Terminology (use precise, modern terms)
Drop "parasuicide/DSH" as a framework. Use: self‑harm (intentional self‑injury/poisoning, irrespective of intent), suicidal ideation, suicidal plan, suicide attempt (intent to die), suicide. Self‑harm and suicide overlap but are distinct — and self‑harm is itself the strongest predictor of later suicide.
The assessment (systematic, not "are you suicidal?")
Ideation → intent → plan (specificity, lethality, preparation) → access to means → previous attempts/self‑harm (the strongest historical factor) → driving illness (depression, bipolar, psychosis, substance use, borderline PD, anorexia) → protective factors → and dynamic/warning features (agitation, insomnia, hopelessness, recent loss, discharge from inpatient care).
The stance that keeps patients safe 🚩
Shift from scoring to managing: identify current danger → reduce access to means (the single most evidence‑based intervention) → treat the driving illness → collaborative safety plan (warning signs, coping strategies, contacts, crisis services) → active follow‑up (the post‑discharge and post‑attempt periods are highest‑risk). Ask directly — enquiry does not increase risk.
Pitfalls
- Using a risk score as a disposition decision.
- Documenting "denies SI" without exploring intent/plan/means or gathering collateral.
Pearls
- 🎯 Manage risk, don't predict it — means restriction + treat the illness + follow up.
- 🩺 Past self‑harm + current hopelessness/agitation/insomnia is a high‑concern constellation regardless of a "calm" presentation.
Next → The commonest substance disorder and its dangerous withdrawal physiology (Concepts 41–42).