PHQ-9 question 9 asks: "Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?" When a patient answers anything other than "not at all," the consultation changes direction.
Most GPs know this requires action. But the specific action — how to structure the conversation, what to ask, how to stratify risk, and when to refer — is not well covered in most revision resources or QOF templates. The PHQ-9 gives you a number. It does not give you a safety assessment.
This guide provides the practical framework.
What a Positive Item 9 Means — and What It Does Not
A score of 1 ("several days") on item 9 means the patient has experienced thoughts of death or self-harm on some days in the past two weeks. This is common in moderate-to-severe depression — approximately 30-40% of patients scoring ≥10 on the PHQ-9 will score 1+ on item 9.
A positive item 9 does not mean the patient is imminently suicidal. It does not mean they have a plan. It does not automatically require crisis team referral or emergency assessment. What it does mean is that a structured suicide risk assessment is required before the consultation ends — because the PHQ-9 does not differentiate between passive death wishes ("I'd be better off dead"), active suicidal ideation ("I've been thinking about ending my life"), suicidal ideation with plan ("I've thought about how I would do it"), and suicidal intent with preparatory behaviour ("I've been stockpiling tablets").
These are clinically and prognostically very different — and the management depends on which category the patient falls into.
The C-SSRS — A Structured Framework
The Columbia Suicide Severity Rating Scale provides a structured approach to differentiating the severity of suicidal ideation. It asks questions in a logical hierarchy, moving from passive ideation to active intent, with each level indicating higher risk. Calculate C-SSRS on iatroX.
Category 1 — Wish to be dead. "Have you wished you were dead or wished you could go to sleep and not wake up?" This is passive ideation — common in depression, associated with distress but not with imminent risk of self-harm in isolation.
Category 2 — Non-specific active suicidal thoughts. "Have you actually had any thoughts of killing yourself?" This moves from passive wishes to active thoughts — a clinically significant escalation.
Category 3 — Active suicidal ideation with any methods (not plan). "Have you been thinking about how you might do this?" The patient has considered methods but has not formulated a specific plan.
Category 4 — Active suicidal ideation with some intent to act. "Have you had these thoughts and had some intention of acting on them?" Intent — even partial — is a high-risk indicator.
Category 5 — Active suicidal ideation with specific plan and intent. "Have you started to work out or worked out the details of how to kill yourself, and do you intend to carry out this plan?" This is the highest-risk category and requires immediate management.
The C-SSRS also asks about suicidal behaviour: actual attempts, interrupted attempts, aborted attempts, and preparatory acts (writing a note, stockpiling medication, researching methods).
How to Structure the Conversation
Start with normalisation. "The questionnaire you completed flagged that you've been having some difficult thoughts. This is something I take seriously, and I want to understand a bit more about what you've been experiencing. Is that okay?" This frames the assessment as care, not interrogation.
Follow the C-SSRS hierarchy. Start with Category 1 and proceed upward only if the patient endorses the current level. If the patient denies passive ideation (Category 1), you do not need to ask about active ideation with plan (Category 4). The hierarchy is designed to be efficient — you stop when the patient's experience is captured.
Ask about protective factors. Reasons for living (children, partner, pets, religious beliefs, future plans), access to support (family, friends, mental health services), and willingness to engage with safety planning.
Ask about risk factors. Previous self-harm or suicide attempts (the strongest predictor of future attempts), substance use, social isolation, recent loss or trauma, access to means (firearms, stockpiled medication), and recent discharge from psychiatric services.
What to Do With the Result
Category 1 only (passive ideation), no risk factors, good protective factors: Acknowledge the distress. Treat the underlying depression (NICE NG222 — stepped care based on PHQ-9 severity). Provide safety-netting advice. Review within 1-2 weeks. Document the assessment. Calculate PHQ-9 on iatroX to determine depression severity and treatment tier.
Category 2-3 (active ideation, with or without method), no plan, no intent, some protective factors: Safety plan in the community. Collaborative safety planning — identify triggers, coping strategies, sources of support, emergency contacts. Remove or reduce access to means (medication stockpiles, sharps). Initiate or optimise depression treatment. Consider referral to primary care mental health (IAPT/NHS Talking Therapies) or community mental health team depending on severity. Review within 1 week. Document comprehensively.
Category 4-5 (active ideation with intent or plan), or any suicidal behaviour: Same-day mental health assessment. Contact the local crisis resolution and home treatment team (CRHTT). If the patient is at immediate risk and unwilling to wait for crisis team assessment, consider emergency department referral. Do not leave the patient alone. Remove access to means immediately. This is a clinical emergency.
Any category with recent suicide attempt, preparatory behaviour, or command hallucinations instructing self-harm: Emergency psychiatric assessment. This overrides the ideation category — recent behaviour is the strongest risk predictor.
Documenting the Assessment
Document clearly: what the patient endorsed (use C-SSRS categories), what risk factors are present, what protective factors were identified, what safety plan was agreed, what referral was made, and when follow-up is planned. This documentation protects both the patient and you — and provides continuity for the next clinician who reviews the record.
The AKT and UKMLA Context
Both exams can present mental health scenarios where item 9 is positive and ask what the most appropriate immediate action is. The answer is not "prescribe an SSRI" (that addresses the depression, not the suicidal ideation). The answer is not "refer to psychiatry" (that may be appropriate but is not the immediate action). The immediate action is a structured safety assessment — the C-SSRS or equivalent — to stratify the risk and determine the appropriate management pathway.
PHQ-9, GAD-7, and C-SSRS are all available on iatroX Calculators with clinical guidance on interpretation and next steps.