Self-Harm and Suicide

Key Points

• Suicide risk is often linked to mental disorders, especially depression and substance-use conditions.
• Lethality assessment must evaluate intent, plan, means, timeline, prior attempts, and protective factors.
• Safety planning includes means restriction, monitoring level, therapeutic communication, and continuity workflows.
• Nonsuicidal self-injury (NSSI) differs in intent but is a strong predictor of future suicide risk.

Pathophysiology

Suicidality emerges from combined effects of emotional pain, hopelessness, cognitive constriction, impulsivity, and social disconnection. Mental illness and acute stressors can intensify this trajectory.

NSSI may temporarily regulate distress but can reinforce maladaptive coping and elevate later lethality risk.

Classification

• Suicidality continuum: Passive death wishes, active ideation, planning, attempt, and near-lethal behavior.
• Risk-context domains: Psychiatric diagnosis, substance use, trauma, social isolation, and prior attempts.
• Self-harm domains: NSSI behaviors versus suicide-intent behaviors.

Nursing Assessment

NCLEX Focus

Ask directly about suicide; direct questioning does not increase suicide risk and improves detection.

• Assess ideation intensity, intent, method, access to means, and timeline.
• Assess past attempts, self-harm history, and current protective factors.
• Assess acute warning signs (agitation, hopelessness, withdrawal, giving away belongings, abrupt behavior shift).
• Assess setting-specific environmental hazards and transition-period risks.
• Assess cultural context, stigma barriers, and help-seeking feasibility.

Nursing Interventions

• Initiate safety precautions based on structured and ongoing risk assessment.
• Build nonjudgmental therapeutic alliance and support disclosure.
• Implement collaborative safety plan with crisis contacts and means-restriction steps.
• Coordinate handoff quality at admission, transfer, and discharge transitions.
• Provide NSSI-focused coping-skill alternatives and emotion-regulation support.

Static-Risk Assumption

Suicide risk changes over time; one-time assessment without reassessment is unsafe.

Pharmacology

Medication can reduce core psychiatric symptoms but may shift energy before suicidality resolves. Nursing monitoring must track activation, adherence, hoarding risk, and early-treatment escalation needs.

Clinical Judgment Application

Clinical Scenario

A client with severe depression denies immediate intent but reports daily thoughts of death, stockpiling medications, and recent social withdrawal.

Recognize Cues: Multiple high-risk lethality indicators are present despite denial of immediate intent. Analyze Cues: Means availability and behavioral changes increase near-term danger. Prioritize Hypotheses: Priority is immediate safety containment and intensive reassessment. Generate Solutions: Initiate precautions, remove means, and activate multidisciplinary suicide-prevention protocol. Take Action: Implement close observation and collaborative crisis plan. Evaluate Outcomes: Reassess intent, means access, and protective-factor stability frequently.

Related Concepts

• depressive-disorders - Major risk domain for suicidality and self-harm.
• bipolar-disorders - Includes elevated suicide risk across mood phases.
• violence-and-safety - Aligns safety management for self-directed and interpersonal risk.
• trauma-informed-care - Supports non-coercive care in high-distress states.
• continued-support - Reinforces post-discharge suicide-risk continuity planning.