Suicidal ideation and risk assessment
Suicidal ideation ranges from passive thoughts of death to an active plan with intent and access to lethal means, and suicide accounts for about 45,000 deaths a year in the United States. Diagnosis is clinical, built on directly asking about intent, plan, and means. A patient with a plan, intent, and access requires emergent hospitalization, involuntary if needed; a patient without intent and with support can be managed as an outpatient with means restriction, close follow-up, and first-line SSRI antidepressant therapy for the driving disorder.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Definition: suicidal ideation is any thought of ending one's own life, from a passive wish to be dead to an active plan with intent and identified means.
- Epidemiology
Burden: suicide causes about 45,000 deaths a year in the United States, the 10th overall cause of death, one every 11 minutes.
- Risk factors
Previous suicide attempt: the single most important predictor, outweighing every factor below.
- Pathophysiology
Working framework: suicidal behavior emerges when a driving condition (depression, mania, psychosis, intoxication, personality pathology) combines with an acute stressor and reduced impulse control.
- Clinical features
Passive ideation: thoughts of being better off dead or not waking up, without a wish to actively end one's own life.
- Differential diagnosis
Major depressive disorder: ideation accompanies a sustained episode of depressed mood or anhedonia with neurovegetative symptoms, unlike intoxication-related ideation, which resolves as the substance clears.
- Diagnosis
Diagnostic basis: a clinical diagnosis established by directly asking about ideation, intent, and plan, identifying access to means, and asking about family history, previous attempts, and…
- Management
First, ensure immediate safety: secure the environment, restrict firearms and medications, and do not leave the patient unsupervised; stabilize any self-harm or ingestion first, then complete the evaluation.
- Complications
Repeat attempt or completed suicide: a previous attempt is the strongest predictor of a future attempt, risk highest right after an attempt or a hospital discharge.
- Prognosis
Recurrence risk: a previous attempt remains the single most important predictor of a future attempt or completed suicide.
- Prevention
Universal depression and suicide screening: screen adults at a routine visit with the PHQ-2, then the PHQ-9 after a positive screen; the PHQ-9 also tracks treatment response, a decrease of at least…
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Major depressive disorder
Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.
- Bipolar I disorder
Bipolar I disorder is a chronic mood disorder defined by at least one manic episode lasting a week or requiring hospitalization, with three or more DIG FAST symptoms causing marked impairment. Diagnosis is clinical after substances and medical mimics are excluded. Acute mania is treated with lithium or valproate, often with an atypical antipsychotic, and most patients need lifelong mood-stabilizer maintenance.
- Borderline personality disorder
Borderline personality disorder is a cluster B personality disorder defined by 5 or more of 9 DSM-5 criteria spanning instability of relationships, self-image, and affect, marked impulsivity, and recurrent self-injury or suicidality; dialectical behavior therapy is the first-line treatment, with pharmacotherapy reserved as a secondary, symptom-targeted adjunct.
- Alcohol use disorder
Alcohol use disorder is a chronic pattern of drinking meeting 2 or more of 11 DSM-5 criteria within a 1-year period, screened with the CAGE or AUDIT-C and confirmed by history. First-line management combines a brief behavioral intervention and cognitive behavioral therapy with naltrexone or acamprosate, reserving disulfiram for highly motivated patients who can maintain abstinence.
- Opioid use disorder
Opioid use disorder is a maladaptive pattern of opioid use causing significant impairment or distress, diagnosed by meeting 2 or more of 11 substance use disorder criteria within a 12-month period. First-line treatment is medication for opioid use disorder: buprenorphine or methadone maintenance for ongoing agonist therapy, or naltrexone once the patient is confirmed opioid-free, paired with psychosocial care and take-home naloxone.
- Delirium
Delirium is an acute, fluctuating disturbance of attention and awareness caused by an underlying medical, toxic, or metabolic insult. Diagnosis rests on the Confusion Assessment Method; management is identification and treatment of the precipitating cause plus withdrawal of deliriogenic drugs, reserving antipsychotics for safety only.