Suicide Risk Assessment in a Patient with Depression
Ms. L, a 35-year-old woman with major depressive disorder, is seen in the outpatient clinic. She reports feeling hopeless and worthless. She has a history of a suicide attempt at age 20 by overdose. She denies current suicidal ideation but says, "I don't see the point in living anymore." She lives alone, has a loaded gun in the house, and recently lost her job. Her PHQ-9 score is 20. The nurse must determine the appropriate level of care and safety planning.
1. What further assessment data are most important to gather to determine Ms. L's risk level?
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The nurse should conduct a comprehensive suicide risk assessment using a validated tool (e.g., C-SSRS) to evaluate:
- Current suicidal ideation: frequency, intensity, duration, and plan.
- Intent and plan: Does she have a specific plan? Does she intend to act?
- Access to lethal means: the loaded gun is a significant risk factor.
- Protective factors: reasons for living, social support, future orientation.
- Substance use: recent alcohol or drug use increases impulsivity.
- Psychosocial stressors: job loss, isolation.
- History of attempts: prior attempt increases risk.
- Hopelessness: her statement "no point in living" indicates hopelessness, a strong predictor.
Given her denial of current ideation but presence of hopelessness, access to a firearm, and recent stressor, she is at high risk and requires immediate safety planning and likely a higher level of care.
2. What is the most appropriate immediate intervention for Ms. L?
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The nurse should:
- Not leave the patient alone; maintain continuous observation if in an inpatient setting, or ensure she is not alone if outpatient.
- Collaborate with the patient to develop a safety plan: identify warning signs, coping strategies, social contacts, and crisis lines.
- Address access to lethal means: involve the patient and family in temporarily removing the firearm from the home (e.g., stored with a trusted person or locked at a gun shop).
- Arrange urgent psychiatric evaluation; consider voluntary admission or, if she refuses and meets criteria, initiate involuntary hold per state law.
- Provide crisis resources: 988 Suicide & Crisis Lifeline.
- Schedule close follow-up within 24-48 hours if discharged.
Documentation should include the risk assessment, safety plan, and actions taken.