PMHNP crisis and suicide: risk assessment, safety planning, and psychiatric crisis management

Columbia Suicide Severity Rating Scale (C-SSRS): The most widely validated suicide risk assessment tool. Assesses ideation (passive death wish → active ideation → ideation with intent → ideation with plan) and behaviour (preparatory acts, attempts, interrupted/aborted attempts). Ask directly about suicidal thoughts — asking about suicide does NOT increase suicide risk (this is a proven misconception).

Risk factors (not predictive — used to inform clinical judgement):

• Static (unchangeable): prior attempt (strongest predictor), family history of suicide, history of trauma/abuse, chronic medical illness
• Dynamic (modifiable — targets for intervention): active psychiatric illness (MDD, bipolar, schizophrenia, SUD), hopelessness (Beck Hopelessness Scale >8), access to means, social isolation, recent significant loss, acute intoxication

Protective factors: Reasons for living, children at home, religious beliefs, strong social support, engaged in psychiatric treatment, fear of death, future orientation. Assess and reinforce.

Risk stratification — guides disposition:

• Low risk: passive ideation, no plan, no intent, strong protective factors, reliable for follow-up → outpatient management with safety plan
• Moderate risk: active ideation with or without plan, intent unclear, ambivalent → consider crisis stabilisation, increase contact, remove means
• High risk: active ideation with plan AND intent, access to means, few protective factors, prior attempt → psychiatric inpatient evaluation
• Imminent risk: intent to act imminently → emergency department, involuntary hold if needed

Stanley-Brown Safety Planning Intervention: A collaborative, evidence-based alternative to safety contracts (no-harm contracts are not evidence-based and may create false reassurance). Six steps: (1) Warning signs — specific thoughts, images, behaviours indicating crisis escalation. (2) Internal coping strategies — things the patient can do alone. (3) Social distractions — people/settings that take mind off crisis. (4) People to reach out to for support. (5) Mental health professionals and crisis services (including 988 Suicide and Crisis Lifeline). (6) Means restriction — making the environment safer.

Lethal means counselling: One of the strongest evidence-based interventions for suicide prevention. Firearms are the most lethal method — removing firearms from the home during a crisis period significantly reduces suicide risk. Counsel family/significant others directly (not just the patient). Discuss temporary storage with trusted person, gun safe, or law enforcement surrender. Medication quantity limits and safe storage — avoid dispensing large quantities of high-overdose-risk medications (TCAs, lithium, opioids, benzodiazepines) to patients at elevated risk.

Psychiatric holds (emergency evaluation holds) allow temporary detention for psychiatric evaluation without patient consent when the person poses a danger to self or others, or is gravely disabled. Laws vary by state.

General principles: Most states allow PMHNP/NP and other licensed mental health clinicians (not just physicians) to initiate emergency holds depending on state licensure laws. Grounds: imminent danger to self, imminent danger to others, or grave disability (unable to care for basic needs due to mental illness). Holds are time-limited (typically 72 hours = "5150" in California, "302" in Pennsylvania) — after which voluntary admission or formal commitment proceedings must begin.

Duty to protect (Tarasoff): Following California Supreme Court ruling (Tarasoff v. Regents), mental health clinicians have a duty to protect identifiable third parties from serious foreseeable threats made by patients. Actions: warn the third party, notify law enforcement, increase supervision, hospitalise patient. Most states have enacted similar laws. This duty overrides patient confidentiality.