Critical Alerts

• Medical stabilization first: Treat overdose, wounds, poisoning before psychiatric evaluation
• Every patient with self-harm needs suicide risk assessment: Don't assume non-suicidal
• High-risk requires 1:1 observation: Until psychiatry evaluation
• Remove access to lethal means: Secure medications, weapons
• Ask directly about suicide: Does not increase risk
• Document risk assessment thoroughly: Stratify as low, moderate, high

Key Risk Factors

Emergency Interventions

Overview

Self-harm refers to intentional self-injury with or without suicidal intent. Suicide is the intentional ending of one's own life. Emergency departments frequently evaluate patients for self-harm and suicidal ideation (SI). A structured risk assessment is essential to determine appropriate disposition and safety measures. The goals are to ensure patient safety, treat underlying medical conditions, and connect patients with appropriate mental health care.

Terminology

Epidemiology

• Suicide is 10th leading cause of death in US: ~47,000 deaths/year
• Attempts: 25× more common than completed suicide
• ED visits for self-harm: 1.4 million/year in US
• Completed suicide rate: Higher in males (4×), older adults, white population
• Attempt rate: Higher in females, adolescents

Etiology

Common Underlying Conditions:

High Suicide Risk Features

Protective Factors (Mitigate Risk)

• Strong social support
• Engaged in treatment
• Future-oriented thinking
• Reasons for living (children, responsibilities, religion)
• No access to lethal means
• No substance intoxication

Other Considerations

Medical Evaluation

Prioritize Medical Stability:

Psychiatric Evaluation

Suicide Risk Assessment:

1. Ideation (current, past)
2. Plan and access to means
3. Intent
4. Prior attempts
5. Risk factors and warning signs
6. Protective factors
7. Clinical judgment → Stratify risk level

Columbia Suicide Severity Rating Scale (C-SSRS):

• Validated, widely used
• Structured questions about ideation and behavior
• Helps standardize assessment

Laboratory Studies

Psychiatric Admission Criteria (High Risk)

• Active suicidal ideation with plan and intent
• Recent lethal attempt
• Psychosis with command hallucinations
• Severe hopelessness, no protective factors
• Inability to contract for safety
• Inadequate outpatient support
• Unable to engage in safety planning

Discharge Criteria (Low Risk)

• No current suicidal ideation or plan
• Adequate support system
• Means restriction in place
• Engaged in safety planning
• Outpatient follow-up arranged
• Not intoxicated
• Able to contact crisis resources

Involuntary Hold

• When patient refuses admission AND meets criteria for danger to self
• Follow state-specific laws (e.g., 5150 in California, 302 in Pennsylvania)
• Document clearly

Follow-Up

For Patient

• "What you're going through is serious, but you can get help."
• "The crisis line is available 24/7: Call or text 988."
• "We've made a safety plan together—please use it."
• "It's important to follow up with mental health care."

For Family/Support Person

• "Your loved one is struggling with thoughts of self-harm."
• "Remove access to firearms, medications, and other means."
• "Watch for warning signs and encourage use of the safety plan."
• "If you're concerned, bring them back to the ED or call 988."

Crisis Resources

• National Suicide Prevention Lifeline: Call or text 988
• Crisis Text Line: Text HOME to 741741
• Veterans Crisis Line: 988, press 1
• Local emergency: 911

Adolescents

• Increasing rates of self-harm and suicide
• Social media, bullying, identity issues
• LGBTQ+ youth at higher risk
• Involve parents/guardians in safety planning
• School-based support

Geriatric

• Higher lethality of attempts
• More likely to use firearms
• Often present with less warning
• Assess for depression, isolation, chronic pain

LGBTQ+

• Higher rates of SI and attempts
• Discrimination, family rejection, identity stress
• Ask about gender identity and pronouns
• Affirming care improves outcomes

Substance Use Disorder

• High comorbidity with suicide
• Intoxication increases impulsivity
• Reassess when sober
• Addres SUD in discharge planning

Chronic Self-Harmers (Borderline PD)

• Frequent ED visits
• NSSI often for emotional regulation
• Still at increased suicide risk
• Dialectical behavior therapy (DBT) is evidence-based treatment
• Avoid dismissive attitudes; treat each presentation seriously

Performance Indicators

Documentation Requirements

• Presenting concern (SI, self-harm, attempt)
• Risk factors and protective factors
• Mental status exam
• Risk stratification (low, moderate, high)
• Disposition rationale
• Safety plan (if discharged)
• Follow-up plan
• Crisis resources provided

Assessment Pearls

• Ask directly about suicide: It does not increase risk
• Prior attempt is strongest predictor: Always ask
• Hopelessness is key: More predictive than depression alone
• Intoxication increases impulsivity: Reassess when sober
• NSSI is not "just attention seeking": It increases suicide risk
• Access to means matters: Especially firearms

Treatment Pearls

• Medical first: Stabilize overdose/injuries before psych eval
• Create safe environment: Remove ligature and sharps
• Document risk assessment: Protects patient and provider
• Safety planning is evidence-based: Not "contracting for safety"
• Means restriction saves lives: Counsel every patient and family
• Follow-up within 72 hours: Critical transition period

Disposition Pearls

• High risk = admission: Don't discharge
• Moderate risk = careful judgment: Psychiatry consult recommended
• Low risk can be discharged: With safety plan and follow-up
• Involve family/supports: In safety planning and means restriction
• Document, document, document: Risk assessment and rationale