A 28-year-old single woman with major depressive disorder is seen in the outpatient psychiatry clinic. She reports depressed mood for 6 months, poor concentration, and guilt about being a burden to her family. She denies suicidal ideation but admits to recurrent thoughts of "not wanting to be alive." On further questioning, she reveals she has stopped taking her antidepressant (sertraline 100 mg daily) for the past 2 weeks because "it wasn't helping anyway." She lives alone, works as a software engineer, and has no close friends. Her father died by suicide when she was 15 years old. She has never attempted suicide. What is the most critical intervention to reduce her suicide risk at this visit?

Question

Accepted Answer

B. Assess for active suicidal ideation, establish safety planning, and ensure medication adherence; consider hospitalization if risk escalates. ## Suicide Risk Assessment and Intervention in Depression

**Key Point:** The most critical intervention in a patient with depressive symptoms and multiple risk factors is **comprehensive risk assessment, safety planning, and ensuring medication adherence**—not simply adjusting medication dose or providing referral alone.

### Risk Factors Present in This Patient

| Risk Factor | Present? | Significance |
|---|---|---|
| **Female gender** | Yes | 3–4× more attempts (but 1/4 completion rate of males) |
| **Age 25–35** | Yes | Peak age for female suicide attempts |
| **Major depressive disorder** | Yes | Highest psychiatric risk for suicide |
| **Passive death wishes** | Yes | Precursor to active ideation |
| **Social isolation** (lives alone, no close friends) | Yes | Loss of protective social buffer |
| **Family history of suicide** (father) | Yes | Genetic/environmental vulnerability |
| **Medication non-adherence** | Yes | Removes protective pharmacotherapy |
| **Hopelessness** ("wasn't helping") | Yes | Strong predictor of suicide risk |
| **No prior attempt** | No | Reduces immediate risk but not protective |

**High-Yield:** The **Columbia-Suicide Severity Rating Scale (C-SSRS)** distinguishes between:
- **Passive ideation:** "I wish I were dead" (present here)
- **Active ideation:** "I want to kill myself" (not present here)
- **Intent:** "I plan to act on these thoughts" (must be assessed)

Passive ideation can escalate to active ideation within days to weeks, especially in untreated or undertreated depression.

### Why This Intervention Is Critical

```mermaid
flowchart TD
  A[Patient with depressive symptoms + risk factors]:::outcome
  A --> B[Comprehensive suicide risk assessment]:::action
  B --> C{Active suicidal ideation or intent?}:::decision
  C -->|Yes| D[Hospitalization / intensive monitoring]:::urgent
  C -->|No| E[Safety planning + identify protective factors]:::action
  E --> F[Ensure medication adherence]:::action
  F --> G[Establish follow-up within 3-7 days]:::action
  G --> H[Psychotherapy + pharmacotherapy]:::action
  H --> I[Monitor for ideation escalation]:::action
```

**Clinical Pearl:** Passive death wishes ("I don't want to be alive") are a **red flag for imminent risk**, especially when combined with:
- Recent medication discontinuation
- Social isolation
- Family history of suicide
- Hopelessness and guilt

This patient is at **moderate-to-high risk** and requires immediate intervention beyond simple medication adjustment.

### Safety Planning Components

1. **Identify warning signs** (sleep loss, increased isolation, substance use)
2. **Internal coping strategies** (distraction, self-soothing)
3. **Social support** (family, friends—though limited in this case)
4. **Professional contacts** (therapist, psychiatrist, crisis line)
5. **Means restriction** (remove access to lethal methods)
6. **Medication adherence** (restart sertraline, explain rationale)

**Mnemonic — IS PATH WARM:** Ideation, Substance abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood changes. This patient scores on multiple items.

Answer

A. Prescribe a benzodiazepine for anxiety and reassure her that her symptoms will improve with time

Answer

C. Refer her to cognitive-behavioral therapy and discharge with a crisis hotline number

Answer

D. Immediately prescribe a higher dose of sertraline and schedule follow-up in 4 weeks

Explanation

Suicide Risk Assessment and Intervention in Depression

Risk Factors Present in This Patient

Why This Intervention Is Critical

Safety Planning Components

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Risk Factor	Present?	Significance
Female gender	Yes	3–4× more attempts (but 1/4 completion rate of males)
Age 25–35	Yes	Peak age for female suicide attempts
Major depressive disorder	Yes	Highest psychiatric risk for suicide
Passive death wishes	Yes	Precursor to active ideation
Social isolation (lives alone, no close friends)	Yes	Loss of protective social buffer
Family history of suicide (father)	Yes	Genetic/environmental vulnerability
Medication non-adherence	Yes	Removes protective pharmacotherapy
Hopelessness ("wasn't helping")	Yes	Strong predictor of suicide risk
No prior attempt	No	Reduces immediate risk but not protective