High-risk patients whose suicide intent is strong and immediate require immediate psychiatric hospitalization. Moderate-risk patients are those who present in a serious suicidal crisis, but who, because of a positive response to initial intervention and favorable social support, are not judged to be in immediate danger. Hospitalization can often be avoided with such patients, provided practical outpatient treatment can be established immediately. Such determinations are most often made in concert with a psychiatric consultant. Available means of suicide, such as firearms or drug caches, should be removed, and any psychotropic medication should be used judiciously and prescribed conservatively. It is important to have a family member take charge of a patient's medications.
Before discharging a patient, the physician must be certain that the patient has a good social support system and there is an absence of clearly pathologic features that predispose the patient to subsequent suicide. The support system usually includes a place to live and family or friends who will support the patient emotionally.
Low-risk patients frequently present with suicidal threats or minor attempts that occur in the context of a clearly definable external crisis. Social support is usually available and responsive. However, because many attempts that appear trivial on first glance are found to have more serious implications on closer examination, all patients presenting following a suicide attempt should be carefully assessed. If there is any question about the safety of discharging a suicidal patient, and psychiatric consultation is not immediately available, the patient should be hospitalized.
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