Key Takeaways
- Major Depressive Disorder requires depressed mood or anhedonia (loss of interest/pleasure) plus at least 4 additional symptoms for at least 2 weeks
- Ask direct questions about suicidal ideation: "Are you thinking about hurting yourself?" "Do you have a plan?"
- The highest suicide risk occurs when depression is lifting and the client has energy to act on suicidal thoughts
- Safety interventions include 1:1 observation, removing sharp objects/belts/shoelaces, and checking that medications are swallowed
- Risk factors for suicide include previous attempts, male gender, older age, chronic illness, recent loss, and access to lethal means
Last updated: January 2026
Depression and Suicide Assessment
Depression is one of the most common mental health disorders, affecting millions worldwide. When depression becomes severe, it can lead to suicidal ideation and behavior. The NCLEX tests your ability to recognize depression, assess suicide risk, and implement appropriate safety interventions.
Major Depressive Disorder (MDD)
Major Depressive Disorder is characterized by persistent low mood or loss of interest/pleasure that impairs daily functioning.
Diagnostic Criteria
At least 5 of the following symptoms for at least 2 weeks, with at least one being depressed mood OR anhedonia:
| Symptom | Description |
|---|---|
| Depressed mood | Feeling sad, empty, hopeless most of the day |
| Anhedonia | Loss of interest or pleasure in activities |
| Weight/appetite changes | Significant increase or decrease |
| Sleep disturbance | Insomnia or hypersomnia |
| Psychomotor changes | Agitation or retardation |
| Fatigue | Loss of energy nearly every day |
| Worthlessness/guilt | Excessive or inappropriate guilt |
| Concentration difficulty | Trouble thinking or making decisions |
| Suicidal ideation | Thoughts of death, suicidal thoughts, or plan |
Mnemonic: SIG E CAPS (like a prescription)
- Sleep changes
- Interest loss
- Guilt/worthlessness
- Energy loss
- Concentration difficulty
- Appetite/weight changes
- Psychomotor changes
- Suicidal ideation
Assessing Depression
Subjective Assessment
- Ask about mood, energy, sleep, appetite
- Inquire about loss of interest in activities
- Explore feelings of hopelessness or worthlessness
- Ask about social withdrawal
- Always ask about suicidal thoughts
Objective Assessment
| Signs | Examples |
|---|---|
| Appearance | Disheveled, poor hygiene, weight changes |
| Behavior | Psychomotor retardation, slow speech, flat affect |
| Cognition | Poor concentration, indecisiveness |
| Affect | Sad, tearful, hopeless expression |
Suicide Assessment
The Critical Rule
Ask direct questions about suicide. Asking does NOT plant the idea. It opens the door for the client to talk about what they may be experiencing.
Questions to Ask
- Ideation: "Are you thinking about hurting yourself?" "Are you having thoughts of suicide?"
- Plan: "Do you have a plan for how you would do it?"
- Means: "Do you have access to [method mentioned]?"
- Intent: "Do you intend to act on these thoughts?"
- Timeline: "When are you thinking about doing this?"
- Protective factors: "What has kept you safe so far?"
Levels of Suicide Risk
| Level | Characteristics | Intervention |
|---|---|---|
| Low | Passive thoughts ("I wish I wasn't here"), no plan | Monitor, outpatient referral |
| Moderate | Frequent thoughts, vague plan, some intent | Close observation, safety planning |
| High | Specific plan, access to means, intent to act | Continuous 1:1 observation, hospitalization |
Suicide Risk Factors
Demographic Factors
| Factor | Increased Risk |
|---|---|
| Gender | Males complete suicide more often; females attempt more |
| Age | Older adults (especially elderly men) highest risk |
| Race | White and Native American populations |
| Marital status | Single, widowed, divorced |
Clinical Factors
| Factor | Description |
|---|---|
| Previous attempt | Strongest predictor of future attempts |
| Mental illness | Depression, bipolar, schizophrenia, substance use |
| Chronic illness | Especially terminal or disabling conditions |
| Hopelessness | Feeling that things will never improve |
| Recent loss | Death, divorce, job loss, financial crisis |
Warning Signs
- Giving away possessions
- Making a will or getting affairs in order
- Saying goodbye to loved ones
- Sudden calmness after period of depression
- Talking about being a burden
- Increased substance use
- Withdrawing from friends/activities
- Searching for methods online
The Paradox of Improvement
Critical nursing knowledge: The highest suicide risk occurs when depression is beginning to lift.
Why?
- During severe depression, clients may lack the energy to act on suicidal thoughts
- As antidepressants begin working, energy returns before mood fully improves
- The client now has the energy to carry out a plan
Nursing implication: Increase monitoring during the first few weeks of antidepressant treatment, especially days 10-14.
Safety Interventions
Environmental Safety
| Intervention | Rationale |
|---|---|
| Remove sharps | Prevent cutting |
| Remove belts, shoelaces, drawstrings | Prevent hanging |
| Remove glass items | Prevent self-harm |
| Check personal belongings on admission | Remove potential weapons |
| Lock medications | Prevent overdose |
| Check-proof rooms | Eliminate anchor points |
Observation Levels
| Level | Description | When to Use |
|---|---|---|
| Continuous (1:1) | Staff within arm's length at all times | High suicide risk |
| Close observation | Visual contact every 15 minutes | Moderate risk |
| Routine observation | Regular unit checks | Low risk |
Medication Administration
- Watch client swallow all medications
- Check mouth (under tongue, cheek) for hidden pills
- Liquid formulations may be preferred
- Count all pills returned on unit
Therapeutic Communication with Depressed/Suicidal Clients
Do:
- Take all statements about suicide seriously
- Ask direct questions
- Listen without judgment
- Express concern and empathy
- Acknowledge pain while instilling hope
- Develop safety plan together
Don't:
- Promise to keep suicidal thoughts secret
- Act shocked or uncomfortable
- Minimize their feelings
- Give advice or platitudes
- Leave a high-risk client alone
Therapeutic Responses
| Client Statement | Non-Therapeutic | Therapeutic |
|---|---|---|
| "I wish I was dead." | "Don't say that!" | "It sounds like you're in a lot of pain. Tell me more about what you're feeling." |
| "Nobody would miss me if I was gone." | "Of course they would!" | "You feel like you're not important to others. What's leading you to feel that way?" |
| "I've thought about taking all my pills." | "You shouldn't do that." | "You've thought about overdosing. Do you have access to medications right now?" |
Antidepressant Medications
SSRIs (First-Line)
| Medication | Key Points |
|---|---|
| Fluoxetine (Prozac) | Long half-life; fewer withdrawal symptoms |
| Sertraline (Zoloft) | Commonly used; fewer drug interactions |
| Paroxetine (Paxil) | More sedating; withdrawal symptoms common |
| Escitalopram (Lexapro) | Well-tolerated |
| Citalopram (Celexa) | QT prolongation at high doses |
Key teaching:
- Takes 2-4 weeks for therapeutic effect
- Don't stop abruptly (withdrawal symptoms)
- May increase suicidal thoughts initially (Black Box Warning)
- Sexual dysfunction is common side effect
SNRIs
| Medication | Key Points |
|---|---|
| Venlafaxine (Effexor) | May increase blood pressure |
| Duloxetine (Cymbalta) | Also used for neuropathic pain |
Other Antidepressants
| Medication | Class | Key Points |
|---|---|---|
| Bupropion (Wellbutrin) | NDRI | No sexual side effects; lowers seizure threshold |
| Mirtazapine (Remeron) | Tetracyclic | Sedating; weight gain; good for insomnia |
| Trazodone (Desyrel) | SARI | Often used for insomnia at low doses |
On the Exam
NCLEX priorities:
- Always ask directly about suicide
- Highest risk = when depression is lifting
- Previous attempt = strongest predictor
- 1:1 observation for high risk
- Check medications are swallowed
- Remove means: belts, sharps, medications
Test Your Knowledge
A client who has been severely depressed for months suddenly appears calm and says they "feel at peace." The nurse should:
A
B
C
D
Test Your Knowledge
A client says, "Sometimes I think my family would be better off without me." What is the most appropriate nursing response?
A
B
C
D
Test Your Knowledge
A client started taking sertraline (Zoloft) 10 days ago. The nurse should be most alert for:
A
B
C
D