Pathophysiology
Clinical meaning
The clinician managing suicidal patients integrates advanced risk assessment with evidence-based prescribing, makes hospitalization vs outpatient decisions, manages medico-legal documentation, and implements system-level suicide prevention. The zero suicide framework is an organizational approach that assumes suicide deaths in healthcare settings are preventable through systematic screening, risk assessment, safety planning, means restriction, and follow-up. Risk formulation requires integrating multiple dimensions: static factors (demographics, history, genetics), dynamic factors (current symptoms, stressors, substance use, means access -- these are MODIFIABLE and should be targeted), and contextual factors (therapeutic alliance, social support, barriers to care). The clinician prescribes with suicide safety in mind: limit quantities of lethal medications, prefer medications with lower overdose lethality (SSRIs over TCAs, buprenorphine over methadone, lithium with close monitoring), and consider rapid-acting interventions for acute suicidality (esketamine, lithium loading). For chronic suicidality (common in BPD), the approach differs: outpatient safety planning with DBT, avoiding reactive hospitalization that may reinforce crisis behavior, while maintaining genuine assessment of acute-on-chronic risk elevation. The clinician documents risk assessment using the clinical formulation model: risk factors, protective factors, clinical rationale for risk level, and...