Editing Mental Health and Psychosocial Nursing (section)

== Suicide Risk Assessment and Prevention ==

=== Risk Factors ===
Demographic and historical: prior attempt (the single strongest predictor), family history of suicide, male sex (higher completion; females attempt more often), age extremes with elevated rates in adolescents and young adults and in adults over 65, particularly older white men, LGBTQ identity without family support, veterans, and Indigenous populations.

Clinical: major depression, bipolar disorder, schizophrenia (especially with command hallucinations), substance use disorder, borderline personality disorder, chronic pain, terminal or disfiguring illness, recent psychiatric discharge, hopelessness (a stronger predictor than depression severity itself), insomnia, agitation, and impulsivity.

Situational: recent loss, humiliation or legal trouble, unemployment, isolation, and '''access to lethal means, especially firearms'''.

Protective factors: children in the home, pregnancy, religious prohibition, strong social support, engagement in treatment, and future orientation.

=== Assessment ===
Ask directly and specifically. Asking about suicide does not plant the idea. Progress from ideation to plan to means to intent to preparatory behavior:
# "Have you had thoughts of killing yourself?"
# "Do you have a plan?"
# "Do you have access to what you would need?"
# "What has stopped you so far?"
# "Have you done anything to prepare, such as giving things away, writing a note, or changing a will?"

'''A specific plan with available and lethal means and a set time is the highest-risk profile and requires immediate one-to-one observation.''' Screening tools include the Columbia-Suicide Severity Rating Scale and the ASQ; they support but do not replace clinical judgment.

Warning signs of imminent risk include a '''sudden unexplained calm or improvement in mood''' in a previously despondent client, which may signal that the decision has been made; giving away prized possessions; saying goodbye; and finalizing affairs.

=== Interventions ===
* Institute the ordered observation level, most often continuous one-to-one within arm's reach, including in the bathroom.
* Remove means: belts, shoelaces, cords, glass, sharps, plastic bags, medications, lighters. Search belongings per policy.
* Environmental safety: breakaway shower rods and hooks, tamper-resistant fixtures, no anchor points, shatterproof glass.
* Count and observe medication administration; check the mouth for cheeking.
* Use a '''collaborative safety plan''' identifying warning signs, internal coping strategies, supportive contacts, professional and crisis contacts, and specific means-restriction steps. '''No-suicide contracts are not evidence-based and should not be relied on for safety.'''
* Recognize the '''high-risk window in the first days to weeks of antidepressant therapy''', when energy and initiative return before mood lifts, and the elevated risk in the weeks after psychiatric discharge.
* Antidepressants carry a boxed warning for increased suicidal thinking and behavior in children, adolescents, and young adults up to age 24; monitor closely and educate families (U.S. Food and Drug Administration, 2018).
* After a suicide death, provide postvention support to survivors and staff.