Suicide risk assessment is one of the most important skills you will develop in psychiatric clinical practice. You must learn to ask direct questions, assess risk factors and protective factors, recognize red flags, involve your preceptor promptly, and document clearly.

Your role is not to predict suicide with certainty. No clinician can do that perfectly. Your role is to gather clinically relevant information, identify acute safety concerns, determine whether the patient can remain safe in the current level of care, and follow preceptor and site policy.

Passive vs Active Suicidal Ideation

Suicidal ideation exists on a spectrum. You should clarify what the patient means rather than assuming.

Passive suicidal ideation

Passive suicidal ideation may include thoughts such as:

• “I wish I would not wake up.”

• “I do not want to be here anymore.”

• “Everyone would be better off without me.”

• “I wish I could disappear.”

• “I do not want to kill myself, but I do not want to keep living.”

Passive suicidal ideation still matters. It may become more concerning when paired with hopelessness, worsening depression, isolation, substance use, prior attempts, access to lethal means, recent loss, psychosis, agitation, or inability to safety plan.

Active suicidal ideation

Active suicidal ideation means the patient has thoughts of killing themselves.

Examples:

• “I have thought about killing myself.”

• “I have been thinking about overdosing.”

• “I keep imagining shooting myself.”

• “I have been looking up ways to die.”

Active suicidal ideation requires more detailed assessment of plan, intent, access to means, timing, preparation, past attempts, protective factors, and ability to remain safe.

Questions to Ask

Ask directly and calmly.

Start with:

• “Have you had thoughts of not wanting to be alive?”

• “Have you had thoughts of killing yourself?”

• “How often are those thoughts happening?”

• “How intense are they?”

• “How long do they last?”

• “What tends to trigger them?”

• “What helps them pass?”

If suicidal thoughts are present, ask:

• “Have you thought about how you would do it?”

• “Do you have access to that method?”

• “Have you taken any steps to prepare?”

• “Do you intend to act on these thoughts?”

• “When do you think you might act on them?”

• “Have you attempted suicide before?”

• “What stopped you from acting on the thoughts?”

• “Do you feel able to stay safe today?”

Do not avoid direct wording. Patients can usually tolerate direct questions when asked respectfully.

Plan

A suicide plan increases concern, especially if it is specific, feasible, lethal, and accessible.

Assess:

• Method

• Specificity

• Timing

• Location

• Access

• Lethality

• Preparation

• Rehearsal

• Secrecy

• Likelihood of acting

Questions:

• “Have you thought about a specific way you would do it?”

• “Have you thought about when or where?”

• “Do you have access to what you would use?”

• “Have you practiced, rehearsed, written notes, gathered pills, or done anything to prepare?”

A vague thought is clinically different from a specific plan with access and intent. Both require assessment, but they are not the same risk picture.

Intent

Intent means the patient’s likelihood or desire to act on suicidal thoughts.

Assess:

• Desire to die

• Ambivalence

• Perceived control over impulses

• Future orientation

• Deterrents

• Hopelessness

• Reasons for living

• Ability to delay action

• Willingness to use support

Questions:

• “Do you intend to act on these thoughts?”

• “How likely do you feel you are to act on them?”

• “On a scale of 0–10, how strong is the urge to act?”

• “What has stopped you from acting so far?”

• “Do you feel able to stay safe until your next appointment?”

• “Would you be willing to let someone help you reduce access to means?”

Intent can change quickly, especially with intoxication, agitation, panic, psychosis, interpersonal crisis, or severe insomnia.

Access to Means

Access to lethal means is a critical part of suicide risk assessment.

Assess access to:

• Firearms

• Stockpiled medications

• Opioids

• Benzodiazepines

• Insulin or other high-risk medications

• Knives or sharp objects when clinically relevant

• Ligatures

• Toxic substances

• Vehicles or bridges when relevant to plan

• Other method-specific means

Questions:

• “Do you have access to firearms?”

• “Are firearms locked, unloaded, or stored outside the home?”

• “Do you have access to large amounts of medication?”

• “Do you have access to the method you mentioned?”

• “Is there someone who can help secure or remove access while you are at risk?”

Means safety should be discussed under preceptor and site guidance. Do not treat means safety as optional when risk is present.

Past Attempts

Past suicide attempts are one of the most important historical risk factors to assess.

Ask:

• “Have you ever attempted suicide before?”

• “When did that happen?”

• “What method did you use?”

• “Did you expect to die?”

• “Did you need medical care?”

• “Were you hospitalized?”

• “What was happening in your life at that time?”

• “What helped afterward?”

• “Have there been near-attempts or times you almost acted?”

Assess the lethality, intent, recency, pattern, and circumstances of prior attempts.

Also assess nonsuicidal self-injury separately. Self-harm and suicide attempts can overlap but are not always the same.

Protective Factors

Protective factors may reduce risk, but they do not erase risk. Do not use protective factors to dismiss serious suicidal ideation.

Possible protective factors include:

• Children, spouse, family, friends, pets, or caregiving role

• Religious or spiritual beliefs

• Fear of death

• Future goals

• Therapeutic alliance

• Willingness to seek help

• Engagement in treatment

• Responsibility to others

• Restricted access to means

• Hopefulness

• Coping skills

• Crisis plan

• Stable housing

• Supportive supervision or monitoring

Questions:

• “What has kept you going?”

• “Who would you contact if thoughts got worse?”

• “What matters enough to stay alive for?”

• “What helps you get through those moments?”

• “Would you be willing to use crisis resources if the thoughts intensify?”

Protective factors should be specific, not generic.

Weak documentation:

“Has protective factors.”

Better documentation:

“Reports protective factors including spouse, children, religious beliefs, and willingness to contact crisis line if suicidal thoughts worsen.”

Acute vs Chronic Risk

You should distinguish between chronic baseline risk and acute escalation.

Chronic risk

Chronic risk may be elevated due to:

• Prior attempts

• Chronic suicidal ideation

• Trauma history

• Serious mental illness

• Substance use disorder

• Chronic pain

• Personality pathology

• Limited supports

• Longstanding depression

• Recurrent hospitalizations

Acute risk

Acute risk may increase due to:

• Current suicidal intent

• Specific plan

• Access to lethal means

• Recent attempt

• Recent loss

• Severe insomnia

• Intoxication

• Withdrawal

• Agitation

• Psychosis

• Mania

• Severe hopelessness

• Recent medication change

• Escalating self-harm

• Domestic violence or unsafe environment

• Inability to safety plan

A patient may have chronic suicidal thoughts but still not be acutely unsafe today. Another patient may have no prior history but present with acute high risk today. Assess both.

Red flags

Involve your preceptor promptly if the patient reports or demonstrates:

• Active suicidal ideation

• Suicide plan

• Intent to act

• Access to lethal means

• Preparatory behavior

• Recent suicide attempt

• Escalating self-harm

• Command hallucinations to self-harm

• Severe hopelessness

• Severe agitation or panic

• Intoxication or withdrawal

• Severe insomnia

• Mania or psychosis

• Inability to identify protective factors

• Inability or unwillingness to safety plan

• Unsafe home environment

• Patient requests secrecy about suicidal thoughts

• Collateral reports higher risk than the patient reports

Do not manage these concerns alone as a student or new clinician without appropriate supervision.

Documentation Expectations

Suicide risk documentation should include what you assessed, what the patient reported, your risk formulation, and the plan.

Document:

• Passive vs active suicidal ideation

• Frequency, intensity, and duration

• Plan

• Intent

• Access to means

• Preparatory behavior

• Past attempts

• Self-harm

• Substance use

• Psychosis or mania concerns

• Protective factors

• Ability to safety plan

• Level-of-care rationale

• Preceptor consultation

• Safety plan or escalation steps

• Follow-up plan

Example:

“Patient reports intermittent passive thoughts of not wanting to wake up occurring several times weekly. Denies active suicidal ideation, plan, intent, preparatory behavior, and access to firearms. Denies prior suicide attempts. Reports protective factors including spouse, children, and willingness to contact crisis resources if symptoms worsen. Safety assessment reviewed with preceptor. Safety plan reviewed and follow-up arranged per site protocol.”

Clinical Presentation Example

A patient being seen for depression says, “I would never do anything, but sometimes I wish I could just not wake up.”

You should not stop at “passive SI.” You should ask:

• “Have you had thoughts of killing yourself?”

• “Have you thought about how you would do it?”

• “Do you have access to medications, firearms, or other means?”

• “Have you ever attempted suicide before?”

• “What stops you from acting on those thoughts?”

• “Do you feel able to stay safe today?”

Then review with your preceptor and document the assessment clearly.

Self-Harm Assessment

Self-harm assessment focuses on intentional self-injury, including nonsuicidal self-injury, suicidal behavior, or behavior that may have mixed intent. You should never assume self-harm is “just attention-seeking” or automatically suicidal. You need to assess intent, function, frequency, severity, medical risk, and safety.

Self-harm can occur in adolescents and adults. It may be associated with depression, trauma, anxiety, eating disorders, personality pathology, substance use, psychosis, developmental disorders, or acute distress.

Nonsuicidal Self-Injury

Nonsuicidal self-injury, or NSSI, refers to intentional self-injury without the stated intent to die.

Examples may include:

• Cutting

• Burning

• Scratching

• Hitting oneself

• Banging head

• Interfering with wound healing

• Carving words or symbols

• Other intentional injury

NSSI still matters clinically. It can cause medical harm, increase shame, escalate over time, and coexist with suicidal ideation.

Questions to Ask

Ask calmly and without judgment.

• “Have you ever hurt yourself on purpose without trying to die?”

• “What have you done to hurt yourself?”

• “When was the last time?”

• “How often does it happen?”

• “What usually triggers it?”

• “What are you feeling before it happens?”

• “What does it do for you in the moment?”

• “Do you ever self-harm and also want to die?”

• “Have you needed medical care for injuries?”

• “Have you ever lost control and injured yourself more severely than intended?”

• “Do you have access to the items you use to self-harm?”

Function of Self-Harm

Understanding the function of self-harm helps guide safety planning and treatment referral.

Self-harm may function to:

• Reduce emotional intensity

• Interrupt numbness or dissociation

• Express distress

• Punish self

• Communicate pain

• Regain a sense of control

• Manage anger

• Cope with trauma reminders

• Relieve anxiety

• Avoid suicidal behavior

• Respond to interpersonal conflict

Ask:

• “What does self-harm do for you in that moment?”

• “Do you feel relief afterward?”

• “Do you feel guilt or shame afterward?”

• “Is it connected to conflict, panic, numbness, trauma reminders, or suicidal thoughts?”

Do not assume motive. Ask.

Frequency and Severity

Assess whether self-harm is occasional, escalating, medically dangerous, or part of a broader safety concern.

Ask:

• “How often has this happened?”

• “Has it been increasing?”

• “Are injuries becoming deeper or more serious?”

• “Have you used more dangerous methods over time?”

• “Have you needed stitches, emergency care, or antibiotics?”

• “Have you hidden injuries from others?”

• “Have you self-harmed while intoxicated?”

• “Have you self-harmed during dissociation or not remembered parts of it?”

Escalating severity or loss of control increases concern.

Medical Risk

Some self-harm injuries require medical evaluation. As a student or new clinician, do not try to judge medical severity alone when there is concern.

Assess:

• Depth

• Bleeding

• Infection signs

• Burns

• Head injury

• Ligature marks

• Overdose

• Loss of consciousness

• Intoxication

• Medical complications

• Need for emergency care

Red flags include:

• Uncontrolled bleeding

• Deep wounds

• Burns

• Infection

• Head injury

• Strangulation or choking behavior

• Overdose

• Self-harm while intoxicated

• Unclear intent

• Self-harm with suicidal thoughts

• Escalating frequency or severity

Involve your preceptor promptly.

Shame and Concealment

Patients may feel ashamed of self-harm and may hide it. A nonjudgmental tone matters.

Helpful language:

• “A lot of people feel embarrassed talking about this. I’m asking so we can understand risk and support you safely.”

• “I’m not here to shame you. I do need to understand what has been happening.”

• “You do not have to show me injuries unless it is clinically necessary and appropriate, but I do need to ask about medical risk.”

Avoid:

• “Why would you do that?”

• “That is just for attention.”

• “You need to stop doing that.”

• “Promise me you will never do that again.”

Promises are not safety plans.

Safety Planning

Self-harm safety planning should be specific.

It may include:

• Identifying triggers

• Identifying early warning signs

• Internal coping strategies

• Grounding skills

• Distress tolerance skills

• Delay strategies

• Reducing access to tools used for self-harm

• Support contacts

• Crisis contacts

• Therapy referral

• Higher level of care assessment when needed

• Follow-up plan

Examples of coping alternatives may include:

• Holding ice

• Cold water grounding

• Paced breathing

• Leaving the triggering environment

• Texting a support person

• Using a crisis line

• Removing or securing sharp objects

• Going to a safer public area

• Urgent appointment or crisis evaluation when needed

Use site-approved safety planning tools and preceptor guidance.

Red flags

Involve your preceptor promptly if self-harm includes:

• Suicidal intent

• Unclear intent

• Escalating severity

• Deep injuries or medical risk

• Self-harm while intoxicated

• Dissociation during self-harm

• Recent suicide attempt

• Access to lethal means

• Refusal or inability to safety plan

• Self-harm in a child or adolescent

• Caregiver unable to maintain safety

• Abuse, trafficking, or unsafe home environment

• Psychosis, command hallucinations, mania, or severe agitation

• Patient requesting secrecy

Documentation Tips

Document self-harm clearly and neutrally.

Include:

• Type of self-harm

• Frequency

• Last episode

• Trigger or function when known

• Suicidal intent denied or endorsed

• Medical risk

• Access to means/tools

• Safety plan

• Preceptor consultation

• Referral or escalation plan

Example:

“Patient reports nonsuicidal self-injury by superficial cutting, most recently one week ago, occurring during periods of intense emotional distress. Patient denies suicidal intent during episodes and denies current active SI, plan, or intent. Reports shame and attempts to conceal behavior. Medical risk reviewed; no current injury requiring urgent medical care reported. Safety plan reviewed with preceptor, including coping alternatives, crisis resources, and reducing access to cutting tools.”

Clinical Presentation Example

An adolescent reports cutting “to calm down” after arguments at home. They deny wanting to die but report the cuts have become deeper over the past month.

This requires more than reassurance. You should assess suicidal ideation, medical risk, frequency, triggers, access to tools, caregiver awareness, home safety, abuse concerns, and ability to safety plan. Review with your preceptor before the visit ends.