Suicidal IdeationMANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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679 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Acute anxiety Acute psychosis Agitation-behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Dementia and behavioral crisis Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp52

Immediate safety priorities

›Imminent risk features requiring immediate action

›Specific plan with access to lethal means

›Firearms in the home — highest lethality risk

›Stockpiled medications

›Other highly lethal method identified

›Stated intent to act on suicidal thoughts

›Command auditory hallucinations directing self-harm

›Acute intoxication with co-occurring active ideation

›Recent suicide attempt within past 3 months

›Highest-risk period post-attempt

›Immediate psychiatric consultation required

›Preparatory behaviors

›Writing a suicide note

›Giving away possessions

›Researching methods online

›Abrupt calmness after prolonged agitation

›May indicate decision to act

›Reassess immediately

Environmental and physical safety

›ED safety measures

›Place in monitored room with direct visualization

›Remove sharps, ligature risks, and unsecured equipment

›1:1 sitter or continuous nursing observation for high-risk patients

›Patient undressed and gowned

›Personal belongings removed and secured

›Search for concealed weapons or medications

›Physical restraints if imminent harm to self or staff

02History/hx81

Ideation characterization

›Passive vs. active ideation distinction

›Passive ideation: wish to be dead without plan

›"I wish I were dead" or "I wish I could go to sleep and not wake up"

›Active ideation without plan

›Thoughts of killing oneself without method in mind

›Active ideation with plan

›Specific method, means, time, or location identified

›Active ideation with intent

›Plan plus intent to act

Ideation severity dimensions

›Frequency, duration, and intensity of thoughts

›Episodic vs. persistent vs. continuous

›Ability to dismiss or control intrusive thoughts

›Degree of distress caused by thoughts

›Controllability

›Patient's perceived ability to resist acting on thoughts

›Deterrents: children, religion, fear of pain, reasons for living

Precipitating and modifying factors

›Acute precipitants

›Relationship loss or breakdown

›Financial crisis or job loss

›Legal problems

›Bereavement or anniversary of loss

›Recent diagnosis of serious illness

›Acute humiliation or public shame event

›Protective factors

›Reasons for living identified by patient

›Future-oriented thinking

›Engagement with social supports

›Religious or cultural prohibition

›Absence of plan or means

Risk factors

›Strongest predictors of attempt

›Prior suicide attempt — single strongest predictor of future attempt and completed suicide

›Number, method, and medical lethality of prior attempts

›Current psychiatric diagnosis

›Major depressive disorder: 17-fold increased risk

›Bipolar disorder — especially mixed states or depressive episodes

›Schizophrenia and psychotic disorders

›Borderline personality disorder

›Substance use disorder

›PTSD

›Demographic and social risk factors

›Male sex: higher completion rate

›Female sex: higher attempt rate

›Age extremes: adolescents/young adults and elderly men

›Social isolation, living alone, widowed or divorced

›Unemployment and low socioeconomic status

›Military or veteran status: 21% higher rate than civilians

›Medical and trauma history

›Childhood adversity (4+ ACEs: OR 30.15 for suicide attempt)

›Chronic pain: doubled odds of attempt

›Traumatic brain injury

›Epilepsy, ALS, COPD, or cancer diagnoses

›Recent discharge from psychiatric hospitalization

›First weeks post-discharge highest-risk period

Psychiatric and medication history

›Prior psychiatric hospitalizations

›Indications and duration of past admissions

›History of involuntary holds

›Current psychiatric treatment

›Medications and adherence

›Psychotherapy engagement

›Medication history relevant to risk

›Antidepressant initiation within past 4–6 weeks

›FDA black box: increased suicidality in patients under 25

›Benzodiazepine use: associated with increased risk

›Corticosteroids, isotretinoin, montelukast, anticonvulsants: treatment-emergent ideation risk

›Substance use history

›Alcohol: major disinhibitor and precipitant

›Stimulant or sedative use

›Intravenous drug use

Collateral history

›Information sources beyond patient

›Family members or caregivers

›Override confidentiality if safety at risk

›Friends, partners, or roommates

›Outpatient treaters

›EMS documentation of scene

›Family history

›Completed suicide in first-degree relative

›Family history of mood disorders or substance use

›Social context

›Domestic violence or abuse

›Housing instability

›LGBTQ+ identity with experience of discrimination or rejection

03Physical Exam/exam51

Vital signs and general appearance

›Vital sign abnormalities

›Tachycardia: agitation, intoxication, withdrawal, fear

›Hypertension: stimulant use, anxiety, pain

›Hypotension: significant ingestion, autonomic dysregulation

›Hypothermia or hyperthermia: toxidrome consideration

›General appearance

›Psychomotor agitation or retardation

›Poor self-care or hygiene

›Evidence of weight loss

Mental status examination

›Appearance and behavior

›Eye contact and engagement

›Cooperation with interview

›Mood and affect

›Flat, tearful, anxious, or irritable

›Congruence of affect with stated mood

›Thought content

›Active suicidal ideation with or without plan

›Hopelessness, worthlessness, helplessness

›Command hallucinations directing self-harm

›Paranoid ideation affecting safety assessment

›Thought process

›Organized vs. disorganized

›Tangential or circumstantial thinking

›Judgment and insight

›Awareness of risk and need for treatment

›Ability to engage in safety planning

04Differential Diagnosis/ddx48

Psychiatric diagnoses underlying suicidal ideation

›Major depressive disorder

›ICD-10: F32.x (single episode), F33.x (recurrent)

›Most common underlying diagnosis in suicidal ideation presentations

›Differentiating: persistent low mood, anhedonia, vegetative symptoms

›Bipolar disorder

›ICD-10: F31.x

›Mixed state or depressive episode: highest suicide risk within bipolar spectrum

›Key feature: hypomanic or manic history, rapid mood cycling

›Schizophrenia and psychotic disorders

›ICD-10: F20.x

›Command hallucinations as direct driver of risk

›Insight impairment complicating assessment

›Borderline personality disorder

›ICD-10: F60.3

›Chronic suicidality with acute crisis exacerbations

›Non-suicidal self-injury often comorbid

Substance-related presentations

›Acute alcohol intoxication with suicidal ideation

›ICD-10: F10.129

›Disinhibition markedly elevates imminent risk

›Reassessment required after sobriety

›Stimulant intoxication

›ICD-10: F14.x, F15.x

›Paranoia and agitation may co-occur

›Sedative or opioid intoxication or withdrawal

›ICD-10: F13.x, F11.x

›Withdrawal dysphoria may precipitate crisis

05Laboratory Tests/lt38

Toxicology screening

›Urine drug screen

›Identifies substance intoxication or use contributing to crisis

›Immunoassay: rapid, widely available, false positives possible

›Confirmatory GC-MS for clinical or legal significance

›Blood alcohol level

›Quantitative: stratifies severity of intoxication

›Guides timing of reassessment after sobriety

›Acetaminophen level

›Mandatory in all presentations where ingestion is possible

›Nomogram-based treatment threshold after 4-hour post-ingestion level

›Level at 4 hours: treatment threshold 1.32 mmol/l (200 mcg/ml)

›Salicylate level

›Obtain when aspirin ingestion suspected

›Therapeutic: 1.1–2.2 mmol/l; toxic: >2.2 mmol/l

Metabolic and organ function

›Basic metabolic panel

›Sodium: hyponatremia with psychiatric medications (SIADH from SSRIs)

›Potassium: dysrhythmia risk if ingestion suspected

›Glucose: hypoglycemia mimicking psychiatric crisis

›Renal function: creatinine and BUN for medication dosing

›Bicarbonate: metabolic acidosis from ingestion or severe agitation

›Liver function tests

›Acetaminophen toxicity evaluation

›Alcohol-related hepatic disease

›Complete blood count

›Anemia as reversible contributor to fatigue and low mood

›Leukocytosis if infectious etiology of AMS

06Diagnostic Tests/dt56

Scoring Systems

›Columbia-Suicide Severity Rating Scale (C-SSRS)

›Most widely validated tool for ED and clinical settings

›Stratifies ideation: passive to active with plan and intent

›Stratifies behavior: preparatory, aborted, interrupted, attempt

›Differentiates suicidal self-injurious behavior from NSSI

›Recommended by Joint Commission for psychiatric patient safety goals

›Ask Suicide-Screening Questions (ASQ)

›4-item validated brief screen for medical and ED settings

›Sensitivity 96.9%, specificity 87.6% for active suicidal ideation

›Positive screen triggers full C-SSRS assessment

›ACEP recommends structured screening in ED (Level B recommendation)

›Patient Health Questionnaire-9 (PHQ-9)

›Item 9 screens for suicidal ideation as part of depression assessment

›Validated USPSTF tool for depression screening in primary care

›Score 0–27; severity: minimal <5, mild 5–9, moderate 10–14, severe >=20

›SAD PERSONS scale (historical)

›10 clinical variables: sex, age, depression, prior attempt, alcohol use, rational thinking loss, social supports, organized plan, no spouse, sickness

›Low sensitivity; not recommended as standalone disposition tool

›Clinical judgment required beyond any scoring tool

›Beck Scale for Suicide Ideation

›21-item clinician-administered tool for ideation intensity

›Research and inpatient settings; not validated for ED triage

›Beck Hopelessness Scale

›Hopelessness independently predicts long-term suicidal behavior

›Score >=9 associated with substantially elevated suicide risk

MRI

›MRI brain: not routinely indicated for suicidal ideation

07Disposition/dispo48

High-risk disposition: inpatient psychiatric hospitalization

›Indications for inpatient admission

›Active suicidal ideation with specific plan and access to means

›Clear intent to act on suicidal thoughts

›Recent serious suicide attempt requiring medical stabilization

›Psychotic or manic features driving suicidal behavior

›Severe depression with psychomotor retardation or psychosis

›Inability to contract for safety or engage in safety planning

›Inadequate social support for outpatient management

›Prior serious attempt with ongoing risk factors

›Involuntary hospitalization criteria

›Danger to self meeting jurisdictional threshold

›Document clinical reasoning and evidence of risk

›Notify legal team or hospital administration if patient refuses

Moderate-risk disposition: crisis stabilization or extended observation

›Crisis unit or 23-hour observation criteria

›Passive ideation or active ideation without plan after initial evaluation

›Precipitant potentially resolving (acute intoxication, acute stressor)

›Psychiatric consultation required during observation

›Reassessment after sobriety or resolution of precipitant

›Observation management

›Repeat mental status and risk stratification

›Initiate or adjust psychiatric medication if indicated

›Social work involvement for collateral and disposition planning

Low-risk disposition: discharge with safety planning

›Discharge eligibility criteria

›Passive ideation only without intent or plan

›Precipitant identified and addressed

08Treatment/t88

Immediate behavioral and environmental interventions

›Safe environment creation

›1:1 monitoring or continuous observation

›High-risk patients: direct line-of-sight

›Document level of observation required and rationale

›Room search and hazard removal

›Personal belongings secured

›Ligature-free environment confirmed

›Therapeutic alliance

›Direct, nonjudgmental communication approach

›Ask directly: "Are you thinking about killing yourself?"

›Less than one-third of patients volunteer ideation unprompted

›Active listening and validation of distress

›Psychoeducation about treatment options

Agitation management

›Verbal de-escalation as first-line intervention

›Calm, quiet room

›Reduce sensory stimulation

›Offer oral medications before parenteral

›Oral sedation options

›Lorazepam 1–2 mg PO

›Benzodiazepines caution: associated with increased suicide risk chronically

›Acceptable acute use for agitation management only

›Olanzapine 5–10 mg PO

›Preferred over benzodiazepines in psychotic agitation

›Haloperidol 2–5 mg PO with lorazepam 1–2 mg PO

›Parenteral sedation for severe agitation

›Droperidol 5–10 mg IM

›Rapid onset: 3–5 minutes

›Monitor QTc

›Haloperidol 5 mg IM plus lorazepam 2 mg IM

›QTc monitoring

›Olanzapine 10 mg IM

›Do not combine IM olanzapine with IM benzodiazepine: respiratory depression risk

›Ketamine 2–4 mg/kg IM for extreme agitation

›Rapid immobilization

›Airway management preparation required

Pharmacotherapy for suicidal ideation

›Lithium

›Reduces suicide attempts and all-cause mortality in unipolar and bipolar mood disorders

›Class I evidence from multiple meta-analyses

›Target serum level: 0.6–1.2 mmol/l

›Initiation in ED: consult psychiatry before initiating

›Narrow therapeutic index: toxicity at levels >1.5 mmol/l

›Symptoms: tremor, confusion, polyuria, dysarthria, coma

›Clozapine

›Reduces suicidal behavior in schizophrenia-spectrum disorders

›FDA-approved specifically for suicidality reduction in schizophrenia

›Restricted use due to agranulocytosis risk

›Requires REMS enrollment and monitoring

›Not initiated from ED without psychiatry coordination

›Esketamine (Spravato)

›FDA-approved for MDD with acute suicidal ideation or behavior

›Used in conjunction with oral antidepressant

›Requires REMS-certified healthcare setting

›2-hour post-dose monitoring required

›Dose: 84 mg intranasal twice weekly for 4 weeks

›Not routinely administered in ED setting

›IV ketamine for acute suicidal ideation

›Rapidly reduces suicidal ideation within 1–4 hours

›Emerging evidence for ED use

›Effect on suicidal behavior not yet proven

›Dose: 0.5 mg/kg IV over 40 minutes (sub-anesthetic)

›Contraindications: uncontrolled hypertension, active psychosis, mania

Antidepressant initiation and adjustment

›SSRIs as first-line for MDD with suicidal ideation in adults >=25 years

›Sertraline 50 mg daily, titrate to 50–200 mg daily

›Escitalopram 10 mg daily, titrate to 10–20 mg daily

›Fluoxetine 20 mg daily, titrate to 20–60 mg daily

›Prefer SSRIs over TCAs: lower overdose toxicity

›Close monitoring in first 4–6 weeks: risk of activation

›Prescribing safety precautions

›Limit initial prescription to 30-day supply

›Avoid citalopram and venlafaxine in overdose-risk patients

›Higher overdose toxicity among antidepressants

›Avoid TCA prescribing in suicidal patients

›Narrow therapeutic window, high lethality in overdose

›FDA black box warning: antidepressants and suicidality under 25

›Risk highest in first weeks and after dose changes

›Mandatory safety counseling and close follow-up

Psychosocial interventions

›Safety Planning Intervention

›Reduces subsequent suicidal behavior vs. usual care

›JAMA Psychiatry 2018: Stanley et al. RCT

›Implemented in ED before discharge in low-to-moderate risk patients

›Crisis resources provided

›988 Suicide and Crisis Lifeline (call or text 988)

›Crisis Text Line: text HOME to 741741

›Local emergency contacts and 911

›Means restriction counseling

›Lethal means counseling reduces suicide attempt rates

›Firearm storage: trigger lock, gun safe, or off-site storage

›Medication safety: pill lock boxes or pharmacist dispensing

09Special Populations/sp83

Pregnancy

›Epidemiology in pregnancy

›Suicide is a leading cause of maternal mortality in high-income countries

›20% of all peripartum deaths in some studies

›Risk elevated in first trimester and immediately postpartum

›Perinatal mood disorders: depression and anxiety most common triggers

›Risk factors specific to pregnancy

›Unplanned or unwanted pregnancy

›Domestic violence (prevalence 15–20% in pregnancy)

›History of mood disorder or prior suicide attempt

›Social isolation and lack of partner support

›Substance use in pregnancy

›Assessment modifications

›Beta-hCG mandatory in all women of childbearing age

›Gestational age affects medication choices

›Obstetric and psychiatry co-management

›Treatment considerations

›SSRIs generally safe in pregnancy: benefit-risk assessment required

›Sertraline preferred: best safety data

›First trimester: SSRI use weighed against untreated depression risk

›Avoid lithium in first trimester: Ebstein anomaly risk (small absolute risk)

›Benzodiazepines: short-term use acceptable in severe agitation

›Neonatal withdrawal possible with chronic use

›Esketamine: not approved in pregnancy, avoid

›Electroconvulsive therapy: may be indicated for severe refractory depression

›Postpartum safety planning essential before discharge

Geriatric

›Epidemiology in older adults

›Highest completed suicide rate in elderly white men

›Higher ratio of attempts to completions than younger adults

›More lethal methods chosen: firearms, hanging

›Less likely to communicate ideation before attempt

›Unique risk factors

›Social isolation and bereavement

›Chronic medical illness: pain, functional decline

›Cognitive impairment: early dementia with preserved insight

›Recent loss of independence or change in living situation

›Polypharmacy and medication interactions

›Assessment challenges

›Underreporting of symptoms: stoicism

›Overlap of depression with medical comorbidities

›Cognitive impairment affecting history validity

›Clinician underestimation of risk in older adults

›Treatment modifications

›Start low, go slow with all psychotropics

›SSRI preferred: escitalopram 5–10 mg daily or sertraline 25–50 mg daily

›Avoid TCAs: anticholinergic burden, fall risk, cardiac toxicity

›Mirtazapine useful if appetite loss and insomnia coexist

›Fall risk with benzodiazepines: use sparingly

›Lithium: careful monitoring; reduced renal clearance with age

›Target level at lower end: 0.5–0.8 mmol/l

›Social support and community engagement as part of plan

›Earlier disposition threshold for inpatient admission

Pediatrics

›Epidemiology in children and adolescents

›Second leading cause of death in ages 10–34 in the United States

›Suicide rate has increased significantly since 2007 in adolescents

›Girls: higher attempt rates; boys: higher completion rates

›Firearms increasingly used by adolescents

›Unique risk factors

›Bullying (in-person and cyberbullying)

›LGBTQ+ identity with unsupportive family environment

›Academic pressure and school-related stressors

›Social media exposure to self-harm content

›Contagion risk: exposure to peer suicidal behavior

›Impulsivity as a trait: high risk with access to means

›ACEs: abuse, neglect, household dysfunction

›Assessment modifications

›Parental consent and involvement required for minors

›Assess parental mental health: depressed parents may minimize risk

›Screen for abuse: child may not disclose freely

›C-SSRS pediatric version validated for ages 6 and above

›Pediatric emergency medicine and child psychiatry consultation

›AAP and ACEP recommend joint evaluation protocols

›FDA black box warning especially relevant

›Antidepressants increase suicidality risk in under-25 age group

›Risk highest in weeks 1–4 and after dose increases

›Monitoring schedule: weekly for first 4 weeks

›Treatment considerations

›Fluoxetine: only SSRI FDA-approved for MDD in ages 8 and above

›Escitalopram: FDA-approved for adolescents 12 and older

›Avoid TCAs entirely in pediatric patients

›Family-based safety planning: parents as active participants

›Lethal means counseling directed at parents

›Firearm storage is primary intervention in pediatric cases

›Dialectical behavior therapy (DBT) has strongest evidence for adolescent suicidality

10Background/b63

Epidemiology

›Global and national burden

›Approximately 700,000 suicide deaths globally per year

›Suicide is a leading cause of preventable death in high-income countries

›United States: over 47,000 suicide deaths per year (approximately 13.5 per 100,000)

›Suicide attempt-to-completion ratio: approximately 25:1

›Emergency department visits for suicidal ideation: over 2.3 million per year in the US

›Demographic patterns

›Men: 3–4 times higher completion rate than women

›Women: 2–3 times higher attempt rate than men

›Peak completion rates: white men over 65 and men aged 20–34

›Indigenous populations: 2–3 times higher rate than non-Indigenous populations

›Veterans: 21% higher suicide rate than age-matched civilians

›Temporal and contextual trends

›Rates increased substantially between 2007 and 2018 in the US

›Firearm: most common method in completed suicide in the US (over 50%)

›Hanging: second most common in men

›Overdose: most common method in women

›Rates increased post-COVID-19 in adolescents and young adults

Pathophysiology

›Neurobiological basis

›Serotonergic dysfunction: reduced 5-HT2A receptor binding in postmortem studies

›HPA axis dysregulation: elevated cortisol, blunted dexamethasone suppression

›Prefrontal cortical thinning: impaired impulse control and emotion regulation

›Glutamate excitotoxicity: basis for rapid response to ketamine

›Neuroinflammation: elevated pro-inflammatory cytokines in suicidal patients

›Genetic and epigenetic factors

›Heritability: 30–50% contribution to suicidal behavior

›Serotonin transporter gene (5-HTTLPR) polymorphism: gene-environment interaction

›Epigenetic modifications: childhood adversity alters gene expression

›Family history of suicide doubles risk independent of psychiatric diagnosis

›Psychological models

›Diathesis-stress model: predisposing vulnerability plus precipitating stressor

›Interpersonal theory: thwarted belongingness and perceived burdensomeness

›Integrated Motivational-Volitional model: defeat, entrapment, then capability to act

›Hopelessness as mediating factor between depression and suicidality

›Cognitive and behavioral mechanisms

›Cognitive constriction: tunnel-vision thinking during crisis

›Impulsivity as key vulnerability trait

›Pain tolerance and acquired capability for self-harm

›Exposure to prior self-harm lowers psychological barrier to future attempt

Therapeutic Considerations

›Evidence hierarchy for suicide-specific interventions

›Lithium: Level I evidence for reducing completed suicide in mood disorders

›Clozapine: only FDA indication specifically for suicidality reduction

›Esketamine: FDA-approved for MDD with acute suicidal ideation or behavior

›Safety Planning Intervention: RCT evidence for reducing ED reattempt rates

›CBT for suicide prevention (CBT-SP): reduces reattempt rates in adolescents

›DBT: strongest evidence for reducing self-harm and attempts in BPD and adolescents

›Pharmacotherapy evidence gaps

›No antidepressant has proven efficacy specifically for suicidality reduction

›SSRIs reduce suicidal ideation indirectly by treating depression

›Ketamine effect on behavior (vs. ideation) remains unproven from RCTs

›Means restriction as evidence-based intervention

›Firearm storage laws associated with reduced firearm suicide rates

›Bridge barriers reduce site-specific jump suicides

›Means restriction is population-level prevention with strongest evidence

›Crisis follow-up contact improves outcomes

›Warm handoff to outpatient care more effective than appointment referral

›Follow-up phone calls after ED discharge reduce reattempt rates

›Brief Contact Interventions: postcards, texts, phone calls — modest benefit

›Joint Commission National Patient Safety Goal for Suicide

›Universal screening in acute care settings

›Risk stratification and documentation

›Safety plan before discharge

›Follow-up contact within 24–48 hours of discharge

11Patient Discharge Instructions/pdi34

copy discharge instructions

›Discharge instructions for suicidal ideation

›Your safety is our priority

›You were seen in the emergency department today because of thoughts of suicide or self-harm

›We have provided you with a safety plan to use if your thoughts return or get worse

›Your safety plan

›Warning signs that a crisis may be developing: review with your provider before leaving

›Coping strategies you can use on your own

›People and places that can provide distraction

›People you can ask for help

›Professionals to contact in a crisis

›Making your environment safer: remove or secure firearms and medications

›Crisis resources

›Call or text 988 to reach the Suicide and Crisis Lifeline anytime

›Text HOME to 741741 for the Crisis Text Line

›Call 911 or go to the nearest emergency department if you feel you may act on your thoughts

›Medications

›Take all medications as prescribed

›Do not stop medications without speaking to your provider

›Store all medications in a locked location out of reach

›Only fill the smallest supply needed

›Alcohol and substances

›Avoid all alcohol and non-prescribed drugs

›These significantly increase the risk of acting on suicidal thoughts

›Return to the emergency department immediately if

›Thoughts of suicide return or become stronger

›You have a specific plan to hurt yourself

›You feel you cannot keep yourself safe

12References/r37

Guidelines and key sources

›Primary guideline references

›VA/DoD Clinical Practice Guideline: Assessment and Management of Patients at Risk for Suicide (2024)

›Comprehensive framework for risk stratification and management

›Validated tools including C-SSRS and safety planning

›ACEP Clinical Policy: Adult Psychiatric Patient in the Emergency Department (Annals of Emergency Medicine, 2017)

›ACEP Level B: structured risk assessment recommended

›ACEP Level B: consultation with psychiatry for high-risk patients

›Joint Commission National Patient Safety Goal for Suicide Prevention (2018)

›Universal screening, risk stratification, safety planning, and follow-up requirements

›USPSTF: Screening for Suicide Risk in Primary Care (2014)

›Insufficient evidence for universal adult screening outside high-risk populations

›USPSTF: Screening for Depression in Adults including Item 9 PHQ-9 (JAMA 2023)

›Landmark clinical studies

›Stanley B et al. Safety Planning Intervention vs. Usual Care in ED (JAMA Psychiatry 2018)

›SPI associated with half the rate of suicidal behavior at 6 months

›Boudreaux ED et al. ED-SAFE 2 Cluster RCT (JAMA Psychiatry 2023)

›ED process improvement including universal screening and SPI reduces reattempts

›D'Anci KE et al. Treatments for Prevention and Management of Suicide: Systematic Review (Annals of Internal Medicine 2019)

›Lithium and clozapine with strongest antisuicidal evidence

›Mann JJ et al. Improving Suicide Prevention Through Evidence-Based Strategies (American Journal of Psychiatry 2021)

›Means restriction and crisis intervention as evidence-based population strategies

›Turecki G, Brent DA. Suicide and Suicidal Behaviour (Lancet 2016)

›Comprehensive review of epidemiology, risk factors, and pathophysiology

›Fazel S, Runeson B. Suicide (New England Journal of Medicine 2020)

›Epidemiology, risk stratification, and clinical management framework

›Knipe D et al. Suicide and Self-Harm (Lancet 2022)

›Updated evidence on interventions, epidemiology, and prevention

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Comprehensive Clinical Review

Structured, evidence-informed, long-form analysis for deeper understanding.

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.