Setting
Inpatient/ED or outpatient clinic — same workflow, setting-appropriate screening.
| Service | Organization | Region | Phone | Referral |
|---|
Reference only — verify contact and eligibility before referral. Life-threatening emergency: 911 · Crisis: 988. Resource changelog
Purpose: Identify patients at elevated suicide risk so you can set level of care and complete required safety interventions before discharge. Assessment stratifies acute, modifiable risk — it does not reliably predict who will die by suicide. The standard of care is an adequate, structured, documented assessment, not accurate prediction.
Screening vs full assessment
Minimum psychiatry evaluation triggers (any one)
Clinical assessment elements (full assessment)
C-SSRS Screener — severity 0–5 + behaviors1,5
PHQ-9 Item 9 — "better off dead / hurting yourself"
ASQ — 4-item peds + adult ED screen4
Stanley-Brown Safety Planning — 6 steps before discharge11
Lethal means counseling (Step 6)
Note: Positive screening or elevated concern requires psychiatric assessment before final disposition unless your institution designates you as a clinician with formal suicide-risk-assessment training.
Purpose: Identify acute risk to others; determine duty-to-warn obligations and disposition. No single tool reliably predicts ED violence — use structured assessment and document reasoning.
Structured tools (forensic/inpatient)13
Key risk factors
Tarasoff / duty to warn12
Who should assess
Note: State Tarasoff/duty-to-warn laws vary — verify local legal requirements.
Purpose: De-escalate behavioral emergencies safely; treat reversible drivers before disposition. Pharmacologic sedation is adjunctive — not a substitute for medical evaluation or psychiatric assessment when indicated.
De-escalation (first-line, always before meds)13
Pharmacologic — IM (cannot take PO)15,16
Oral (cooperative)
Monitoring & safety
Note: Follow institutional restraint/sedation protocols and monitoring standards.
Purpose: Rule out or stabilize medical conditions mimicking or complicating psychiatric presentation before psychiatric disposition. Prefer medical screening exam over "medical clearance."
AAEP minimum for ALL psychiatric patients17,18
Labs — not routine if alert/cooperative, normal vitals, noncontributory history, normal exam19
Screening tools21
Red flags → full workup first
Note: This tool is for medically cleared patients — complete medical screening before psychiatric disposition.
Purpose: Determine whether the patient can make a specific treatment or disposition decision at this moment. Capacity is decision- and time-specific; it is not the same as competency (a court determination).
Appelbaum 4 components12
Principles
Process
Who should assess
Note: State law governs surrogate decision-making and involuntary treatment.
Purpose: Identify when less-restrictive alternatives are insufficient to protect the patient or others. Criteria, duration, and process vary by state — this is an educational framework only.
Criteria (typically require ALL)
Hold types
Document & rights
Clinical role
Note: Verify your state's commitment statutes and hospital policy before initiating a hold.
Purpose: Match psychiatric intensity to multidimensional need — risk, function, comorbidity, environment, history, and engagement. LOCUS supports disposition planning; it does not replace clinical judgment.
Six dimensions (each 1–5)22
Six levels
Scoring (total 6–30, approx)
Note: Use alongside safety screening (Tier 1) and institutional placement criteria.
Purpose: Determine appropriate SUD level of care using six biopsychosocial dimensions. Especially important when psychiatric and substance-use needs overlap.
Six dimensions (4th ed.)25
Levels
Principles
Note: Benzo and alcohol withdrawal may require medical admission regardless of psychiatric LOC.
Purpose: Identify when less-restrictive settings cannot safely manage acute psychiatric risk or medical instability.
General indications29
Factors associated with admission from ED30
Note: Bed availability and payer criteria also affect placement — document clinical reasoning.
Purpose: Provide structured intermediate intensity between outpatient and inpatient for patients who need more than weekly visits but not 24-hour hospital care.
PHP — ≥20 h/wk (≈5–6 h/day × 5)32
IOP — 9–19 h/wk (≈3 h/day × 3–5)34
Note: Confirm program accepts patient's insurance and acuity before discharge.
Purpose: Short-term observation and stabilization as an alternative to inpatient admission when crisis may resolve with brief structured intervention.
Note: CSU is not a substitute for psychiatric evaluation when Tier 1A consult triggers are met.
Purpose: 24-hour supervised care below hospital level for patients who cannot safely live independently but do not require acute inpatient medical management.
Note: Verify bed availability, funding source, and program scope before promising placement.
Purpose: Stabilize acute psychosis, rule out organic causes, and match level of care to safety and functional impairment.
Note: Exclude delirium and substance-induced psychosis before labeling primary psychotic disorder.
Purpose: Treat acute mania safely, initiate mood stabilization, and prevent harm from impulsivity and poor judgment.
Note: Mania impairs judgment — reassess capacity for discharge decisions.
Purpose: Treat depression while stratifying suicide risk separately — depression severity alone does not determine disposition.
PHQ-9 bands8
Note: Item 9 positive is a screen — not a discharge clearance by itself.
Purpose: Medically stabilize intoxication, reassess psychiatric status when sober, and link to SUD care when indicated.
Note: Intoxication lowers inhibition — reassess suicide and violence risk after sobriety.
Purpose: Prevent morbidity and mortality from withdrawal while planning appropriate ASAM level of care.
Alcohol — CIWA-Ar (10 items, 0–67)39
Opioid — COWS (11 items, 0–47)41
Benzodiazepine27
Note: Withdrawal management is a medical decision first — psychiatry consult for co-occurring SI/psychosis.
Purpose: Initiate or bridge evidence-based opioid-use treatment from the ED or inpatient setting to reduce overdose mortality.
Note: Follow local ED buprenorphine initiation protocols and state prescribing rules.
Purpose: De-escalate acute distress, ensure safety, and link to longitudinal DBT-oriented care — avoid iatrogenic reinforcement of crisis cycles.
Note: Validate distress while setting limits — diagnosis alone is not an admission indication.
Purpose: Recognize delirium as an acute medical neurocognitive syndrome requiring medical workup — not primary psychiatric disposition.
Note: CAM-positive delirium overrides psychiatric disposition planning until medically addressed.
Evidence-based bibliography. Citations reflect published guidelines and primary sources summarized in this reference. Verify against current versions and local policy.
Condensed for point-of-care reference. Always consult primary guidelines and state-specific law.