About This Page
This is a clinician-written, evidence-based guide aligned to the MCC Examination Objectives. It is structured by clinical presentation — the way the MCCQE tests and the way patients actually present. Management reflects current Canadian guidelines (CMA, CFPC, CPS). Always cross-reference with institutional protocols and clinical judgment.
The Bottom Line
- Ask directly: suicidal thoughts, plan, intent, access to means, preparatory acts, past attempts, current intoxication, psychosis, and protective factors
- Risk assessment is not prediction. The clinical task is risk formulation and risk reduction: treat drivers, restrict means, mobilise supports, and choose a safe disposition
- High-risk features include recent attempt, high-lethality method, persistent intent, access to firearms/large medication supply, psychosis, intoxication, severe agitation, hopelessness, and lack of supports
- Self-harm can be suicidal, non-suicidal, ambivalent, impulsive, or communicative — never dismiss it as attention-seeking
- Capacity and involuntary assessment are jurisdiction-specific in Canada, but the exam principle is consistent: serious imminent risk plus refusal of safe care may require urgent involuntary psychiatric assessment
Approach to the Presentation
Suicidal ideation and self-harm require calm, direct, non-judgemental enquiry. Start with medical stabilisation after overdose, poisoning, laceration, hanging, drowning, trauma, or intoxication. Then assess desire to die, ideation frequency, plan, intent, rehearsal, preparatory acts, access to means, lethality, rescue likelihood, regret, ambivalence, triggers, and protective factors. Explore depression, bipolar disorder, psychosis, PTSD, personality disorder, substance use, pain, domestic violence, bullying, legal/financial stress, shame, isolation, and cultural/spiritual supports. Collateral is often essential and may be justified for safety depending on local law and urgency.
Differential Diagnosis
| diagnosis | likelihood | key features | distinguishing test |
|---|---|---|---|
| Major depressive episode with suicidal intent | must-not-miss | Hopelessness, anhedonia, guilt, insomnia, appetite change, psychomotor change, persistent desire to die | Clinical depression assessment + suicide risk formulation |
| Bipolar disorder / mixed state | must-not-miss | Suicidality with agitation, racing thoughts, reduced sleep, impulsivity, irritability, antidepressant activation, or history of mania/hypomania | Mood history and collateral; urgent psychiatry if mixed/manic |
| Psychosis with command hallucinations or delusions | must-not-miss | Command hallucinations, persecutory delusions, nihilistic delusions, severe guilt, disorganisation, poor insight | Mental status exam + collateral; urgent psychiatric assessment |
| Substance intoxication or withdrawal | must-not-miss | Alcohol, opioids, benzodiazepines, stimulants, cannabis; disinhibition, impulsivity, withdrawal distress, overdose risk | Toxicology when useful, blood alcohol if relevant, withdrawal scales, reassess when clinically sober |
| Non-suicidal self-injury | common | Self-injury to regulate distress without intent to die, often cutting/burning; may coexist with suicidal ideation | Intent, function of behaviour, lethality, ambivalence, and pattern over time |
| Personality disorder crisis | common | Interpersonal trigger, fear of abandonment, affective instability, impulsive self-harm, chronic emptiness, rapid shifts in intent | Longitudinal history; assess acute-on-chronic risk and supports |
| Adjustment disorder / acute situational crisis | common | Suicidality after relationship, academic, work, financial, immigration, legal, or health stressor | Temporal relationship and risk formulation |
| PTSD / trauma-related suicidality | less common | Intrusions, shame, hyperarousal, dissociation, avoidance, substance use, self-harm after trauma reminders | Trauma-informed assessment and dissociation screen |
Red Flags & Key History
Symptoms
Current intent, specific plan, access to means, rehearsal, note, giving away possessions, or final communications
Recent suicide attempt or high-lethality/low-rescue attempt
Command hallucinations, persecutory or nihilistic delusions, severe agitation, or mania/mixed state
Current intoxication or withdrawal with suicidal thoughts
No supports, homelessness, domestic violence, safeguarding concerns, or inability to agree to safety plan
Ambivalence, reasons for living, willingness to involve supports
Signs
Medical instability after overdose, poisoning, hanging, laceration, drowning, or trauma
Severe agitation, intoxication, confusion, psychosis, or impaired capacity
Superficial injuries do not rule out high suicidal intent
Calmness after decision to die can be falsely reassuring
Approach to Investigation
First-line
Medical assessment after self-harmABCs, vitals, glucose, toxidrome exam, wound assessment, ECG, acetaminophen/salicylate levels, pregnancy test, ethanol level, and labs according to overdose or injury
Structured suicide enquiryIdeation, plan, intent, access to means, timing, preparation, past attempts, substances, psychosis, agitation, protective factors, supports, and willingness to accept help
Risk formulationSynthesize static risk, dynamic risk, protective factors, foreseeable scenarios, and modifiable interventions; do not rely on a scale alone
Collateral and recordsFamily/friends/EMS/primary care/pharmacy records clarify attempt details, supports, access to means, medications, and deterioration
Second-line
Psychiatric diagnostic assessmentDepression, bipolar disorder, psychosis, PTSD, personality disorder, substance use, eating disorder, pain, cognitive disorder, domestic violence, and safeguarding
Capacity assessmentAssess ability to understand, appreciate, reason, and communicate a choice about care/disposition
Specialist
Crisis psychiatry / ED mental health assessmentIndicated for active intent, plan, recent attempt, psychosis, severe agitation, intoxication, unclear safety, lack of supports, or need for admission
Involuntary psychiatric assessmentConsider when serious risk is present and patient refuses safe assessment or treatment; criteria vary by province but safety principle is high-yield
Management Principles
CAMH Suicide Risk Guidance + Mental Health Commission of Canada resources + provincial Mental Health Acts1
Immediate medical and environmental safety
- Treat overdose, poisoning, lacerations, trauma, withdrawal, intoxication, pain, and medical instability first
- Do not leave a high-risk patient alone; remove ligature risks, sharps, medications, and other means where feasible
- Use the least restrictive safe setting but escalate to observation, ED hold, or admission when risk is high
2
Collaborative safety planning
- Identify warning signs, internal coping strategies, social distractions, trusted contacts, professional crisis resources, ED instructions, and reasons for living
- Means restriction: firearms removal/secure storage, limit medication quantities, involve family/pharmacy, reduce access to ligatures or poisons where practical
- Avoid no-suicide contracts; they do not reduce risk and can replace meaningful planning
3
Treat underlying drivers
- Depression: psychotherapy and/or antidepressant with early follow-up; urgent psychiatry for psychotic depression, catatonia, or severe suicidality
- Bipolar/mixed state or psychosis: urgent psychiatry; avoid antidepressant monotherapy in suspected bipolar disorder
- Substance use: withdrawal management, opioid agonist therapy where indicated, harm reduction, and addiction medicine referral
Complications & Pitfalls
- Using a score as a decision-maker: Tools can structure documentation but cannot predict suicide reliably.
- Dismissing self-harm: Non-suicidal self-injury can coexist with acute suicidal intent and predicts future risk.
- Discharging while intoxicated: Reassess suicidality, capacity, and supports when clinically sober.
- No means restriction: Risk reduction requires concrete steps, especially around firearms and medications.
MCCQE1 Exam Tips
- 1Asking about suicide does not increase suicide risk
- 2After suicidal disclosure, assess plan, intent, means, past attempts, substances, psychosis, and supports
- 3No-suicide contracts are not recommended; safety planning and means restriction are preferred
- 4An intoxicated suicidal patient should be reassessed when clinically sober
- 5High-lethality attempt, firearm access, command hallucinations, or active intent usually means urgent psychiatric assessment/admission-level care
- 6Confidentiality can be breached when necessary to prevent serious imminent harm; document reasoning clearly
practicetest your knowledge on suicidal ideation & self-harmApply what you've learnt with MCCQE1-style questions from the iatroX Q-Bank — psychiatric and beyond.
open q-bank