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Clinical Decision Tree for Suicide Risk

Based on the Suicide Risk Assessment and Management Decision Tree (Joiner et al., 1999; Chu et al., 2015). This semi-structured framework guides risk stratification and links risk levels to actionable clinical interventions.

Step 1: Assess Suicidal Ideation & Behavior

Does the patient currently have suicidal ideation?

Has the patient made a suicide attempt in the past 90 days?

Does the patient have access to lethal means (firearms, medications, etc.)?

Step 2: Acute Risk Factors Present

Count the number of acute risk factors present (e.g., severe agitation, acute intoxication, recent loss, severe hopelessness, command hallucinations, insomnia).

Step 3: Chronic Risk Factors Present

Count the number of chronic risk factors (e.g., previous attempts, psychiatric history, substance abuse, trauma history, chronic illness).

Risk Level Reference & Recommended Interventions

Low Risk

Criteria:

  • • Suicidal ideation without plan or intent
  • • No recent attempt
  • • Few acute risk factors
  • • Protective factors present

Interventions:

  • • Encourage social support activation
  • • Provide crisis resources (988 Lifeline)
  • • Schedule follow-up appointment
  • • Monitor at regular intervals

Moderate Risk

Criteria:

  • • Suicidal ideation with plan but no intent
  • • Multiple acute risk factors
  • • Prior attempt history
  • • Limited protective factors

Interventions:

  • • All low-risk interventions, plus:
  • • Develop safety plan collaboratively
  • • Means restriction counseling
  • • Schedule frequent follow-up / phone check-ins
  • • Consider increasing treatment intensity

Severe Risk

Criteria:

  • • Suicidal ideation with plan AND intent
  • • Preparatory behavior without immediate action
  • • Severe acute risk factors (agitation, intoxication)
  • • Minimal protective factors

Interventions:

  • • All moderate-risk interventions, plus:
  • • Immediate means restriction
  • • Constant observation / monitoring
  • • Consider voluntary hospitalization
  • • Notify emergency contacts with consent
  • • Do not leave patient alone

Extreme Risk

Criteria:

  • • Active suicidal intent with plan and means
  • • Recent suicide attempt (within 90 days)
  • • Imminent risk of self-harm
  • • Unable to maintain safety

Interventions:

  • • Ensure continuous supervision
  • • Immediate means restriction
  • • Arrange emergency psychiatric evaluation
  • • Consider involuntary hospitalization (EOD)
  • • Activate emergency services if needed (911)
  • • Document thoroughly

Clinical Note: This decision tree is a consultation aid, not a substitute for comprehensive clinical assessment. Risk categorization should be integrated with clinical judgment, knowledge of the patient, and contextual factors. Always document your clinical reasoning.

References

Chu, C., et al. (2015). Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update. Journal of Clinical Psychology, 71(12), 1186-1200.

Joiner, T. E., et al. (1999). Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice. Professional Psychology: Research and Practice, 30(5), 447-453.