Which clinical feature best distinguishes high suicide risk from low suicide risk in a patient with major depressive disorder?

Explanation

## Distinguishing High from Low Suicide Risk in Depression ### Key Discriminator: Specificity of Intent and Means **High-Yield:** The presence of **active suicidal ideation with a concrete plan AND access to lethal means** is the single most powerful discriminator of imminent suicide risk. This combination transforms passive wish-to-die into actionable intent. ### Risk Stratification Framework | Feature | Low Risk | Moderate Risk | High Risk | |---------|----------|---------------|----------| | Suicidal Ideation | Absent or passive only | Present, vague | Active, specific | | Plan Specificity | None | Vague/incomplete | Detailed, concrete | | Access to Means | No | Limited | Immediate access | | Intent | Ambivalent | Fluctuating | Resolved, determined | | Recent Attempt | No | Remote past | Recent or multiple | ### Why Each Feature Matters **Key Point:** Core depressive symptoms (retardation, anhedonia, mood duration) are **necessary but insufficient** for suicide risk assessment. They establish vulnerability but not imminence. **Clinical Pearl:** A patient with severe depression but no plan or means has lower acute risk than a mildly depressed patient with a loaded gun and a written note. The **plan + means combination** is what converts depression into a psychiatric emergency. ### Suicide Risk Assessment Domains ```mermaid flowchart TD A[Patient with Depression]:::outcome --> B{Suicidal Ideation?}:::decision B -->|No| C[Low acute risk]:::outcome B -->|Yes - Passive| D{Plan present?}:::decision B -->|Yes - Active| E{Specific plan?}:::decision D -->|No| F[Moderate risk]:::outcome D -->|Yes| G{Access to means?}:::decision E -->|No| H[Moderate-High risk]:::outcome E -->|Yes| I{Immediate access?}:::decision G -->|No| J[Moderate risk]:::outcome G -->|Yes| K[HIGH RISK]:::urgent I -->|Yes| K I -->|No| H ``` **Mnemonic: SAD PERSONS** (Columbia Protocol for risk assessment) - **S**ex (male > female, 3–4:1) - **A**ge (15–24, 45–54, >75) - **D**epression / Hopelessness - **P**revious attempt - **E**thanol / substance abuse - **R**ational thinking loss (psychosis) - **S**ocial support (isolated) - **O**rganized plan - **N**ewly divorced/separated - **S**ickness (chronic/terminal illness) **Warning:** Do NOT assume that mild depression = low risk if plan + means are present. Conversely, do NOT assume severe depression alone = imminent danger if no plan exists. [cite:Harrison 21e Ch 397]