Suicide risk assessment and safety planning after overdose (MEQ)

(i) Structured assessment. Engage privately once medically able. Ask directly about ideation, intent at time of overdose and now, planning, preparatory acts, alcohol role, regret vs disappointment at survival, hopelessness, sleep, agitation. Explore depression history, prior attempt details, access to amitriptyline and other means, social supports, reasons for living. MSE with quoted content. Collateral from ex-partner/family/GP if safe and consented. Capacity and legal options if high risk and declining care. Scales (e.g. C-SSRS concepts) may structure enquiry but do not replace formulation.^[1][5]

(ii) Formulation factors. Static: prior overdose, recurrent depression history. Dynamic: recent high-lethality attempt with intent to die, alcohol co-ingestion, relationship breakdown, living alone, residual minimisation (may reduce help-seeking), access to TCA stockpile, untreated depression. Protective: now engaging with ED care, some embarrassment/regret (probe carefully), potential to re-engage supports, willingness to discuss plan if alliance built. Formulation: elevated near-term risk driven by recent attempt, means access, isolation, and untreated depression; not reassured by minimisation alone.^[5]

(iii) Safety plan and means. Collaborative written Stanley-Brown-style plan: personal warning signs; internal coping; social distraction contacts/places; people to call for help; professionals/local crisis services (jurisdiction-specific numbers); means restriction — remove/lock amitriptyline and other excess meds (pharmacy destruction or trusted third party), limit dispensing, alcohol avoidance during acute phase, environmental safety at home. Reasons for living listed concretely. SPI with follow-up has RCT support versus usual ED care.^[1]

(iv) Disposition and peak risk. Options depend on residual intent, insight, supports, and ability to secure means: voluntary or involuntary inpatient if intent remains high or safety at home impossible; intensive crisis/home treatment if supports and means control are robust; only then urgent outpatient with booked review within 24–72 hours. Evidence shows elevated suicide rates after psychiatric hospitalisation and high risk after self-harm presentations — transitions need active aftercare, not passive discharge.^[2][5]

(v) Pharmacology. Lithium — meta-analytic evidence for reduced suicide risk in mood disorders if bipolar spectrum/mood disorder indication fits, with standard monitoring.^[3] Clozapine — InterSePT evidence for reduced suicidal behaviour in schizophrenia/schizoaffective disorder when indicated, with full monitoring.^[4]