Suicide risk assessment is one of the most consequential clinical skills in psychiatry. Done well, it identifies the patient at imminent risk and shapes appropriate intervention. Done poorly — reduced to box-checking or formulaic scoring — it produces documentation that doesn't reflect clinical thinking and care that doesn't match risk. The skill is structured judgment, not algorithmic scoring.
The ideation hierarchy escalates from passive to acute. Passive ideation: "I sometimes wish I weren't here." Active ideation: "I'm thinking about killing myself." Plan: "I've thought about how I would do it." Intent: "I'm thinking about doing it." Means access: weapon, medications, specific method available. Preparation: rehearsing, writing letters, giving things away, securing means. Recent attempt: the strongest single predictor of future attempt. Each level changes clinical management.
Static risk factors are demographic and historical. Prior attempts (strongest predictor). Family history of completed suicide. Male sex (more completed suicides). Older age. Chronic illness. Recent hospitalization (especially psychiatric — the period after discharge is highest-risk). These don't change visit-to-visit; they create baseline risk.
Dynamic risk factors are the current state. Acute psychiatric symptoms — severe depression, psychosis with command hallucinations, agitation, insomnia, hopelessness (the strongest single dynamic factor). Recent loss — death, divorce, job loss, financial ruin, legal trouble. Acute substance intoxication or withdrawal. These vary; they're what's happening now.
Protective factors are the counterweight. Reasons for living. Family or social supports. Religious or spiritual beliefs that proscribe suicide. Engagement in treatment. Future orientation. Means restriction in place. Children at home. These mitigate risk but don't eliminate it.
The risk assessment integrates all four. The patient with passive ideation, prior attempt history, current severe depression and hopelessness, firearm at home, and inadequate supports is in high acute risk despite the "passive" framing — because the static factors, dynamic factors, and means access all weigh heavily. The patient with active ideation but no plan, strong supports, and clear engagement may be at lower acute risk than the prior case.
Document the reasoning, not just the conclusion. "Low risk" without supporting evidence is inadequate. "Moderate acute risk based on...; protective factors include...; disposition decision: outpatient with safety plan, follow-up in 3 days, means restriction agreement reviewed" — that's documentation that captures the clinical thinking.