Psychosocial, Behavioral & Cognitive · Topic 5 of 7

Suicide Risk Assessment

Psychosocial · suicide prevention

Suicide Risk Assessment

Stabilize, keep the patient safe and observed, screen with a validated tool, then assess, restrict lethal means and build a written safety plan before discharge.

Key numbers

Screen with a validated toolAge ≥ 12

Ask about firearms; restrict lethal meansFirearms: 55% of suicides

Write a safety plan with the patient988 crisis line

01 · The ruleScreen with a validated tool

Joint Commission NPSG 15.01.01: screen patients evaluated or treated for behavioral health conditions with a validated tool (e.g., ASQ, PHQ-9, C-SSRS) from age 12; a positive screen triggers an evidence-based suicide risk assessment.

02 · DoAsk about firearms; restrict lethal means

Ask about firearms and other lethal means and counsel on removing or locking them away; firearms caused 55% of US suicides in 2023.

03 · DoWrite a safety plan with the patient

Build a written safety plan with the patient — warning signs, coping steps, contacts and crisis lines (988), lethal-means safety; safety planning plus follow-up calls cut suicidal behavior 45% over 6 months.

What it is

Core idea

ASQ: four questions in 20 secondsThe NIMH Ask Suicide-Screening Questions (ASQ) — four questions, about 20 seconds — is validated for youth and adult medical patients; the C-SSRS can both screen and grade severity.

Causes & risk factors

Why it happens

Prior attempt and a concrete plan raise risk must knowKey risk factors: a previous attempt, a detailed plan or preparation, depression, bipolar disorder or schizophrenia, substance use, chronic pain or new serious illness, hopelessness, recent loss, social isolation and access to firearms.

Highest risk: the weeks after dischargeSuicide risk peaks in the days to weeks after discharge from an ED or psychiatric admission and stays high for 6–12 months; book follow-up within the first week and add follow-up calls.

Presentation

What you'll see

Calm after an attempt is not safetyAfter an attempt, a brief mood lift can lead the patient to deny problems; the risk of later suicide remains high without ongoing treatment and support.

Do right now

In this order

First moves

Stabilize first; never leave the patient alone

→

Screen with a validated toolAge ≥ 12

→

Ask about firearms; restrict lethal meansFirearms: 55% of suicides

→

Write a safety plan with the patient988 crisis line

Why each step

Stabilize first; never leave the patient aloneAfter an attempt, treat the injury or overdose first (antidote, supportive care) and keep the at-risk patient under continuous observation in a safe location until a secure setting or psychiatric evaluation is reached.

Screen with a validated toolJoint Commission NPSG 15.01.01: screen patients evaluated or treated for behavioral health conditions with a validated tool (e.g., ASQ, PHQ-9, C-SSRS) from age 12; a positive screen triggers an evidence-based suicide risk assessment.

Ask about firearms; restrict lethal meansAsk about firearms and other lethal means and counsel on removing or locking them away; firearms caused 55% of US suicides in 2023.

Write a safety plan with the patientBuild a written safety plan with the patient — warning signs, coping steps, contacts and crisis lines (988), lethal-means safety; safety planning plus follow-up calls cut suicidal behavior 45% over 6 months.

Management

Orders

Remove ligature points and self-harm objectsPsychiatric units must remove anchor points for hanging; on medical units (not ligature resistant), remove objects usable for self-harm and keep high-risk patients under continuous monitoring while awaiting transfer.

Check acetaminophen in every intentional ingestionConsider occult acetaminophen overdose in every intentional ingestion and check a serum level — early poisoning causes few symptoms but is lethal and treatable.

Imminent risk: hold and transfer to secure careWhen suicide is imminent, most US jurisdictions require the clinician to act — notify an empowered agency or use an emergency hold; medically unstable or delirious patients stay on a medical unit with suicide precautions.

Prescribe small supplies of low-lethality drugsFor at-risk patients, dispense medications in small, sublethal quantities, prefer antidepressants that are not lethal in overdose (avoid tricyclics), and see the patient more often early in treatment.

The rules

Know these

Medical patients: assess when risk appearsNPSG 15.01.01 does not require universal screening of patients treated primarily for medical conditions, but those with a new serious diagnosis, poor prognosis or psychosocial stress should be assessed when indicated.

Document the risk level and the planDocument the overall suicide risk level and the plan to mitigate it, follow policies for reassessment and monitoring of high-risk patients (e.g., one-to-one observation), and give discharge counseling and follow-up.

Screening or risk assessment?

Commonly confused

Who	Patients evaluated or treated for behavioral health conditions, age 12+
Tool	Brief validated screener (ASQ, PHQ-9, C-SSRS screen)
Asks about	Presence of suicidal ideation
Output	Positive or negative

Teach & follow up

Patient education

Asking about suicide does not plant the ideaAsk directly about suicidal thoughts, plans and intent; the fear that asking implants the idea is baseless, and asking conveys awareness of the patient's despair.

More detail

Reference

Show 4 reference facts

Lithium reduces suicide deaths in major depression and bipolar disorder, clozapine reduces suicide risk in schizophrenia, and intranasal esketamine is used with an oral antidepressant for depression with acute suicidality.

USPSTF finds insufficient evidence (I statement) to screen asymptomatic adults in primary care for suicide risk — distinct from the Joint Commission requirement for behavioral health patients.

About 90% of people who die by suicide have a diagnosable psychiatric disorder, and about 83% saw a physician in the preceding year — most at-risk patients pass through health care.

Psychotherapies that reduce suicide risk include CBT for suicide prevention, dialectical behavior therapy, collaborative assessment and management of suicidality (CAMS) and specific family therapies.

Pearl

Ask directly — asking never plants the idea — then take away the means and write the plan together.

Sources · The Joint Commission — R3 Report Issue 18: National Patient Safety Goal for suicide prevention (NPSG 15.01.01, EPs 1–7), Nov 2019, updated Dec 2025 · Merck Manual Professional — Suicidal Behavior · NIMH — Ask Suicide-Screening Questions (ASQ) Toolkit · Stanley B et al. Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the ED. JAMA Psychiatry 2018;75:894–900 · USPSTF. Screening for Depression and Suicide Risk in Adults: Recommendation Statement (suicide risk: I statement). JAMA 2023;329:2057–2067 · Merck Manual Professional — Acetaminophen Poisoning · Merck Manual Professional — Medications for Treatment of Depression · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).