Depression and Suicide Prevention

Recognizing depression, treatment options, and assessing suicide risk

Mental Health

Major depressive disorder

≥5 symptoms for ≥2 weeks, including depressed mood or loss of interest:

Memory hook: SIG E CAPS Sleep change · Interest lost · Guilt or worthlessness · Energy low · Concentration poor · Appetite or weight change · Psychomotor slowing or agitation · Suicidal thoughts.

Screen with PHQ-9. Rule out thyroid disease, anemia, medications, substance use. Older adults may show memory problems or physical complaints.

Treatment

Psychotherapy (CBT and others) + antidepressants (4–6 weeks for full effect).
ECT: severe, psychotic or treatment-resistant depression, or high suicide risk. Consent; NPO; anesthesia and a muscle relaxant. Afterwards: brief confusion, headache, short-term memory loss; reorient, safety.
Esketamine nasal spray (treatment-resistant): observe ≥2 h in a certified setting (dissociation, sedation, ↑ BP); no driving that day.
Transcranial magnetic stimulation; bright light therapy (seasonal pattern).
Postpartum depression: zuranolone (oral, 14 days). Brexanolone IV was withdrawn from the US market in 2025. Updated

Suicide risk

Ask directly

"Are you thinking about killing yourself?" Asking does not put the idea in someone's head. Then: plan? method? access (especially firearms)? timing? intent? Use a tool such as the Columbia scale (C-SSRS).

Risk factors

Previous attempt (strongest), a specific plan with access to means, depression, substance use, men, older adults, LGBTQ+ youth, chronic pain or illness, recent loss, isolation, recent psychiatric discharge.

Warning signs

Giving away possessions, saying goodbye, writing a will, sudden calm or improvement after severe depression (may have decided on a plan, or now has energy to act).

Nursing actions

High risk: 1:1 continuous observation, within arm's reach as ordered.
Remove dangerous items (belts, cords, sharps, plastic bags, glass); search belongings per policy.
Check that oral medications are swallowed (no "cheeking").
Safety plan together: warning signs, coping steps, people to contact, removing access to means. No-suicide contracts are not effective: don't rely on them. Updated
Crisis line: call or text 988 (Suicide & Crisis Lifeline).

Priority A patient who says "I won't be a problem much longer" or "It doesn't matter now" needs a direct question about suicide right away, not reassurance or a change of subject.