Responsibility to family / young children at home.
Religious / moral beliefs prohibiting suicide.
Strong social support system and therapeutic alliance.
High-Yield Board Trap: “No-suicide contracts” do NOT decrease suicide rates and are never the correct answer on Step 2 CK. Use collaborative safety planning.
Clinical Evaluation
Ideation: Thoughts of wanting to die or killing oneself.
Passive SI: Wish to be dead / sleep and not wake up, without active plan or intent.
Active SI: Thoughts of taking specific action to end one’s life.
Plan: The specific method, mechanism, location, or timeline developed to carry out suicide.
Intent: The conscious commitment, desire, or decision to act on suicidal thoughts and carry out the lethal act.
Risk Stratification & Management
High / Imminent Risk (Active SI + Plan and/or Intent):
Place on constant 1:1 observation and secure the environment (remove sharps/ligatures).
Offer voluntary psychiatric admission.
If patient refuses admission: Initiate involuntary psychiatric hospitalization (emergency hold). c
Rule: Breach confidentiality immediately to ensure safety; family or surrogate consent is not required for an involuntary hold.
Moderate Risk (Active SI + Plan, but NO Intent / Strong Protective Factors):
Evaluate for Intensive Outpatient Program (IOP) or voluntary brief observation.
Perform lethal means counseling: Instruct family/caregivers to secure/remove firearms and lock up medications.
Low Risk (Passive SI, NO Plan, NO Intent):
Outpatient management with scheduled psychiatric/PCP follow-up within 24–72 hours.
Establish a collaborative safety plan and provide 24/7 crisis hotline information (988).
Evidence-Based Treatments
Lithium:
Proven to reduce suicide risk and all-cause mortality in Bipolar Disorder and unipolar MDD maintenance.
Clozapine:
Only antipsychotic FDA-approved specifically to decrease suicidal behavior in Schizophrenia and Schizoaffective Disorder.
Electroconvulsive Therapy (ECT):
Fastest and most effective intervention for acute, severe suicidality associated with:
Severe refractory major depression.
Psychotic depression or severe bipolar depression.
Refusal to eat/drink (life-threatening inanition) or severe catatonia.
Severe suicidality during pregnancy when medications are contraindicated or too slow.
Dialectical Behavior Therapy (DBT):
Best therapy to reduce recurrent self-harm and suicide attempts in Borderline Personality Disorder (BPD).
High-Yield Exam Pearls
Direct Inquiry: Asking directly about suicidal ideation does NOT plant ideas or increase suicide risk; it is the essential standard of care.
Minors:
Actively suicidal minors require immediate notification of parents/guardians.
Parental consent is not required to place an acutely suicidal minor on an emergency psychiatric hold.
Post-Discharge Window:
The first month after discharge from an inpatient psychiatric unit carries the highest risk for completed suicide; mandatory close outpatient follow-up is critical.