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psych.suicidality.ed.core.v1PRODUCTION
psych.suicidality.ed.core.v1

Suicidality — ED risk assessment and disposition

psychiatryacuteadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Acute (ED setting) presentation of suicidal ideation or behavior; objective is risk stratification → safety planning → disposition, NOT initiation of longitudinal antidepressant therapy (APA 2003 PMID 14627059; Joint Commission NPSG 2024)

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ED context confirmed

Patient inputs (21)

Adolescent (<18) has different disposition pathway + family/guardian involvement; geriatric (>65) has higher completed-suicide rate (especially older white men) (APA 2003 PMID 14627059; VA/DoD 2019)

Lifetime attempts + recency; first 90 days post-attempt is highest-risk; ≥1 attempt in past year = high acuity (APA 2003 PMID 14627059; VA/DoD 2019)

Children at home, religious objection, future-oriented goals, reasons-for-living list — mitigators in shared-decision admission discussion (Stanley-Brown 2012 PMID 22642958; APA 2003 PMID 14627059)

Acute intoxication confounds assessment — must re-assess after clearance; chronic SUD elevates baseline risk (VA/DoD 2019; APA 2003 PMID 14627059)

MDD / bipolar / schizophrenia / PTSD / borderline PD / SUD — drives concurrent treatment plan + sibling dossier handoff (APA 2003 PMID 14627059)

Isolated patient is higher-risk for discharge; supports must be specifically engageable for safety plan (Stanley-Brown 2012 PMID 22642958; VA/DoD 2019)

Medication review for QT-prolonging agents (if antipsychotic planned), acetaminophen large supply (overdose substrate), stockpile of any med (VA/DoD 2019; APA 2003 PMID 14627059)

Acute intoxication common; reassessment after clearance required before disposition (VA/DoD 2019; Joint Commission NPSG 2024)

Medical clearance — rule out organic delirium / hypoglycemia / electrolyte cause of altered mental state (Joint Commission NPSG 2024)

Firearms (3–5× suicide risk), large-quantity meds, vehicle, height access; means restriction is the single most effective intervention (VA/DoD 2019; Yip Lancet 2012)

C-SSRS Ideation 1–5 — wish to be dead → active SI with plan and intent; drives disposition (Posner 2011 PMID 22193671)

C-SSRS Behavior — actual attempt, interrupted attempt, aborted attempt, preparatory acts, NSSI; recent attempt is #1 predictor of completed suicide (Posner 2011 PMID 22193671; APA 2003 PMID 14627059)

Specific method + time + place increases acuity; vague ideation differs from concrete plan (APA 2003 PMID 14627059)

Stated intent to act vs ideation only — explicit ask: "Do you intend to act on these?" Refusal to deny intent is itself concerning (APA 2003 PMID 14627059; VA/DoD 2019)

If altered mental state with trauma signs / focal neuro findings / first-onset late-life psychosis with SI (APA 2003 PMID 14627059)

Familial loading — first-degree relative completed suicide elevates risk (APA 2003 PMID 14627059)

Loss (death, divorce, job, financial, legal), relational rupture, anniversary of past loss (APA 2003 PMID 14627059)

If overdose attempt — Rumack-Matthew nomogram for APAP; salicylate level for ASA toxicity (APA 2003 PMID 14627059)

Hypothyroidism mimics depression and irritability — baseline for any new antidepressant (APA 2003 PMID 14627059)

Women of childbearing age — affects medication choice + autonomy considerations (APA 2003 PMID 14627059)

QTc baseline if antipsychotic planned for agitation or as bridge (APA 2003 PMID 14627059)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningactive_si_with_plan_intent_means
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrecent_suicide_attempt_within_90_days
    Documented suicide attempt within past 90 days (highest-risk period for recurrence) (APA 2024; VA/DoD 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpsychosis_with_command_hallucinations_to_self_harm
    Command hallucinations directing self-harm, suicide, or harm to others (APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpostpartum_psychosis_with_infanticidal_ideation
    Postpartum psychosis (within 4 weeks of delivery) with thoughts or impulses of harming infant (APA 2016 Guideline Watch)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefusal_of_safety_planning_or_voluntary_admission
    Patient with active SI refuses to engage in safety planning OR refuses voluntary admission when criteria met (APA 2024; Joint Commission NPSG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_agitation_with_safety_threat
    Severe agitation creating immediate safety threat to patient or staff in context of SI (APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecent_attempt_within_72h
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereelopement_risk
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefailed_outpatient_safety_planning
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Evidence-based suicide-reduction pharmacotherapy (initiated by admitting team, not in ED) (APA 2024; VA/DoD 2019)
axis: suicidality_evidence_based_pharmacotherapy_referenced
Selected axis "Evidence-based suicide-reduction pharmacotherapy (initiated by admitting team, not in ED) (APA 2024; VA/DoD 2019)" by default fallback (first axis)
  • lithium
    add on
    mood_stabiliser
    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
    triggers: recurrent_unipolar_MDD_with_chronic_SI, bipolar_disorder, admitted_for_SI
    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
    rxcui 6448
  • clozapine
    add on
    atypical_antipsychotic
    12.5 mg PO daily — slow titration per REMS • PO • daily titration
    triggers: schizophrenia_with_recurrent_SI, schizoaffective_with_SI, treatment_resistant_psychosis_with_SI
    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
    rxcui 2626
  • esketamine
    add on
    NMDA_antagonist_intranasal
    84 mg intranasal (per ASPIRE protocol for SI indication) • intranasal • twice weekly × 4 weeks induction (in select centers; SPRAVATO REMS)
    triggers: MDD_with_acute_SI_and_failed_conventional_treatment
    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
    rxcui 2119365
  • ketamine
    add on
    NMDA_antagonist_IV
    0.5 mg/kg IV over 40 min • IV • 2× weekly × 6–8 sessions then taper (off-label; specialty centers)
    triggers: acute_SI_with_severe_MDD_in_specialty_setting
    Wilkinson 2018 meta-analysis — single ketamine infusion reduces SI within 24 hours; off-label; specialty psychiatry centers; not ED-initiated as standalone
    rxcui 6130

outpatient playbook — drug actions (6)

  1. 1. continue inpatient-initiated pharmacotherapy as prescribed (lithium / clozapine / esketamine / SSRI/SNRI per parent dossier)
    per discharge med list • PO / intranasal / IV per agent • per agent
    trigger: Stable on discharge regimen, adherent, no urgent side effect
    Outpatient ED-bridge dossier does not initiate new pharmacotherapy; longitudinal Rx is owned by parent dossier (psych.depression.core.v1 for MDD, future psych.bipolar.core.v1, etc.) (APA 2024)
  2. 2. lithium level + TSH + Cr if on lithium
    lithium 0.6–0.8 mmol/L target • lab • q5-7d during titration; q3-6 mo maintenance
    trigger: Patient discharged on lithium for SI reduction (Cipriani BMJ 2013 PMID 23814104)
    Narrow therapeutic + thyroid/renal monitoring is the deprescribing-protection backbone (APA 2024)
  3. 3. clozapine ANC monitoring (REMS)
    per REMS schedule — weekly × 6 mo, biweekly × 6 mo, then monthly • lab • per REMS
    trigger: Patient discharged on clozapine (Meltzer NEJM 2003 PMID 12511175)
    REMS-mandatory; missed ANC stops drug dispensation (Meltzer NEJM 2003 PMID 12511175)
  4. 4. esketamine intranasal at certified center
    84 mg per ASPIRE protocol — induction 2× weekly × 4 wks then taper • intranasal under REMS supervision • per induction/maintenance phase
    trigger: Patient discharged on esketamine for MDD with acute SI (ASPIRE-1 PMID 32699884; ASPIRE-2 PMID 32731224)
    2 h post-dose observation required (FDA SPRAVATO REMS 2019)
  5. 5. naloxone Rx (take-home) for any patient with OUD history or opioid prescription
    rxcui 7242
    4 mg intranasal × 2 sprays per kit; dispense 2 kits • intranasal • PRN suspected overdose; train patient + family in administration
    trigger: Co-occurring OUD OR concurrent benzodiazepine + opioid OR prior overdose (ASAM 2020; SAMHSA TIP 50 2015)
    Bystander naloxone is evidence-based for opioid-overdose reversal; standard discharge co-prescription for high-risk patients (ASAM 2020)
  6. 6. no new benzodiazepine initiation for "anxiety" in patient with SI history
    N/A • N/A • N/A
    trigger: Anxiety symptom in suicidal-history patient (APA 2024; APA 2016 Guideline Watch)
    Disinhibition risk in active or recently-active SI; choose buspirone / SSRI titration / CBT-CP / hydroxyzine if non-BZD agent needed (APA 2016 Guideline Watch)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Suicidal ideation (passive or active) on presentation or screening (Posner 2011 PMID 22193671; Joint Commission NPSG 2024); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Suicidality — ED risk assessment and disposition** (psych.suicidality.ed.core.v1).
Phenotype framing: Genuine SI vs delirium with paranoid ideation vs dementia with disinhibited statements vs intoxication-driven impulsivity (re-assess sober) vs communication request without intent (especially adolescents) vs malingering (rare — never primary assumption) (APA 2003 PMID 14627059; VA/DoD 2019)
Scope: Acute (ED setting) presentation of suicidal ideation or behavior; objective is risk stratification → safety planning → disposition, NOT initiation of longitudinal antidepressant therapy (APA 2003 PMID 14627059; Joint Commission NPSG 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Evidence-based suicide-reduction pharmacotherapy (initiated by admitting team, not in ED) (APA 2024; VA/DoD 2019)**.
1. 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 (mood_stabiliser, add on) — 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
2. clozapine 12.5 mg PO daily — slow titration per REMS PO daily titration (atypical_antipsychotic, add on) — 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
3. esketamine 84 mg intranasal (per ASPIRE protocol for SI indication) intranasal twice weekly × 4 weeks induction (in select centers; SPRAVATO REMS) (NMDA_antagonist_intranasal, add on) — 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
4. ketamine 0.5 mg/kg IV over 40 min IV 2× weekly × 6–8 sessions then taper (off-label; specialty centers) (NMDA_antagonist_IV, add on) — Wilkinson 2018 meta-analysis — single ketamine infusion reduces SI within 24 hours; off-label; specialty psychiatry centers; not ED-initiated as standalone

Setting playbook (outpatient) — Bridge from ED/inpatient discharge to longitudinal mental-health care: bridge appointment ≤ 1 week per Zero Suicide framework; Stanley-Brown safety plan reinforced and signed; lethal-means restriction confirmed (firearm out of home / medication lockbox); Caring Contacts call cascade at 24 h, 72 h, 1 week; ASIST or CALM referral for high-risk; family/support engaged; ED-SAFE-style structured screening at each touchpoint (Boudreaux 2017 PMID 28245301; Stanley/Brown 2018 PMID 30209345; Zero Suicide / Coffey 2015 PMID 26677000; Motto Caring Contacts 2001 PMID 11433109)
5. continue inpatient-initiated pharmacotherapy as prescribed (lithium / clozapine / esketamine / SSRI/SNRI per parent dossier) per discharge med list PO / intranasal / IV per agent per agent — Stable on discharge regimen, adherent, no urgent side effect (Outpatient ED-bridge dossier does not initiate new pharmacotherapy; longitudinal Rx is owned by parent dossier (psych.depression.core.v1 for MDD, future psych.bipolar.core.v1, etc.) (APA 2024))
6. lithium level + TSH + Cr if on lithium lithium 0.6–0.8 mmol/L target lab q5-7d during titration; q3-6 mo maintenance — Patient discharged on lithium for SI reduction (Cipriani BMJ 2013 PMID 23814104) (Narrow therapeutic + thyroid/renal monitoring is the deprescribing-protection backbone (APA 2024))
7. clozapine ANC monitoring (REMS) per REMS schedule — weekly × 6 mo, biweekly × 6 mo, then monthly lab per REMS — Patient discharged on clozapine (Meltzer NEJM 2003 PMID 12511175) (REMS-mandatory; missed ANC stops drug dispensation (Meltzer NEJM 2003 PMID 12511175))
8. esketamine intranasal at certified center 84 mg per ASPIRE protocol — induction 2× weekly × 4 wks then taper intranasal under REMS supervision per induction/maintenance phase — Patient discharged on esketamine for MDD with acute SI (ASPIRE-1 PMID 32699884; ASPIRE-2 PMID 32731224) (2 h post-dose observation required (FDA SPRAVATO REMS 2019))
9. naloxone Rx (take-home) for any patient with OUD history or opioid prescription 4 mg intranasal × 2 sprays per kit; dispense 2 kits intranasal PRN suspected overdose; train patient + family in administration — Co-occurring OUD OR concurrent benzodiazepine + opioid OR prior overdose (ASAM 2020; SAMHSA TIP 50 2015) (Bystander naloxone is evidence-based for opioid-overdose reversal; standard discharge co-prescription for high-risk patients (ASAM 2020))
10. no new benzodiazepine initiation for "anxiety" in patient with SI history N/A N/A N/A — Anxiety symptom in suicidal-history patient (APA 2024; APA 2016 Guideline Watch) (Disinhibition risk in active or recently-active SI; choose buspirone / SSRI titration / CBT-CP / hydroxyzine if non-BZD agent needed (APA 2016 Guideline Watch))

Non-pharmacologic actions:
- Bridge appointment SCHEDULED ≤ 1 week post-discharge — confirmed during ED/inpatient discharge process per Zero Suicide framework; documented in discharge note with date + time + provider (Zero Suicide / Coffey JAMA Psychiatry 2015 PMID 26677000)
- Stanley-Brown Safety Plan handout SIGNED by patient — physical copy given AND digital copy in patient portal; family member receives copy with consent (Stanley/Brown 2012 PMID 22642958)
- Lethal-means restriction CONFIRMATION — at the bridge appointment, explicit verification that the documented means-restriction plan from ED discharge is in place (firearm verifiable storage location with trusted person or law-enforcement-held; medications in lockbox / dispensed in 1-week quantities); document non-compliance and escalate (VA/DoD 2019; Yip 2012 PMID 22726520)
- Caring Contacts TELEPHONE CALL CASCADE — staff or care navigator places brief non-demanding check-in calls at 24 h, 72 h, and 1 week post-discharge per Motto/Bostwick protocol; document outcome of each call and route any concerning content to clinical team (Motto Psychiatr Serv 2001 PMID 11433109; Comtois Suicide Life Threat Behav 2019)
- Caring Contacts EXTENDED CASCADE — letter or text-message contacts at 1, 2, 3, 4, 6, 8, 10, 12, 18, 24 months for patients who declined ongoing outpatient mental-health follow-up (Motto 2001 PMID 11433109 — 2-yr suicide death halved)
- ASIST (Applied Suicide Intervention Skills Training) referral for high-risk patients with weak natural-support engagement — community-based gatekeeper training for the patient and/or their identified supports (VA/DoD 2019)
- CALM (Counseling on Access to Lethal Means) referral — structured family/clinician counseling on firearm and medication restriction (VA/DoD 2019; Yip 2012 PMID 22726520)
- Family / support-system involvement — explicit invitation to at least one bridge appointment with patient consent; psychoeducation on warning signs, safety plan use, and crisis resources (Stanley/Brown 2012 PMID 22642958)
- CBT-SP (Cognitive Behavioral Therapy for Suicide Prevention) or DBT (Dialectical Behavior Therapy) referral for recurrent SI, especially with borderline PD, NSSI, or chronic SI; weekly outpatient sessions × 10–20 weeks (Brown JAMA 2005; Linehan Arch Gen Psychiatry 2006)
- CAMS (Collaborative Assessment and Management of Suicidality) framework where available — patient + clinician collaboratively rate drivers of suicidality at each visit (Jobes Crisis 2017 PMID 28468526)
- 988 Suicide & Crisis Lifeline (call/text 988) + local crisis line numbers REINFORCED at every visit; safety plan crisis-line list updated (SAMHSA TIP 50 2015)
- Coordination with primary-care provider — share discharge summary, safety plan, and follow-up cadence; PCP visit booked within 2 weeks (Zero Suicide / Coffey 2015 PMID 26677000)
- Coordination with school / employer per patient consent — return-to-baseline-functioning planning; accommodations if needed (VA/DoD 2019)

AVOID / contraindication checks:
- SSRI_avoid_initiation_in_ED_for_active_SI_with_unknown_bipolarity — APA 2003 PMID 14627059
- Benzodiazepine_avoid_acute_SI_disinhibition_risk — APA 2016 Guideline Watch
- No_suicide_contract_not_evidence_based_use_SPI_instead — Stanley Brown 2012 PMID 22642958
- Lithium_baseline_renal_thyroid_pregnancy_caution — Cipriani BMJ 2013 PMID 23814104
- Clozapine_REMS_ANC_monitoring_required — Meltzer NEJM 2003 PMID 12511175
- Esketamine_REMS_post_dose_observation_2h — FDA SPRAVATO REMS 2019
- Ketamine_BP_dissociation_specialty_monitoring — Wilkinson Am J Psychiatry 2018 PMID 29183199

Monitoring

Regimen monitoring:
- lithium level q5 7d during titration then q3 6mo — APA 2003 PMID 14627059; Cipriani BMJ 2013 PMID 23814104
- TSH Cr q6mo on lithium — APA 2003 PMID 14627059
- clozapine ANC weekly x6mo biweekly x6mo then monthly — Meltzer NEJM 2003 PMID 12511175; FDA REMS
- esketamine BP pre post dose observation 2h — FDA SPRAVATO REMS 2019
- cssrs serial inpatient admission — Posner 2011 PMID 22193671; Joint Commission NPSG 2024
- caring contacts follow up call 48 72h post discharge — Stanley JAMA Psychiatry 2018 PMID 29387873

Setting (outpatient) monitoring:
- C-SSRS at every visit (Posner 2011 PMID 22193671)
- PHQ-9 + GAD-7 trajectory (Kroenke 2001)
- Lithium level + TSH + Cr q3-6 mo if on lithium (APA 2024)
- Clozapine ANC per REMS schedule if on clozapine (Meltzer NEJM 2003 PMID 12511175)
- Adherence + side-effect screen at every visit (APA 2024)
- Caring Contacts log — completion rate of 24 h / 72 h / 1 wk + extended cascade (Motto 2001 PMID 11433109)
- Means-restriction status at every visit — re-confirm firearm + medication storage explicitly (VA/DoD 2019)
- Substance-use re-screen at every visit (SAMHSA TIP 50 2015)
- Functional status — return-to-work / school / social role; isolation flag (Zero Suicide / Coffey 2015 PMID 26677000)

Follow-up plan: 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)
- Close-out criterion: Handoff complete

Monitoring phase: Continuous observation while active SI in ED; re-assess C-SSRS q1–2h; vitals q1h if intoxicated; mental status q1–2h; on admission, q15-minute checks initially (Joint Commission NPSG 2024; Posner 2011 PMID 22193671)

Disposition

Current setting: outpatient — Bridge from ED/inpatient discharge to longitudinal mental-health care: bridge appointment ≤ 1 week per Zero Suicide framework; Stanley-Brown safety plan reinforced and signed; lethal-means restriction confirmed (firearm out of home / medication lockbox); Caring Contacts call cascade at 24 h, 72 h, 1 week; ASIST or CALM referral for high-risk; family/support engaged; ED-SAFE-style structured screening at each touchpoint (Boudreaux 2017 PMID 28245301; Stanley/Brown 2018 PMID 30209345; Zero Suicide / Coffey 2015 PMID 26677000; Motto Caring Contacts 2001 PMID 11433109)

Disposition criteria:
- Transition from sepsis-of-care suicide-prevention surveillance to routine mental-health care — at 6 months stable on regimen, C-SSRS at low-risk baseline, safety plan internalized and rehearsed, means restriction maintained, supports engaged, no attempts or self-harm — patient is transitioned out of intensive Caring Contacts cascade but continues routine follow-up with prescriber (APA 2024)
- Continued indefinite outpatient surveillance for patients with chronic recurrent SI (borderline PD, recurrent MDD with chronic SI, schizophrenia with prior attempts) — no clean exit; continue Stanley-Brown SPI + lethal-means restriction + measurement-based care indefinitely (APA 2024; Linehan Arch Gen Psychiatry 2006)
- Re-admit to ED or inpatient psych per escalation triggers — outpatient pathway can fail without indicating prior outpatient care was wrong; document and re-stabilise (Stanley/Brown 2018 PMID 30209345; Zero Suicide / Coffey 2015 PMID 26677000)

Escalation triggers (move to higher acuity):
- C-SSRS Ideation ≥ 4 (active SI with method) + access-to-means in place → URGENT ED evaluation; do NOT wait for next scheduled visit (Posner 2011 PMID 22193671; APA 2024)
- Any new suicide attempt or significant self-harm behavior → IMMEDIATE ED transfer; activate Caring Contacts emergency-contact protocol; family notified per patient consent (APA 2024; Joint Commission NPSG 2024)
- Failed engagement with safety plan OR refuses lethal-means restriction at follow-up → strengthens admission rationale; escalate to ED or PHP same-day; triggers severity_trigger.failed_outpatient_safety_planning (APA 2024; Stanley/Brown 2018 PMID 30209345)
- Substance-use relapse with concurrent rising SI → ED + dual-diagnosis admission consideration (SAMHSA TIP 50 2015; VA/DoD 2019)
- Caring Contacts call cascade unsuccessful (patient unreachable) at 72 h AND 1 wk → wellness-check via local crisis-response team OR law enforcement per protocol; family contacted (Motto 2001 PMID 11433109)
- Psychosis emergence with command hallucinations → ED + psychiatric admission consideration (APA 2024)
- Pregnancy in patient on lithium / clozapine / divalproex → urgent psych co-management for medication reconciliation; do NOT abruptly discontinue mood stabilizer (APA 2024; Cohen 2010)
- New medication-overdose-attempt-substrate prescribed (TCA, large APAP supply, large benzodiazepine supply) → dispense in 1-wk quantities only OR switch to safer agent OR confirm lockbox in place (VA/DoD 2019)

Patient Action Plan

**Stanley-Brown Safety Planning Intervention (SPI) + Lethal Means Restriction (Stanley-Brown 2012 PMID 22642958; VA/DoD 2019)**
Personalised values: personal_warning_signs, internal_coping_strategies, social_distractions_people_places, support_people_names_numbers, professional_contacts, crisis_lines, means_restriction_plan, protective_factors_reasons_for_living.

**Stable — passive thoughts manageable with self-care; no plan/intent; intact supports (Stanley-Brown 2012 PMID 22642958)** (green):
Triggers:
- 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)
Actions:
- 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)

**Warning — increasing ideation, hopelessness, or stress; no plan/intent (Stanley-Brown 2012 PMID 22642958; VA/DoD 2019)** (yellow):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- 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)

**Crisis — active SI with plan / intent / means OR recent attempt OR severe agitation OR psychosis (APA 2003 PMID 14627059; Posner 2011 PMID 22193671)** (red):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- Any red-zone trigger — go to emergency department immediately; do not wait for an outpatient appointment (APA 2024; Joint Commission NPSG 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)

Citations

- 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 [PMID:14627059](https://pubmed.ncbi.nlm.nih.gov/14627059/)
- Cited evidence (PMID 22642958) [PMID:22642958](https://pubmed.ncbi.nlm.nih.gov/22642958/)
- Cited evidence (PMID 29387873) [PMID:29387873](https://pubmed.ncbi.nlm.nih.gov/29387873/)
- Cited evidence (PMID 22193671) [PMID:22193671](https://pubmed.ncbi.nlm.nih.gov/22193671/)
- Cited evidence (PMID 23814104) [PMID:23814104](https://pubmed.ncbi.nlm.nih.gov/23814104/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 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 — PMID:14627059
  • Cited evidence (PMID 22642958) — PMID:22642958
  • Cited evidence (PMID 29387873) — PMID:29387873
  • Cited evidence (PMID 22193671) — PMID:22193671
  • Cited evidence (PMID 23814104) — PMID:23814104