Patient handout

Suicidality — ED risk assessment and disposition

PRODUCTION

1. Your condition

This handout is for suicidality — ed risk assessment and disposition. Your care team identified this based on: suicidal ideation (passive or active) on presentation or screening (posner 2011 pmid 22193671; joint commission npsg 2024).

Other reasons your team may use this plan: recent suicide attempt — overdose, lacerations, hanging, firearm, other method (apa 2003 pmid 14627059; va/dod 2019); recent self-harm behavior with or without suicidal intent (posner 2011 pmid 22193671); phq-9 item 9 score ≥1 on routine screening (any setting) (kroenke jgim 2001).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
lithium	300 mg PO BID — target level 0.6–0.8 mmol/L (suicide reduction may be present at lower levels)	PO	BID with level monitoring	Cipriani BMJ 2013 NMA — lithium reduces suicide attempts and completed suicide in both unipolar and bipolar; baseline renal + thyroid + pregnancy considerations; initiation in inpatient or specialty outpatient setting, not ED
clozapine	12.5 mg PO daily — slow titration per REMS	PO	daily titration	InterSePT — clozapine reduced suicide attempts vs olanzapine in schizophrenia + schizoaffective; REMS with weekly ANC × 6 mo then biweekly × 6 mo then monthly; not initiated in ED
esketamine	84 mg intranasal (per ASPIRE protocol for SI indication)	intranasal	twice weekly × 4 weeks induction (in select centers; SPRAVATO REMS)	ASPIRE-1, ASPIRE-2 — esketamine + standard care reduced MADRS faster than placebo + standard care in MDD with acute SI; FDA approved for this indication; REMS — 2 hour post-dose observation; not standalone in ED; NEEDS_SOURCE_REVIEW for ASPIRE PMIDs
ketamine	0.5 mg/kg IV over 40 min	IV	2× weekly × 6–8 sessions then taper (off-label; specialty centers)	Wilkinson 2018 meta-analysis — single ketamine infusion reduces SI within 24 hours; off-label; specialty psychiatry centers; not ED-initiated as standalone

Plan: Evidence-based suicide-reduction pharmacotherapy (initiated by admitting team, not in ED) (APA 2024; VA/DoD 2019)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable — passive thoughts manageable with self-care; no plan/intent; intact supports (Stanley-Brown 2012 PMID 22642958)

If you have:

No suicidal thoughts OR passing thoughts patient can self-manage (Stanley-Brown 2012 PMID 22642958)
Sleep / appetite / energy at baseline (APA 2024)
Engaging with usual activities and supports (Stanley-Brown 2012 PMID 22642958)
Means restriction in place (VA/DoD 2019)

Do this:

Continue prescribed medications without interruption (APA 2024)
Attend all scheduled outpatient appointments (Stanley JAMA Psychiatry 2018 PMID 29387873)
Engage in identified coping strategies (Stanley-Brown 2012 PMID 22642958)
Keep crisis line numbers (988 + local) accessible (SAMHSA TIP 50 2015)
Maintain means restriction agreement (firearms, meds) (VA/DoD 2019)

YELLOW — Warning — increasing ideation, hopelessness, or stress; no plan/intent (Stanley-Brown 2012 PMID 22642958; VA/DoD 2019)

If you have:

Recurring thoughts of suicide WITHOUT specific plan or intent (Posner 2011 PMID 22193671)
Increased hopelessness or worthlessness (APA 2024; VA/DoD 2019)
Sleep disruption, social withdrawal, increased substance use (APA 2024; VA/DoD 2019)
Recent stressor (relational, financial, legal, anniversary) (APA 2024)
PHQ-9 rising or PHQ-9 item 9 score ≥1 (Kroenke JGIM 2001)

Do this:

Use SPI Step 2 internal coping strategies (breathing, grounding, distraction) (Stanley-Brown 2012 PMID 22642958)
Use SPI Step 3 — go to a safe place (specific to patient — coffee shop, family, library) (Stanley-Brown 2012 PMID 22642958)
Contact SPI Step 4 support person from list (Stanley-Brown 2012 PMID 22642958)
Contact provider for early appointment within 1 week (Stanley JAMA Psychiatry 2018 PMID 29387873)
Reduce or eliminate alcohol / substance use (VA/DoD 2019)
Confirm means restriction is in place; if not, restore immediately (VA/DoD 2019)
Call 988 Suicide & Crisis Lifeline (call or text 988) if escalating (SAMHSA TIP 50 2015)

Call your provider if:

Thoughts become more frequent or specific (Stanley-Brown 2012 PMID 22642958)
Inability to use coping strategies (Stanley-Brown 2012 PMID 22642958)
Specific method comes to mind even briefly (Posner 2011 PMID 22193671)
Increased alcohol or substance use (VA/DoD 2019)
Loss of contact with supports (Stanley-Brown 2012 PMID 22642958)

RED — Crisis — active SI with plan / intent / means OR recent attempt OR severe agitation OR psychosis (APA 2003 PMID 14627059; Posner 2011 PMID 22193671)

If you have:

Specific thoughts of method, time, or place (Posner 2011 PMID 22193671; APA 2024)
Stated intent to act (Posner 2011 PMID 22193671)
Access to means (firearm, large-quantity meds, vehicle, height) (VA/DoD 2019)
Recent self-harm or attempt (APA 2024; VA/DoD 2019)
Hallucinations directing self-harm (APA 2024)
Inability to keep self safe (Joint Commission NPSG 2024)

Do this:

Call 988 (US) / local crisis line / 911 NOW (SAMHSA TIP 50 2015)
Go to the nearest emergency department immediately — do not wait (APA 2024; Joint Commission NPSG 2024)
Do not be alone — call SPI Step 4 support person to come with you OR call 988 to dispatch crisis team (Stanley-Brown 2012 PMID 22642958)
Hand any means (firearms, pills) to a trusted person or law enforcement BEFORE going (VA/DoD 2019)
Do not use alcohol or non-prescribed substances (VA/DoD 2019)
Tell someone specifically — "I am having thoughts of suicide and I need help right now" (Stanley-Brown 2012 PMID 22642958)

Call your provider if:

Any red-zone trigger — go to emergency department immediately; do not wait for an outpatient appointment (APA 2024; Joint Commission NPSG 2024)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

C-SSRS active SI (Ideation 4 or 5) WITH stated intent AND access to means (firearm, large-quantity meds, vehicle, height) (APA 2024; Posner 2011 PMID 22193671)(life-threatening)
Documented suicide attempt within past 90 days (highest-risk period for recurrence) (APA 2024; VA/DoD 2019)(life-threatening)
Command hallucinations directing self-harm, suicide, or harm to others (APA 2024)(life-threatening)
Postpartum psychosis (within 4 weeks of delivery) with thoughts or impulses of harming infant (APA 2016 Guideline Watch)(life-threatening)
Severe agitation creating immediate safety threat to patient or staff in context of SI (APA 2024)
Patient with active SI refuses to engage in safety planning OR refuses voluntary admission when criteria met (APA 2024; Joint Commission NPSG 2024)(life-threatening)
Documented suicide attempt within past 72 hours (presentation-day to 1-week is the highest-acuity subset of the post-attempt recurrence window) (Posner 2011 PMID 22193671; ED-SAFE Boudreaux 2017 PMID 28245301)
Active SI patient demonstrates flight risk in the ED (verbalises intent to leave AMA, attempts to leave, removed monitoring, ligature-eligible behavior in waiting area) prior to disposition decision (Joint Commission NPSG.15.01.01 2019)
At outpatient bridge appointment, patient declines or fails to engage with safety plan, refuses lethal-means restriction verification, declines Caring Contacts, OR has lost/never-implemented the discharge safety plan (Stanley/Brown 2018 PMID 30209345; Zero Suicide / Coffey JAMA Psychiatry 2015 PMID 26677000)

5. Follow-up

For discharged patients — 24–72 h outpatient appointment confirmed before leaving ED; safety plan printed and given; 988 + local crisis line numbers; means restriction agreement signed with patient + family; follow-up call from ED social work within 48–72 h (Stanley JAMA Psychiatry 2018 PMID 29387873; SAMHSA TIP 50 2015)

6. Sources

Guideline: APA Practice Guideline for Suicidal Behaviors 2003 + 2016 Guideline Watch + APA 2025 update + Joint Commission NPSG.15.01.01 (2019) + Stanley-Brown SPI + ED-SAFE (Boudreaux 2017) + Zero Suicide (Coffey 2015) + VA/DoD 2019