Suicidality is a cross-cutting clinical concern across psychiatric disorders. Approximately 49,000 suicide deaths occur annually in the United States; suicide is among the leading causes of death for young adults and for adults over 75. Most patients who die by suicide have a diagnosable psychiatric illness, but the diagnosis spans depression, bipolar disorder, schizophrenia, anxiety disorders, substance use, eating disorders, and personality disorders.
Risk factors stratify into static and dynamic:
Static — prior suicide attempt (strongest single predictor — multiplies risk substantially), male sex (completed suicide; women attempt more frequently but men die more), family history of suicide, history of trauma, chronic medical illness, certain occupations (physicians and dentists notably elevated), LGBTQ+ identity (driven by minority stress, not identity itself), older age (in men).
Dynamic — current psychiatric illness severity, current substance use, recent loss or stressor, recent psychiatric hospitalization (highest risk in 30 days post-discharge), current ideation/plan/intent, access to lethal means, social isolation, current hopelessness, current command hallucinations, current insomnia.
Risk is dynamic — changes hour to hour with circumstances. Static risk factors identify populations needing vigilance; dynamic factors identify acute moments.
Assessment:
Structured tools: Columbia Suicide Severity Rating Scale (C-SSRS) — most widely used, structured assessment of ideation severity (wish to be dead, suicidal thoughts, suicidal thoughts with method, suicidal thoughts with intent, suicidal thoughts with plan) and behaviors (attempts, preparatory acts). Ask Suicide-Screening Questions (ASQ) — brief screening tool. Patient Safety Plan Intervention (Stanley-Brown) for collaborative safety planning.
Direct questioning does not increase suicide risk — multiple studies confirm this. Direct inquiry shows respect for the patient's experience and provides an opportunity for intervention. Documenting that screening occurred and outcomes is essential.
Evidence-based interventions:
Means restriction is among the strongest evidence-based interventions, particularly for firearm safety. Firearms account for ~50% of US suicide deaths. Firearm safety counseling, temporary storage outside the home during high-risk periods, and gun lock distribution all reduce suicide. The conversation is uncomfortable but life-saving.
Safety planning (Stanley-Brown) — collaborative written plan with warning signs, coping strategies, social contacts for support, professional contacts, means restriction. Brief but evidence-based intervention reducing repeat suicide attempts.
Treat underlying disorders — many suicides involve untreated or under-treated psychiatric illness. Aggressive treatment of mood disorders, substance use, psychotic illness reduces suicide risk.
Specific evidence-based therapies: CBT for suicide prevention (CBT-SP), DBT for chronic suicidality, collaborative assessment and management of suicidality (CAMS).
Specific medications: lithium reduces suicide in mood disorders (specific evidence beyond mood stabilization). Clozapine reduces suicide in schizophrenia. Ketamine reduces acute suicidal ideation rapidly. Antidepressants in general modestly reduce risk in older adults (early concerns about increased risk in younger patients were partially borne out for adolescents but the overall picture is treatment-positive).
Higher levels of care: hospitalization for imminent risk, partial hospital programs for elevated risk, intensive outpatient programs.
Documentation: careful contemporaneous notes describing assessment, risk stratification, safety planning, means restriction discussion, follow-up plan, and patient/family communication. Both clinically and legally important.
When you encounter a patient with suicidality, the framework matters. Structured assessment, dynamic risk monitoring, means restriction counseling, evidence-based treatment of underlying conditions, safety planning. The interventions exist and they save lives.