not generic) with named contacts and concrete strategies?

Quality Audit

• Validated screening tool administered and scored (C-SSRS, ASQ, or PHQ-9 Item 9 at minimum)
• Prior suicide attempts documented with method, lethality, date, and precipitant
• Access to lethal means specifically assessed (firearms, medications, other)
• Substance use at time of assessment documented (intoxication or withdrawal state)
• Current ideation characterized for frequency, duration, controllability, and deterrents
• Protective factors documented as a distinct section (not embedded in narrative)
• Risk level explicitly stated (low, moderate, high, imminent) with supporting rationale
• Safety plan completed or updated with all six Stanley-Brown components
• Means restriction counseling documented (discussed, agreed to, or declined)
• Follow-up plan documented with specific timeframe (within 24h, 48h, 72h, 1 week)
• Collateral contact identified and contacted (or documented as unavailable)
• Disposition consistent with assessed risk level
• If patient discharged to outpatient, caring-contacts protocol initiated (follow-up call within 24-48 hours)
• Documentation timestamped with clinician name and credentials

Guidelines

1. Never rely solely on a patient's denial of suicidal ideation — patients frequently minimize; corroborate with collateral, behavioral observations, and historical risk factors.
2. Always assess access to firearms explicitly and document the response — lethal means counseling is the single most evidence-based intervention for reducing suicide deaths.
3. Do not use "suicide contracts" or "no-harm contracts" — these have no evidence of effectiveness and may create a false sense of security. Use the Stanley-Brown Safety Planning Intervention instead.
4. Reassess suicide risk at every clinical transition: admission, level-of-care change, pass or privilege change, discharge, and any change in clinical status.
5. Document the clinical reasoning for the risk-level determination, not just the conclusion — a court will evaluate whether the reasoning was sound, not just whether a risk level was assigned.
6. PHQ-9 Item 9 score of 1 or greater requires further assessment — a score of 1 ("several days") is not "low risk" without additional evaluation.
7. For patients presenting post-attempt, ensure medical clearance is completed before psychiatric evaluation and document the transition of care.
8. Cultural considerations matter — suicide risk expression varies across cultures; use culturally adapted screening when available and document interpreter use if applicable.