Nursing Field Notes / Mental Health · Med-Surg Course
Suicide Risk 🛟
Ask directly · a plan is the risk · safety comes before everything
NG-399
Mental Health
ADHD-friendly visual edition
Asking someone directly whether they are thinking of killing themselves does not plant the idea. It is the single most important assessment question in psychiatric nursing, and it has to be asked in plain words.
Ask it directly“Are you thinking of killing yourself?”
What raises risk mostA specific plan, the means, and a time
The dangerous liftSudden calm after depression — she has decided
PrioritySafety first. Never leave a high-risk patient alone.
🧨 What starts it
How you assess it
Work through these in order. Each step raises the risk level.
- Ideation — “Are you thinking about killing yourself?” Plain words. Not “hurting yourself”, which means something different.
- Plan — “Have you thought about how?” A specific method is a large jump in risk.
- Means — “Do you have access to that?” A gun at home, saved medication.
- Timing — “When were you thinking of doing it?” A date is imminent risk.
- Intent — “What has stopped you so far?” This finds the protective factors and it is a kind question.
- Previous attempts — the strongest single predictor of a future attempt.
What raises the risk
- A previous attempt — the strongest predictor
- Specific plan with available means
- Depression, bipolar disorder, schizophrenia, PTSD
- Substance use — it removes the brake
- Recent loss: bereavement, job, relationship, health
- Chronic pain or terminal illness
- Social isolation, giving possessions away, putting affairs in order
- Older men, and adolescents, are both higher-risk groups
The sudden calm
A profoundly depressed patient who becomes suddenly peaceful and energised has often made the decision. Energy returns before mood lifts on antidepressants, which is why the first two weeks of treatment are the most dangerous. Sudden improvement is a warning, not a relief.
🔎 What you will see
What she might say or do
- “Everyone would be better off without me.”
- “I won’t be a problem much longer.”
- Giving away possessions, making a will, saying goodbye
- Sudden withdrawal, or sudden calm
- Increased alcohol or drug use
- Hoarding medication, buying a weapon
- Reckless behavior, a sense that nothing matters
Take every statement literally. Do not reinterpret it as attention-seeking.
How to respond in the moment
- Stay with her. Do not leave to go and find someone.
- Use her words back. “You said you would not be a problem much longer. Tell me about that.”
- Be calm, direct and non-judgmental. Silence is allowed.
- Do not promise to keep it secret. Say so before she asks.
- Do not argue, moralise, or say “you have so much to live for”. It closes the conversation.
No-suicide contracts
A signed “contract for safety” is not evidence-based and does not prevent suicide. A collaborative safety plan — warning signs, coping steps, who to call, means restriction — is what current practice uses.
🩺 What you do
What you actually do
- Ensure immediate safety. One-to-one observation for high risk — that means constant, arm’s-length, including in the bathroom.
- Remove the means. Belts, shoelaces, cords, razors, glass, plastic bags, medication. Search belongings per policy.
- Notify the provider and document the exact words she used.
- Build a safety plan with her, not for her.
- Restrict access at home: lock or remove firearms and medication, involve family.
- Treat the underlying illness and the substance use.
Environment and observation
- Room near the nurses’ station, no isolation at the end of a corridor.
- Check ligature points: shower rails, door hinges, curtain tracks.
- Plastic cutlery, no glass, supervised razors.
- Watch shift change and mealtimes — observation lapses there.
- Document every check with the actual time, not in blocks afterwards.
Medication and the danger window
- SSRIs carry a boxed warning for increased suicidal thinking in people under 25.
- Energy improves before mood does. Weeks one and two are the highest-risk period, not before treatment.
- Dispense limited quantities. Tricyclics are lethal in overdose — a week’s supply can kill.
- Check that she is actually swallowing inpatient doses.
- Lithium and clozapine both reduce suicide risk over time, but need monitoring.
⚡ Quick recall
Ask it directly“Are you thinking of killing yourself?”
What raises risk mostA specific plan, the means, and a time
The dangerous liftSudden calm after depression — she has decided
PrioritySafety first. Never leave a high-risk patient alone.
Does asking about suicide put the idea in someone’s head?
No. Asking directly is the correct action and it does not increase risk.
Which single factor best predicts a future attempt?
A previous attempt.
A severely depressed patient suddenly seems peaceful. What does that suggest?
She may have decided on a plan. Increase observation and reassess — do not relax.
When is antidepressant risk highest?
The first two weeks. Energy returns before mood lifts, so she can act on it.
What does one-to-one observation mean?
Constant, within arm’s reach, including the bathroom. Not a check every 15 minutes.
Is a no-suicide contract good practice?
No. It is not evidence-based. Build a collaborative safety plan instead.