1. History
- Key HPI questions (use a nonjudgmental, empathic approach — rapport itself is therapeutic and improves future treatment engagement): [1]
- What happened? Describe the event in the patient's own words
- Method used (ingestion, cutting, hanging, firearm, jumping, etc.) — method predicts future risk and lethality [2]
- Timing: When did the attempt occur? How long ago?
- Intent to die: Did the patient want to die? What was the expected outcome?
- Planning vs. impulsivity: Was this premeditated or impulsive? Were preparations made (e.g., note, giving away possessions, researching methods)?
- Precautions against discovery: Was the patient alone? Did they take steps to avoid being found?
- Lethality: What was the objective medical severity? Also assess the patient's perception of lethality (may differ from actual) [3]
- Precipitating events: recent loss, rejection, legal/financial crisis, relationship conflict, disciplinary action [4-5]
- Substance use at time of attempt (alcohol, drugs) — acute intoxication is a major precipitant [4]
- Current suicidal ideation: Does the patient still wish to die? Ongoing plan or intent?
- Access to lethal means (firearms, medications, sharps) [6]
2. Alarm Features
- High-lethality method (firearm, hanging, jumping) — firearms are 85–90% fatal per attempt [7]
- Ongoing intent to die or active plan after medical stabilization
- Violent or highly planned attempt (e.g., note left, affairs arranged)
- Attempt made in isolation with precautions against rescue
- Refusal to engage in safety planning or accept help
- Command auditory hallucinations directing self-harm
- Mixed-state bipolar disorder or psychotic depression — significantly increases imminent risk [2]
- Recent discharge from psychiatric hospitalization (highest risk period is first weeks post-discharge) [2]
- Altered mental status, hemodynamic instability, or respiratory compromise from the attempt itself
3. Medications
Relevant medication contributors:
- Medications that may worsen suicidality: antidepressants carry an FDA black box warning for increased suicidality in patients <25 years, particularly in the first weeks of treatment or after dose changes [8]
- Benzodiazepines are associated with increased suicide risk in borderline personality disorder [9]
- Medications used in overdose: acetaminophen, opioids, TCAs, benzodiazepines, and SSRIs are among the most common
Pharmacotherapy for suicidality:
- Lithium — reduces suicide attempts and all-cause mortality in unipolar and bipolar mood disorders [10-12]
- Clozapine — reduces suicidal behaviors in schizophrenia/schizoaffective disorder (requires REMS monitoring for agranulocytosis) [10][13]
- Ketamine/esketamine — rapidly reduces suicidal ideation within hours; IV ketamine (0.5 mg/kg) shows benefit within 24 hours lasting up to 1–6 weeks. Intranasal esketamine (Spravato) is FDA-approved for MDD with acute suicidal ideation/behavior [12-14]
- SSRIs — first-line for underlying depression; reduce suicidal ideation in adults ≥25 years [8][15]
- Avoid prescribing large quantities of potentially lethal medications (TCAs, opioids) at discharge
Cautions:
- Close monitoring required when initiating or adjusting antidepressants, especially in youth [8]
- Prescribe limited quantities of medications with overdose potential at discharge
4. Diet
- Not a primary consideration in acute management
- Alcohol avoidance is critical — substance misuse is a strong precipitating factor for suicide and promotes disinhibition/impulsivity [4]
- Adequate nutrition and hydration during inpatient stabilization
- Long-term: address substance use disorders as part of comprehensive treatment
5. Review of Systems
- Psychiatric: depressed mood, anhedonia, hopelessness, worthlessness, insomnia/hypersomnia, psychomotor agitation, anxiety, panic attacks, hallucinations (especially command type), racing thoughts
- Neurologic: altered mental status, headache, seizures (especially post-ingestion)
- Toxicologic symptoms: nausea/vomiting, abdominal pain, diaphoresis, tremor, tachycardia, altered consciousness
- Trauma-related: lacerations, fractures, internal injuries depending on method
- Chronic pain: associated with increased lifetime suicide attempt risk (OR 2.15) [1]
- Sleep disturbance: an independent risk factor for suicidal behavior [16]
6. Collateral History and Family History
- Collateral is essential — less than one-third of patients with suicidal behaviors express intent to their clinician. Family, friends, EMS, and primary care providers can provide critical context [2]
- Obtain information about: recent behavioral changes, substance use, stressors, prior attempts, medication access, firearm access
- Family history of suicide — strong predisposing factor (Table 1 in Fazel & Runeson, NEJM) [4]
- Family history of psychiatric illness (mood disorders, substance use)
- Childhood adversity: OR for suicide attempt with ≥4 adverse childhood experiences vs. none is 30.15 [1]
- Social context: living situation, employment, relationship status, legal issues, military/veteran status
7. Risk Factors
The following figure from Fazel & Runeson (NEJM 2020) illustrates how risk factors accumulate across the lifespan:
Predisposing factors: [1][4][16]
- Previous suicide attempt — single strongest clinical predictor
- Psychiatric disorders: depression (17× increased risk), bipolar disorder, schizophrenia-spectrum, substance use disorders, PTSD, personality disorders (especially borderline)
- Family history of suicidal behavior
- Childhood sexual abuse / adverse childhood experiences
- Personality traits: impulsivity, aggression
Precipitating factors: [4]
- Drug and alcohol misuse (strong association)
- Access to lethal means (moderate association)
- Stressful life events: relationship loss, financial crisis, legal problems, bereavement
- New diagnosis of terminal or chronic illness
Demographic: [1][16-17]
- Male sex (higher completion rate), female sex (higher attempt rate)
- Single, divorced, or separated
- Social isolation, living alone
- Unemployment, low socioeconomic status
- Veterans/military (higher firearm suicide rate)
- LGBTQ+ youth (increased risk)
8. Differential Diagnosis
- Non-suicidal self-injury (NSSI): self-harm without intent to die; important to distinguish but may coexist with suicidal intent
- Accidental overdose/ingestion: particularly in substance use disorders or pediatric patients
- Psychotic episode with self-harm: command hallucinations or disorganized behavior
- Delirium or acute intoxication: altered behavior mimicking suicidal intent
- Factitious disorder/malingering: rare but consider in secondary gain contexts
- Domestic violence/abuse: injuries may be inflicted by others but reported as self-harm
- Medical conditions mimicking psychiatric symptoms: hypothyroidism, delirium, brain tumor, metabolic derangements [18]
9. Past Medical History
- Prior suicide attempts — number, methods, lethality, and timing (recurrence most likely within 3–6 months of first presentation) [2]
- Prior psychiatric hospitalizations
- Psychiatric diagnoses: depression, bipolar disorder, schizophrenia, PTSD, personality disorders, anxiety disorders
- Substance use disorders
- Chronic pain conditions, epilepsy, TBI, chronic medical illness [4][17]
- Current and past psychiatric medications and adherence
- Prior engagement with mental health services
10. Physical Exam
Vital signs: Tachycardia, hypotension, bradycardia, hypothermia/hyperthermia, respiratory depression — all may indicate toxicologic emergency
Method-specific focused exam:
- Ingestion: mental status (GCS), pupil size/reactivity, skin (diaphoresis vs. dry/flushed), bowel sounds, tremor, muscle tone [19]
- Laceration/cutting: wound depth, tendon/nerve/vascular involvement, active hemorrhage
- Hanging/strangulation: airway patency, cervical spine tenderness, ligature marks, voice changes, subcutaneous emphysema
- Firearm: trauma survey per ATLS
- Jumping: full trauma assessment
General: Look for signs of chronic self-harm (scars on forearms, thighs), track marks, evidence of substance use
11. Lab Studies
Labs are guided by the method of attempt and clinical presentation:
- All intentional overdoses: [19]
- Serum acetaminophen and salicylate levels (obtain even in "unknown" ingestions — these are ubiquitous in OTC medications)
- BMP (electrolytes, creatinine, glucose, anion gap)
- Blood gas (identify acidosis/alkalosis)
- Serum ethanol level
- Pregnancy test (women of childbearing age)
- Hepatic function panel (if acetaminophen or hepatotoxic agent suspected)
- Serum lactate (lactate ≥5.0 mmol/L is a strong predictor of death in overdose) [20]
- Troponin (elevated troponin on admission: OR 21.1 for death in drug overdose) [20]
- Specific drug levels as indicated (lithium, digoxin, iron, theophylline, etc.)
- Urine drug screen: limited acute utility due to poor sensitivity/specificity, but may provide supportive information [19]
- CBC: if significant blood loss or concern for hematologic toxicity
- Coagulation studies: if anticoagulant ingestion or significant hemorrhage
- TSH, B12, folate: consider in initial psychiatric workup to rule out medical contributors to depression [18]
12. Imaging
- Chest X-ray: if hypoxic, tachypneic, obtunded, or aspiration risk (hanging, overdose with decreased consciousness) [19]
- Abdominal imaging: CT if body packing suspected or large ingestion of radiopaque pills
- CT head/C-spine: if hanging, jumping, firearm injury, or altered mental status with unclear etiology
- Trauma imaging per ATLS: as indicated by mechanism
- Imaging is not routinely needed for uncomplicated ingestions with a known substance and normal exam
13. Special Tests
Screening and risk stratification tools:
The Columbia-Suicide Severity Rating Scale (C-SSRS) is the most widely validated tool for ED suicide risk stratification: [2][21-22]
- ASQ (Ask Suicide-Screening Questions): 4-item tool validated in pediatric and adult ED populations; 97% sensitivity, 88% specificity in pediatric EDs [8]
- PHQ-9 Item 9: useful as a screening component for suicidal ideation [23]
- Safety Planning Intervention (SPI): a structured, collaborative, brief cognitive-behavioral intervention completed in the ED — associated with reduced suicidal behavior when combined with follow-up contact [24]
Toxicology-specific:
- Contact Poison Control (1-800-222-1222) for all intentional ingestions
- Rumack-Matthew nomogram for acetaminophen ingestion timing/level
- Done nomogram for salicylate toxicity
14. ECG
ECG is essential in all intentional overdoses and should be obtained early: [19][25]
- QRS >100 ms: classic for TCA toxicity — predicts seizures and ventricular arrhythmias [26-27]
- Rightward terminal 40-ms QRS axis (>120°): highly specific for TCA poisoning [27]
- R wave in aVR >3 mm: suggests sodium channel blockade
- QTc prolongation >500 ms: highest risk feature for adverse cardiovascular events (OR 11.2); seen with TCAs, antipsychotics, methadone, many psychotropics [25][28]
- Sinus tachycardia: anticholinergic effects (TCAs, antihistamines) or sympathomimetics
- Brugada pattern: can be unmasked by TCA overdose [29]
- Bradycardia/AV block: beta-blocker, calcium channel blocker, digoxin, clonidine overdose
The following figure illustrates the ECG progression in sodium channel blocker toxicity:
15. Assessment
Clinical summary framework:
- Stabilize medical/surgical consequences of the attempt first (ABCs, toxicologic management)
- Then perform a comprehensive biopsychosocial assessment once medically cleared [1][4]
- Assess current suicidal ideation, intent, and plan — intent fluctuates and is not always a reliable predictor of future behavior [1]
- Stratify acute risk: high, intermediate, or low per the VA/DoD algorithm [6]
Severity stratification: [31]
- High risk: high-lethality method, clear intent to die, ongoing ideation, psychosis, refusal of help
- Intermediate risk: ambivalent intent, impulsive attempt, some protective factors present
- Low risk: low-lethality method, no ongoing ideation, strong social support, engaged in safety planning
Complications to consider:
- Medical: organ damage from ingestion (hepatic failure from acetaminophen, renal failure), aspiration pneumonia, rhabdomyolysis, anoxic brain injury (hanging, near-drowning)
- Psychiatric: worsening depression, PTSD from the attempt itself, treatment-emergent suicidality
16. Treatment Plan
Initial stabilization (ED):
- ABCs — secure airway if compromised (hanging, overdose with decreased consciousness)
- Treat the medical consequences of the attempt per method:
- Overdose: decontamination (activated charcoal if within 1–2 hours and airway protected), specific antidotes (N-acetylcysteine for acetaminophen, naloxone for opioids, sodium bicarbonate for TCA with QRS >100 ms), supportive care [19]
- Lacerations: wound care, repair, vascular/surgical consultation as needed
- Trauma: per ATLS protocols
- 1:1 observation and environmental safety: remove sharps, cords, tubing, toxic substances, plastic bags from room [6][32]
- Benzodiazepines first-line for toxin-associated seizures [19]
Psychiatric intervention in the ED:
- Safety Planning Intervention (SPI): collaborative, personalized plan including warning signs, coping strategies, trusted contacts, crisis resources, and lethal means restriction. SPI + follow-up telephone contact reduced suicidal behavior by ~50% compared to usual care [6][8][24]
- Lethal means counseling: discuss temporary removal of firearms from the home, safe medication storage, and other means restriction. Emphasize the temporary nature; avoid words like "confiscate" [6-7]
- No-suicide contracts are ineffective and should NOT be used [8][10][24]
Pharmacotherapy:
- Treat underlying psychiatric disorder (depression, psychosis, bipolar disorder)
- Lithium for mood disorders with suicidality [10-11]
- Clozapine for schizophrenia/schizoaffective disorder with suicidality [10][13]
- Consider ketamine/esketamine for rapid reduction of suicidal ideation in MDD [12-13]
- Prescribe limited quantities of medications at discharge
Psychotherapy (outpatient):
- CBT for suicide prevention — patients are ≥50% less likely to have a repeat attempt [22]
- Dialectical behavior therapy (DBT) for borderline personality disorder
- Problem-solving therapy
17. Disposition
Admission criteria: [6][10][31]
- High-lethality attempt with clear intent to die
- Ongoing suicidal ideation, plan, or intent after medical stabilization
- Psychosis, command hallucinations, severe agitation
- Inability to contract for safety (note: this refers to genuine clinical judgment, not a "no-suicide contract")
- Lack of social support or safe discharge environment
- Active substance intoxication precluding reliable assessment
- Need for medical/surgical admission for consequences of the attempt
- When in doubt, inpatient care is the prudent option [10]
- Involuntary hospitalization may be required if the patient refuses and remains at high risk — clinicians should be familiar with local mental health legislation [1][10]
Discharge criteria: [8][10]
- No ongoing suicidal ideation, intent, or plan
- Medical consequences of the attempt are resolved
- Completed safety plan in collaboration with patient
- Lethal means counseling completed with family/caregivers
- Outpatient follow-up arranged (ideally within 24–72 hours)
- Social support system identified and engaged
- Crisis resources provided (988 Suicide & Crisis Lifeline, crisis text line)
Observation indications:
- Intermediate risk patients who may benefit from brief observation (e.g., intoxicated patients who need reassessment when sober)
- Patients awaiting psychiatric consultation or transfer to psychiatric facility
Specialist consultation triggers:
- Psychiatry consultation for all suicide attempts in the ED [32]
- Toxicology/Poison Control for all intentional ingestions
- Surgery/trauma as indicated by mechanism
- Social work for disposition planning, family support, and resource coordination
18. Follow Up / Return Precautions
Follow-up timing:
- Outpatient mental health follow-up within 24–72 hours of ED discharge — risk for subsequent suicidal behavior is greatest in the first 6 months following a crisis [24]
- Recurrence of self-harm is most likely within 3–6 months of first presentation [2]
- Post-discharge caring contact (brief, nondemanding texts or calls) reduces suicide attempts at 1 year [22]
- Follow-up telephone calls after ED discharge decrease subsequent suicidal behavior [8]
Return precautions — instruct patient and family to return immediately for:
- Return of suicidal thoughts, urges, or plans
- Worsening depression, hopelessness, or agitation
- Increased substance use
- New access to lethal means
- Inability to follow through with safety plan
- Any new medical symptoms related to the attempt (e.g., delayed acetaminophen toxicity — RUQ pain, jaundice)
Patient/family counseling:
- Educate on the 988 Suicide & Crisis Lifeline (call or text 988) and Crisis Text Line (text HOME to 741741)
- Reinforce lethal means restriction: firearms stored locked/unloaded or temporarily removed from home; medications secured [6-8]
- Avoid alcohol and substance use — promotes disinhibition and impulsivity
- Engage family/caregivers as safety monitors with patient's consent [4]
- Normalize help-seeking; emphasize that acute suicidal ideation is often self-limited and treatable [8]
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