Lethal means counseling with family is evidence-based component of violence prevention
Patient Discharge Instructions
copy discharge instructions
What is homicidal ideation
Homicidal ideation means having thoughts about harming or killing another person
These thoughts exist on a spectrum from brief, unwanted thoughts to specific plans
You were evaluated today and determined to be safe for discharge with a safety plan
Your diagnosis and treatment plan
Your doctor identified the following concern contributing to your thoughts:
You have been given the following prescription or medication change if applicable
It is very important to take your medications exactly as prescribed
Alcohol and drug use significantly increase the risk of acting on violent thoughts — avoid all substances
Your safety plan
Keep your written safety plan with you at all times
Your emergency contacts are listed in your safety plan
If you feel your thoughts are getting stronger, call a trusted person before acting
Remove or secure any firearms or weapons from your home
Ask a family member or friend to safely store any weapons during this time
Follow-up appointment
You have a psychiatry or mental health appointment scheduled within 24-72 hours
If you cannot make your appointment, call to reschedule immediately
Do not skip follow-up — this is an important part of your treatment
Return to emergency department immediately if
Your thoughts of harming others become stronger or more specific
You develop a specific plan or target
You have access to a weapon and feel unable to resist using it
You feel you cannot keep yourself or others safe
You develop thoughts of harming yourself
Your agitation, aggression, or paranoia worsens significantly
You experience a medication side effect that concerns you
Crisis resources
988 Suicide and Crisis Lifeline: call or text 988 (also covers violence crisis)
Crisis Text Line: text HOME to 741741
Local crisis team: contact information provided by social work
If immediate danger to self or others: call 911
References
Guidelines and key sources
ACEP Clinical Policy 2017
Nazarian DJ et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine. 2017
Supports targeted laboratory testing based on clinical presentation for psychiatric ED patients
APA Resource Documents
Buchanan A et al. Psychiatric Violence Risk Assessment. American Psychiatric Association. 2011
Kapoor R et al. Resource Document on Risk-Based Gun Removal Laws. American Psychiatric Association. 2018
APA Resource Document on Seclusion or Restraint. American Psychiatric Association. 2022
VA/DoD Clinical Practice Guidelines
Arias-Reynoso M et al. Management of First-Episode Psychosis and Schizophrenia (SCZ). Department of Veterans Affairs. 2023
Abrams T et al. Management of Bipolar Disorder (BD). Department of Veterans Affairs. 2023
Epidemiology and risk assessment studies
Violence and mental illness epidemiology
Whiting D, Lichtenstein P, Fazel S. Violence and Mental Disorders: A Structured Review. Lancet Psychiatry. 2021
Carbone JT et al. Homicidal Ideation and Forensic Psychopathology: Evidence From the 2016 NEDS. Journal of Forensic Sciences. 2020
Sun CF et al. Homicidal Ideation and Psychiatric Comorbidities in Inpatient Adolescents Aged 12-17. Frontiers in Psychiatry. 2022
Asnis GM et al. Violence and Homicidal Behaviors in Psychiatric Disorders. Psychiatric Clinics of North America. 1997
Risk assessment tools
Beaudry G et al. Evaluating Risk of Suicide and Violence in Severe Mental Illness: OxMIS and OxMIV. Frontiers in Psychiatry. 2022
Välimäki M et al. Risk Assessment for Aggressive Behaviour in Schizophrenia. Cochrane Database. 2024
Pharmacological management
Agitation treatment evidence
Uribe ES et al. Pharmacological Management of Acute Agitation in Psychiatric Patients: Umbrella Review. BMC Psychiatry. 2025
Bak M et al. Pharmacological Management of Agitated and Aggressive Behaviour: Systematic Review and Meta-Analysis. European Psychiatry. 2019
Kim HK et al. Safety and Efficacy of Pharmacologic Agents for Rapid Tranquilization in the ED. Expert Opinion on Drug Safety. 2021
Stetson SR, Osser DN. Psychopharmacology of Agitation in Acute Psychotic and Manic Episodes. Current Opinion in Psychiatry. 2022
Maniaci MJ et al. Patients Threatening Harm to Others Evaluated Under the Florida Involuntary Hold Act. Southern Medical Journal. 2019
Legal and ethical references
Duty to protect
Felthous AR. The Clinician's Duty to Protect Third Parties. Psychiatric Clinics of North America. 1999
Boulos N et al. Tarasoff in Missouri: Duty to Warn and Protect. Journal of Forensic Sciences. 2023
Bersoff DN. Protecting Victims of Violent Patients While Protecting Confidentiality. American Psychologist. 2014
Knoll JL. The Psychiatrist's Duty to Protect. CNS Spectrums. 2015
Radley A, Felthous AR. How Specific is the Specificity Rule in Duty to Warn Jurisprudence. Journal of Forensic Sciences. 2025
Firearm safety and de-escalation
Carter PM, Cunningham RM. Clinical Approaches to Prevention of Firearm-Related Injury. NEJM. 2024
Spencer S, Johnson P, Smith IC. De-Escalation Techniques for Managing Non-Psychosis Induced Aggression. Cochrane Database. 2018
Pediatric references
Saidinejad M et al. Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies. Pediatrics. 2023
Hua LL. Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics. 2021
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.