Psych / Mental Health · Mood Disorders
Depression & Suicide Risk Assessment and Safety
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.
If you or someone you know is in crisis: call or text 988 (Suicide & Crisis Lifeline, U.S.) or call 911 for immediate danger. This guide is for exam study, not for diagnosing or treating anyone.
1. Overview
Major depressive disorder (MDD) involves a persistent low mood and/or most of the day, nearly every day, for at least about 2 weeks, with physical and cognitive changes that impair functioning. Biology (serotonin, norepinephrine, dopamine dysregulation; HPA-axis stress response), genetics, trauma, chronic illness, and social stressors all contribute. Related: persistent depressive disorder (chronic, lower-grade), seasonal pattern, .
Rule out medical causes: hypothyroidism, anemia, vitamin deficiencies, substance use, medications (e.g., corticosteroids, some beta-blockers), and in older adults, dementia or delirium.
2. Signs & Symptoms — “SIG E CAPS”
Sleep change · Interest loss · Guilt/worthlessness · Energy loss · Concentration poor · Appetite/weight change · Psychomotor agitation or slowing · Suicidal thoughts. Plus depressed mood. Older adults may present with somatic complaints or memory problems; teens with irritability.
3. Suicide Risk Assessment (top priority)
Ask directly: “Are you thinking about killing yourself?” Asking does not increase risk. Then assess:
| Assess | Questions/indicators |
|---|---|
| Ideation | Frequency, intensity |
| Plan | Specific? How, when, where? |
| Means / lethality | Access to firearms, stockpiled meds? |
| Intent | Do they intend to act? |
| History | Prior attempts (strongest predictor) |
| Protective factors | Support, reasons for living, engagement in care |
Risk factors: prior attempt, depression or other mental illness, substance use, access to firearms, recent loss, chronic pain/illness, social isolation, hopelessness, family history, LGBTQ+ minority stress, history of trauma. Men die by suicide more often; women attempt more often. Older white men and adolescents are high-risk groups.
Warning signs: talking about wanting to die or being a burden, giving away possessions, saying goodbye, searching for means, withdrawal, increased substance use, and a sudden calm or improved mood after deep depression (may signal a decision).
Validated tools (e.g., ASQ for youth, Columbia Suicide Severity Rating Scale, PHQ-9 item 9) are used per facility policy.
4. Priority Nursing Actions
- Safety: for active ideation with plan, 1:1 continuous observation (arm’s length per policy), never leave alone, including in the bathroom
- Environmental safety: remove ligature points, belts, shoelaces, cords, sharps, plastic bags, glass; search belongings per policy; check that meds are swallowed (mouth checks)
- Develop a collaborative (warning signs, coping, contacts, 988, lethal means counseling — locking or removing firearms and medications). “No-suicide contracts” are not reliable and are not recommended
- Therapeutic presence; short, frequent contacts; don’t argue with hopelessness, but offer hope
- Basic needs: nutrition, hydration, sleep, hygiene — set small achievable goals; give simple choices
- Risk rises as energy returns — the first 1–3 weeks after starting antidepressants or after discharge are high-risk
5. Medications & Treatments
- SSRIs/SNRIs first-line; also bupropion, mirtazapine, TCAs, MAOIs (see Psychopharmacology guide)
- Boxed warning: increased suicidal thinking in children, teens, and young adults (< 25) — monitor closely early in treatment
- TCA overdose is highly lethal (arrhythmias) — dispense limited supplies to at-risk patients
- Electroconvulsive therapy (ECT): for severe, treatment-resistant, catatonic, or acutely suicidal depression. Nursing: informed consent, NPO, remove dentures/jewelry, pre-meds (short-acting anesthetic + muscle relaxant like succinylcholine), monitor airway post-procedure; expect temporary confusion and short-term memory loss
- Others: esketamine nasal spray (monitored setting), TMS, psychotherapy (CBT, interpersonal therapy), light therapy for seasonal pattern
6. Emergencies
- Active suicide attempt / overdose: ABCs, call rapid response/911, poison control (1-800-222-1222), identify substance
- Serotonin syndrome (from combined serotonergic drugs) — see Psychopharmacology
7. Patient & Family Education
- Antidepressants take 2–6 weeks; keep taking even when feeling better; don’t stop abruptly (discontinuation syndrome)
- Family: know warning signs, remove/lock lethal means, call or text 988 any time
- Avoid alcohol; keep follow-up appointments
8. Memory Aids
- “SIG E CAPS” for symptoms
- “Sudden calm = red flag”
- “Energy before mood” — energy improves before mood, raising suicide risk early
9. NCLEX-Style Practice Questions
1. A patient with severe depression says, “My family would be better off without me.” What is the nurse’s best response?
A. “Your family loves you very much.”
B. “Are you thinking about killing yourself?”
C. “Let’s talk about something more positive.”
D. “Why would you say something like that?”
Answer: B. Statements about being a burden require a direct suicide question. A is reassurance, C changes the subject, D is a “why” question.
2. A patient who has been withdrawn for weeks is suddenly cheerful and gives a roommate her favorite jewelry. What should the nurse do first?
A. Document improvement in mood
B. Assess the patient for suicidal ideation and plan
C. Encourage group participation
D. Notify the provider about discharge readiness
Answer: B. Sudden calm plus giving away possessions are warning signs of suicide.
3. Which factor is the strongest predictor of a future suicide attempt?
A. Female gender
B. Previous suicide attempt
C. Living with a spouse
D. Having a chronic headache
Answer: B. A prior attempt is the strongest single predictor.
4. Which actions are appropriate for a patient on suicide precautions? Select all that apply.
A. Remove belts and shoelaces
B. Allow private bathroom use with the door closed
C. Perform checks to ensure medications are swallowed
D. Maintain continuous observation per order
E. Ask the patient to sign a no-suicide contract instead of observation
Answer: A, C, D. Privacy in the bathroom (B) is unsafe on close observation; no-suicide contracts (E) do not replace monitoring.
5. Three weeks after starting sertraline, a 19-year-old reports feeling more energetic. Why does the nurse continue close monitoring?
A. Energy may return before mood improves, increasing suicide risk
B. Sertraline commonly causes hypertensive crisis
C. The medication should be stopped once energy improves
D. Increased energy means the dose is too high
Answer: A. Young adults have a boxed warning; returning energy can enable acting on suicidal thoughts.
References
Bains, N., & Abdijadid, S. (2023). Major depressive disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/
National Institute of Mental Health. (n.d.). Suicide prevention. Retrieved October 15, 2026, from https://www.nimh.nih.gov/health/topics/suicide-prevention
National Institute of Mental Health. (n.d.). Ask Suicide-Screening Questions (ASQ) toolkit. Retrieved October 15, 2026, from https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials
Substance Abuse and Mental Health Services Administration. (n.d.). 988 Suicide & Crisis Lifeline. Retrieved October 15, 2026, from https://www.samhsa.gov/mental-health/988
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page