Police take Ms. L, age 23, to the emergency room (ER) after her fiancé called them. He told the police that after a “night of drinking” they argued about a girl he had flirted with. Ms. L took out a loaded gun and threatened to shoot herself. She eventually handed the gun over to the police.
In the ER, Ms. L’s blood alcohol level is 0.20%. She tells the admitting emergency room nurse, “I would never hurt myself. I drank too much and was acting stupid. I just want to go home and sleep it off. I promise not to harm myself.” Emergency room staff observe Ms. L smile and giggle while waiting for a psychiatric evaluation.
What would you do? Hospitalize Ms. L for safety, or accept her promise not to hurt herself and send her home? What criteria would you use?
Knowing how to assess patients such as Ms. L is an essential psychiatric skill, whether or not you trained in forensic psychiatry. This article includes case reports that illustrate techniques for evaluating patients who may harbor suicidal or homicidal thoughts.
Evaluating danger to self
Your role is to weigh an individual’s risk factors for suicide against potential protective factors and to make a judgment call. Potential risk factors for suicide include (but are not limited to):
- current suicidal thoughts
- prior suicide attempts
- presence of a comorbid psychiatric disorder (particularly depression)
- intoxication or ongoing substance use
- feelings of hopelessness
- marked anxiety
- recent stressors
- family history of suicide
- lack of psychosocial support.1
Also review information that is reasonably available. In the ER, records from other facilities or private psychiatric treatment notes may not be accessed easily. However, in addition to conducting a suicide risk assessment and mental status examination, consider reviewing the collateral information outlined in Table 2.
Furthermore, do not rely on “no-suicide” contracts. They do not guarantee that a person won’t attempt suicide, and they will not provide legal protection if the patient commits suicide after being released from your care.2
What to document. After completing your evaluation, specifically document:
- that a suicide risk assessment was conducted
- what risk factors were present
- interventions to address those risk factors
- the level of risk determined (minimal, moderate, or high)
- factors that may protect the patient against suicide.
Table 1
Evaluating suicidality: Sample questions to ask
| Do you wish you were dead? |
| Do you have thoughts about harming yourself? |
| Do you have an actual plan as to how you would harm yourself? If yes: Have you taken any steps to enact that plan? If so, what were they? |
| Have you ever attempted suicide before? If yes: What stopped you from enacting this plan? What do you think would keep you from acting on this plan in the future? |
| Has anyone in your family or close to you committed suicide? |
| How close have you come to killing yourself? |
Table 2
Sources of information to assess suicidality in the ER
| Police reports on circumstances that led the patient to come to the ER |
| ER nursing/physician notes |
| Family members’/friends’ statements regarding reasons for the patient’s visit |
| Observations by anyone assigned to monitor the patient while awaiting your consult |
| Laboratory and physical exam findings, particularly related to substance use and/or self-injurious behavior |
| Psychiatric records at that facility |
| Concerns expressed by anyone responsible for the patient if he/she is released from the hospital |
| ER: emergency room |
CASE REPORT: Paranoid and armed
Mr. J, age 21, is brought involuntarily to the psychiatric ER by police. His mother reports he was locked in his room with a gun, claiming “the FBI is going to kill me.”
Mr. J’s mother tells the ER psychiatrist that her son has schizophrenia, paranoid type, and stopped taking risperidone, 3 mg/d, 4 weeks ago. She explains that Mr. J sometimes “hears voices” whispering to him that his medications are poison and to not trust his family. She states that Mr. J also abuses alcohol and methamphetamine and has 2 prior arrests for assault with a deadly weapon.