Assessment and Management of Suicidal Ideation

Risk Assessment

Patients who express a desire to die should be immediately evaluated for suicide risk and considered for psychiatric hospitalization if they continue to express a desire to die, remain agitated or hopeless, are unable to participate in a safety plan, lack adequate support, or have a history of high-lethality suicide attempts, according to the American Academy of Pediatrics 1, 2
The assessment should include multiple risk factors: self-directed behaviors, suicidal thoughts, current psychiatric conditions, psychiatric symptoms, social determinants, adverse life events, access to lethal means, physical health conditions, and demographic characteristics, as recommended by the American Psychiatric Association 3, 4
Certain signs indicate high risk, including persistence in endorsing a desire to die, continuous agitation or severe hopelessness, inability to participate in safety planning, inadequate support system, and previous high-lethality suicide attempts, according to the American Academy of Pediatrics 2
Additional risk factors to be considered include gender, comorbid substance abuse, and high levels of anger or impulsivity, as noted by the American Academy of Pediatrics 2

Cognitive-behavioral therapy (CBT) focused on suicide prevention is recommended to reduce the risk of suicide attempts in patients with a history of suicidal behavior in the last 6 months, according to the American College of Physicians 4, 5
CBT (including problem-solving therapies) is suggested to reduce suicidal ideation in patients with a history of self-directed violence, as recommended by the American College of Physicians 4, 5
Although dialectical behavior therapy (DBT) combines elements of CBT, skills training, and mindfulness techniques to help patients develop emotional regulation, interpersonal effectiveness, and distress tolerance skills, the evidence is insufficient to recommend for or against its use to reduce suicidal ideation, according to the American College of Physicians 4, 6

Clozapine is suggested to reduce the risk of suicide attempts in patients with schizophrenia or schizoaffective disorder who exhibit suicidal ideation or a history of suicide attempts, according to the American College of Physicians 4, 5
Ketamine infusion is suggested as an adjunctive treatment for short-term reduction of suicidal ideation in patients with suicidal ideation and major depressive disorder, as recommended by the American College of Physicians 4, 5

A safety planning discussion is an essential element of care and should include identification of warning signs and potential triggers for recurrent suicidal ideation, coping strategies, healthy activities, responsible social supports, and contact information for professional supports, including instructions on how and when to reaccess emergency services, as recommended by the American Academy of Pediatrics 1, 2
Sending periodic caring communications (e.g., postal mail, text messages) for 12 months after hospitalization related to suicide risk may reduce the risk of suicide attempts, according to the American College of Physicians 4, 6
The use of self-guided digital interventions (app or web) that include CBT-based therapeutic content is suggested for short-term reduction of suicidal ideation, as recommended by the American College of Physicians 4, 5

The greatest risk of new suicide attempt occurs in the months following an initial attempt, according to the American Academy of Pediatrics 1, 2
A large percentage of suicide attempts are impulsive, with 24% of patients implementing their plan within 0 to 5 minutes after deciding to attempt suicide, as noted by the American Academy of Pediatrics 1, 2
Counseling on lethal means restriction is a fundamental component of discharge planning, including suggestions for securing knives, locking medications, and removing firearms, as recommended by the American Academy of Pediatrics 1, 6

The American College of Physicians recommends developing a collaborative crisis response plan immediately, including clear identification of warning signs, self-management coping skills, social support contacts, and crisis resources, as part of managing suicidal ideation remotely 7

Dialectical behavior therapy (DBT) combines CBT, skills training, and mindfulness techniques, and is most beneficial for patients with borderline personality disorder and recent self-directed violence, according to the Annals of Internal Medicine 7
Problem-solving therapy can be delivered effectively via telehealth, specifically aimed at improving coping with stressful life experiences, as recommended by the Annals of Internal Medicine 7

Restricting access to lethal means is a critical intervention, regardless of other treatments, and can reduce suicide risk by firearms, jumping, or medication overdose, as noted by the Annals of Internal Medicine 8

Sending periodic caring communications for 12 months following any crisis or hospitalization can reduce suicide attempts, though sustained contact is necessary, with evidence showing weak but positive support for this intervention, according to the Annals of Internal Medicine 7, 8, 9

Self-guided digital interventions (apps or web-based) that include CBT-based therapeutic content can provide short-term reduction in suicidal ideation, and should be used as adjuncts to, not replacements for, direct telehealth therapy, with evidence being weak but supportive for this approach, as noted by the Annals of Internal Medicine 8, 9

Ketamine infusion may be considered for rapid short-term reduction in severe suicidal ideation, though evidence for preventing actual attempts is insufficient, according to the Annals of Internal Medicine 8, 9

The 2019 VA/DoD guidelines noted insufficient evidence for technology-based methods as routinely practiced, but this was based on older studies that did not assess telehealth as currently implemented, while the 2024 updated guidelines and recent high-quality trials now support telehealth delivery, as reported by the Annals of Internal Medicine 7, 8