Reference — Mental Health
Suicide Risk Assessment Reference
Suicide risk assessment is a core nursing competency. Nurses are often the first to identify warning signs and the most frequent point of contact for patients at risk. This reference covers warning signs, risk factors, protective factors, direct assessment techniques, and nursing escalation principles.
Educational use only. Suicide risk assessment requires clinical judgment and institutional protocol. Any identified suicide risk must be escalated immediately per facility protocol. In an emergency, call 911. The 988 Suicide and Crisis Lifeline is available 24/7. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Warning Signs
Immediate indicators that require same-day assessment and intervention.
| Warning Sign | Clinical Significance |
|---|---|
| Expressing suicidal ideation | Direct statements ("I want to die", "I'd be better off dead") or indirect ("I won't be a burden much longer") — any verbalization requires immediate assessment |
| Giving away possessions | Giving away valued items suggests the person is preparing for death; highly concerning behavioral warning sign |
| Sudden calmness after depression | Abrupt resolution of agitation or apparent mood improvement may indicate the person has made a decision and feels relief — do not interpret as improvement without assessment |
| Researching or obtaining means | Searching for methods, obtaining firearms or stockpiling medications indicates active planning — high immediate risk |
| Saying goodbyes | Unexpected visits, calls, or messages to family/friends to say goodbye; putting affairs in order |
| Increased hopelessness | Hopelessness is a stronger predictor of suicide than depression severity — "There is no reason to go on" |
| Increasing substance use | Escalating alcohol or drug use is both a risk factor and a warning sign of impending crisis |
| Social withdrawal | Isolating from family, friends, care team; refusing meals, visitors, treatment |
Risk Factors
| Category | Factors |
|---|---|
| Psychiatric | Major depression, bipolar disorder (especially mixed states), schizophrenia, borderline personality disorder, substance use disorders, PTSD, eating disorders |
| History | Prior suicide attempts (strongest single predictor), family history of suicide or suicide attempts, history of trauma or abuse |
| Medical | Chronic pain, terminal illness, traumatic brain injury, epilepsy, cancer, HIV/AIDS, recent new diagnosis of serious illness |
| Psychosocial | Recent significant loss (death, divorce, job, financial), social isolation, lack of social support, recent humiliation or shame |
| Demographic | Male sex (higher completion rate), adolescent and young adult age, older adult age (especially isolated older men), LGBTQ+ (higher risk, especially youth), veteran status |
| Access to means | Access to firearms (most lethal method), stockpiled medications, presence of other lethal means in the home |
Protective Factors
Factors that reduce suicide risk — assess alongside risk factors to form a complete picture.
- Social connectedness: Strong family support, close friendships, sense of belonging in a community
- Reasons for living: Responsibility for children, pets, or others; religious or moral beliefs that prohibit suicide
- Problem-solving skills: Ability to generate alternatives and manage crises adaptively
- Engaged in treatment: Active participation in mental health care; therapeutic alliance with providers
- Means restriction: No access to lethal means; firearms secured; medications locked or limited
- Hope for the future: Sense that circumstances can improve; future orientation
- Fear of death or methods: Fear of pain or the dying process can serve as a deterrent
Nursing Assessment — Direct Questioning
Direct, compassionate questioning about suicidal ideation is both required and therapeutic. Research consistently shows that asking about suicide does NOT plant the idea — it provides relief and opens the door for help-seeking.
Screening Question
"Are you having thoughts of hurting yourself or ending your life?"
If "Yes" — Assess Further (IS PATH WARM / Columbia Protocol)
- Ideation: How frequent? Passive ("I wish I were dead") or active ("I am planning to kill myself")?
- Plan: Does the person have a specific method? How detailed is the plan?
- Means: Does the person have access to the planned method (firearm, medications)?
- Intent: Does the person intend to act? Is there a timeframe?
- Prior attempts: History of prior attempts significantly elevates risk; ask about method and medical severity
Risk is highest when ideation is active, plan is specific and lethal, means are available, and there is a history of prior attempts.
Nursing Actions
| Risk Level | Nursing Action |
|---|---|
| Imminent / High | Do not leave the patient alone; remove or secure all ligature risks and sharp objects; notify provider and charge nurse immediately; initiate 1:1 observation; document and escalate per protocol; consider psychiatric emergency evaluation |
| Moderate | Maintain safe environment; notify provider; increase monitoring frequency; discuss safety planning with patient; ensure follow-up appointment; involve support system with patient consent |
| Low / Screening Positive | Document findings; notify provider; provide 988 Lifeline number; safety planning discussion; reinforce protective factors; ensure outpatient mental health referral; patient and family education |
Escalation Principles
- Always err on the side of safety — when in doubt, escalate and document
- Suicidal ideation is never a patient secret to keep — safety overrides confidentiality; inform the care team
- Never promise confidentiality when safety is at stake — this is an absolute boundary of the therapeutic relationship
- Document all findings verbatim where possible, including the exact words the patient used
- Safety contracts ("no-harm contracts") have limited evidence and do not replace a comprehensive safety plan — do not rely on them as the sole intervention
- Means restriction counseling is one of the most effective suicide prevention interventions — address access to firearms and lethal medications
- Follow institutional protocol — every facility has a suicide risk assessment and response protocol; know yours before the situation arises
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with American Psychiatric Association (DSM-5-TR) · American Psychiatric Nurses Association (APNA) · SAMHSA. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →