Suicide Risk Factors and Signs

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High-risk PHQ-9 results signal the need for clinical judgment, not automatic assumptions or actions.

Thoughtful assessment, clear communication, and proportional responses are central to patient safety.

When handled well, the PHQ-9 can become a meaningful intervention rather than just a screening tool.

The Patient Health Questionnaire-9 (PHQ-9) is a tool most clinicians are familiar with. It's quick, familiar, and widely trusted across health care settings. However, when a patient's results indicate high risk, they deserve more than a quick glance. It signals that they may be carrying a level of distress that affects mood, safety, functioning, and quality of life. How you respond in that moment matters. It can shape trust, determine next steps, and, in some cases, prevent serious harm.

The PHQ-9 is a nine-item screening tool used to assess the presence and severity of depressive symptoms. Each item corresponds to diagnostic criteria for major depressive disorder and asks patients how often they have experienced specific symptoms over the past two weeks.1

Scores range from minimal to severe and are often used to guide clinical decision-making, track symptom changes over time, and support conversations about mental health. Because it’s brief and easy to administer, the PHQ-9 is widely used in primary care, specialty care, behavioral health, and workplace health settings.1

While the PHQ-9 is a powerful screening assessment, it’s not a diagnostic tool. Its value lies in identifying patients who may need further evaluation, not in providing definitive answers on its own.

What High-Risk PHQ-9 Results Reveal

A high PHQ-9 score suggests that depressive symptoms are frequent, persistent, and likely interfering with daily life. Patients may be struggling to work, maintain relationships, or care for themselves.2 However, the score alone doesn’t tell the whole story.

Item 9, which asks about thoughts of death or self-harm, deserves special attention. Any response other than “not at all” indicates increased risk and should prompt further assessment.3 Importantly, this doesn’t mean the patient intends to harm themselves. Many people endorse number nine because they feel overwhelmed, hopeless, or exhausted rather than actively suicidal. The purpose of a follow-up isn’t to assume the worst, but to understand what the response truly reflects.

Setting the Tone for a Meaningful Conversation

Patients often feel vulnerable when discussing suicidal thoughts. Some worry about being judged, while others fear losing control over what happens next. How you respond in the first few minutes can either ease these concerns or intensify them.

A calm, straightforward approach is usually the most effective. Acknowledge the results, express concern, and invite the patient to elaborate. Avoid rushing, even when time is limited. People are more likely to be honest when they feel respected and heard.

Conducting a Clear and Compassionate Risk Assessment

When item nine is positive, a direct suicide risk assessment is essential. Asking plainly about suicidal thoughts, intent, and plans doesn’t increase risk or put ideas into a patient’s mind.4 Research consistently shows that direct questioning improves detection and patient trust.

You should explore whether thoughts are passive or active, how often they occur, and whether the patient feels in control of them. Questions about intent, planning, access to means, and previous attempts provide crucial context. However, it's equally important to ask about protective factors, such as family responsibilities, personal values, or supportive relationships.

Suicide Risk Factors and Signs

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This assessment should feel like a conversation, not an interrogation. Patients often share more when questions are asked with curiosity rather than urgency.

Translating Information Into Clinical Judgment

Once you’ve gathered the necessary information, you must synthesize it into a clear sense of risk. Some patients will report fleeting, passive thoughts with no intent and strong reasons for living. Others may describe ongoing ideation paired with emotional numbness, ambivalence, or worsening stressors. A smaller but critical group will present with active intent, specific planning, or access to lethal means.

Clinical judgment is central at this stage. The PHQ-9 supports decision-making, but it doesn’t replace it. Two patients with the same score may require very different responses.

When Immediate Action Is Required

If a patient is assessed to be at high or imminent risk, safety must take precedence. This may involve remaining with them, engaging in on-site mental health support, or arranging an emergency evaluation.3 Whenever possible, you should explain what’s happening and why.

Patients are more likely to cooperate when they understand that you’re taking actions to protect them. Even in urgent situations, respect and transparency matter.

Supporting Patients in Outpatient and Ongoing Care

Many people with high PHQ-9 scores can be managed safely outside of emergency settings. In these cases, structure is key. Patients should leave the visit knowing what the next steps are and when they’ll be followed up. Effective suicide prevention requires a combination of approaches, including safety planning interventions, systems-level strategies, brief interventions with follow-up care, and evidence-based psychotherapies.

Collaborative safety planning is an important part of this process. Rather than focusing on what a patient shouldn’t do, safety plans emphasize practical steps they can take when distress increases. This includes recognizing early warning signs, using coping strategies, reaching out to specific supports, and knowing where to seek urgent help if needed.

Follow-up should be timely and intentional. Delays can unintentionally reinforce feelings of isolation or unimportance. Early follow-up care is associated with a reduced risk of suicide.5

The Role of Documentation

Thorough documentation is an essential component of managing high-risk PHQ-9 results. Notes should clearly reflect the score, the content of the risk assessment, and the clinician’s reasoning.

Document what the patient reported, how you evaluated the risk, and why you took particular actions. Clear documentation supports continuity of care and demonstrates sound clinical decision-making.

Remembering the Human Behind the Assessment

Behind every PHQ-9 is a person who may have spent weeks or months managing distress on their own. For some patients, completing the questionnaire may be the first time they have acknowledged how badly they’re feeling.

Being taken seriously can be profoundly validating. Even brief moments of empathy and clarity can make a meaningful difference in how supported a patient feels.

Screening Can Become a Turning Point

High-risk PHQ-9 results deserve careful attention, but they don’t need to provoke fear or uncertainty. With a steady approach, direct assessment, and clear follow-up, you can respond effectively while maintaining trust and safety.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the 988 Suicide & Crisis Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.

1. Hlynsson, J.I., Skúlason, S., Andersson, G. et al. Why are we still using the PHQ-9? A Historical Review and Psychometric Evaluation of Measurement Invariance. Psychiatr Q (2025). https://doi.org/10.1007/s11126-025-10208-9

2. Johns Hopkins Health Plans. DMS-E - Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults. https://www.hopkinsmedicine.org/johns-hopkins-health-plans/providers-ph…

3. Horowitz LM, Ryan PC, Wei AX, Boudreaux ED, Ackerman JP, Bridge JA. Screening and Assessing Suicide Risk in Medical Settings: Feasible Strategies for Early Detection. Focus (Am Psychiatr Publ). 2023 Apr;21(2):145–151. doi: 10.1176/appi.focus.20220086. Epub 2023 Apr 14. PMID: 37201144; PMCID: PMC10172561.

4. UC Health. How to Talk to Someone Who is Suicidal. (2023). https://www.uchealth.com/en/media-room/articles/how-to-talk-to-someone-…

5. Che SE, Gwon YG, Kim KH. Follow-Up Timing After Discharge and Suicide Risk Among Patients Hospitalized With Psychiatric Illness. JAMA Netw Open. 2023 Oct 2;6(10):e2336767. doi: 10.1001/jamanetworkopen.2023.36767. PMID: 37812420; PMCID: PMC10562943.

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