# Suicide Risk Assessment and Safety Planning

## Introduction

Suicide is the twelfth leading cause of death in the United States, claiming over 49,000 lives annually. Nearly half of individuals who die by suicide visit a primary care provider within the month preceding their death. Family medicine physicians must be skilled in identifying risk, performing structured assessments, creating safety plans, and knowing when to escalate care.

## Epidemiology

Suicide rates have increased approximately 30% since 2000. The highest rates occur in middle-aged men (ages 45 to 64) and older men (ages 75 and older). Suicide is the second leading cause of death in individuals aged 10 to 34. Firearms account for over 50% of suicide deaths. For every completed suicide, there are approximately 25 attempts and 250 instances of serious ideation.

## Risk and Protective Factors

### Risk Factors

A prior suicide attempt is the strongest predictor of future death by suicide. Psychiatric disorders including depression, bipolar disorder, schizophrenia, borderline personality disorder, and substance use disorders increase risk. Access to lethal means, particularly firearms, is a major risk factor. Chronic pain and chronic medical illness, recent loss, relationship conflict, financial stress, and legal problems all contribute. Social isolation and lack of belonging, family history of suicide, and a history of adverse childhood experiences or trauma are additional risk factors. LGBTQ+ youth face disproportionately elevated risk.

### Protective Factors

Protective factors include strong social connectedness and supportive relationships, reasons for living (including children and religious beliefs), effective mental health treatment and therapeutic alliance, problem-solving and coping skills, and restricted access to lethal means.

![Risk factor stratification chart for suicide assessment](suicide-risk-factors-chart.jpg)

## Screening

### Universal Screening

The PHQ-9 item 9 ("thoughts that you would be better off dead or of hurting yourself") serves as a passive screen during depression assessment. The Columbia Suicide Severity Rating Scale (C-SSRS) is a structured screening tool that distinguishes passive ideation, active ideation, intent, plan, and behavior. The Ask Suicide-Screening Questions (ASQ) is a four-item validated tool for emergency and clinical settings.

### When to Perform a Deeper Assessment

A deeper assessment is warranted for any positive response on PHQ-9 item 9, C-SSRS, or ASQ, as well as for clinical suspicion based on behavioral cues such as giving away possessions, sudden calmness after depression, increased substance use, or withdrawal from activities.

## Structured Risk Assessment

### Key Domains to Evaluate

The assessment should evaluate ideation (frequency, duration, intensity, and controllability of suicidal thoughts), plan (specificity, lethality, and feasibility), intent (stated desire to act on thoughts), access to means (firearms, medications, and other lethal means in the home), preparatory behaviors (writing notes, giving away possessions, researching methods), timeline (imminent versus chronic ideation), reasons for living (hopefulness and protective factors), and prior attempts (number, recency, lethality, and circumstances).

### Risk Stratification

| Risk Level | Features | Management |
|-----------|----------|------------|
| Low | Passive ideation; no plan/intent/preparatory behavior; multiple protective factors | Safety plan; optimize psychiatric tx; f/u 1-2 weeks; crisis resources |
| Moderate | Active ideation; some plan elements; no immediate intent; limited protective factors | Safety plan + means counseling; increase tx intensity; same/next-day BH referral; f/u 1 week |
| High | Active ideation + specific plan + access to means + intent or preparatory behavior | Do not leave alone; immediate psych evaluation (ED/crisis unit); safe transport; document rationale |

Low risk involves passive ideation without plan, intent, or preparatory behavior, with multiple protective factors. Moderate risk involves active ideation with some plan elements but no immediate intent and limited protective factors. High risk involves active ideation with a specific plan, access to means, intent to act, or recent preparatory behavior.

### Documentation

The assessment should be documented in a structured note including risk factors, protective factors, level of risk, and clinical rationale for management decisions. Scales alone should not determine disposition; clinical judgment integrating all data is essential.

![Columbia Suicide Severity Rating Scale screening pathway](cssrs-screening-pathway.jpg)

## Safety Planning

### The Stanley-Brown Safety Plan

The Stanley-Brown Safety Planning Intervention is an evidence-based, brief intervention that reduces suicidal behavior. It is a collaborative, patient-driven document with six steps. Step 1 helps the patient identify personal warning signs and internal states that precede suicidal crises. Step 2 identifies internal coping strategies the patient can do alone to distract from suicidal thoughts, such as exercise, music, or breathing exercises. Step 3 identifies social contacts for distraction, meaning people and social settings the patient can engage with to reduce isolation. Step 4 identifies people to ask for help, meaning trusted individuals the patient can tell about their crisis. Step 5 lists professionals and agencies to contact, including the therapist, prescriber, 988 Suicide and Crisis Lifeline, Crisis Text Line (text HOME to 741741), and local emergency services. Step 6 addresses making the environment safe by reducing access to lethal means.

### Lethal Means Counseling

Direct questions about access to firearms, medications, and other means should be asked. Temporary removal or secure storage of firearms during periods of elevated risk should be recommended, including gun locks and storage outside the home with a trusted person. Limited quantities of potentially lethal medications should be prescribed. Family members should be engaged in means restriction when appropriate. Research shows that means restriction is one of the most effective suicide prevention strategies.

## Management by Risk Level

### Low Risk

Management includes completing safety planning, optimizing treatment of underlying psychiatric conditions, scheduling close follow-up within one to two weeks, and providing crisis resources (988 Lifeline).

### Moderate Risk

Management includes safety planning with lethal means counseling, increased treatment intensity (adding or adjusting medications, increasing therapy frequency), consideration of same-day or next-day behavioral health referral, follow-up within one week, and involving supportive contacts with the patient's consent.

### High Risk

The patient should not be left alone. Immediate psychiatric evaluation should be facilitated through the emergency department or a crisis stabilization unit. Safe transport should be arranged, and the patient should not be allowed to drive. Emergency services should be contacted if the patient is unwilling to go voluntarily and meets criteria for involuntary hold. Clinical decision-making should be documented thoroughly.

## Postvention and Follow-Up

Patients discharged after a crisis or suicide attempt are at highest risk in the first one to four weeks. Caring contacts, which are brief follow-up calls or messages, reduce reattempt rates. A follow-up appointment should be scheduled within 48 to 72 hours of discharge. The safety plan should be re-assessed at every subsequent visit. If a patient dies by suicide, staff and other patients should be supported, and a structured debriefing should be considered.

![Safety plan template with six-step Stanley-Brown framework](safety-plan-template.jpg)

## Clinical Pearls

Asking about suicide does not increase risk; it opens a therapeutic dialogue and can be life-saving. The transition from inpatient psychiatric care to outpatient follow-up is the highest-risk period, making warm handoffs essential. Means restriction, particularly firearm counseling, is one of the most impactful interventions a primary care physician can perform. A safety plan is not a no-suicide contract; contracts have no evidence of effectiveness and may provide false reassurance. Clinical reasoning for disposition decisions, not just the risk level, should be documented.

## References

1. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. *Cogn Behav Pract*. 2012;19(2):256-264.
2. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings. *Am J Psychiatry*. 2011;168(12):1266-1277.
3. Mann JJ, Michel CA, Auerbach RP. Improving suicide prevention through evidence-based strategies: a systematic review. *Am J Psychiatry*. 2021;178(7):611-624.
4. Barber CW, Miller MJ. Reducing a suicidal person's access to lethal means of suicide: a research agenda. *Am J Prev Med*. 2014;47(3S2):S264-S272.