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Suicide risk assessed (MDD, MDD ADOL)

CPT4 code

Name of the Procedure:

Suicide Risk Assessment (Major Depressive Disorder, Adolescents)


A suicide risk assessment is a systematic process to understand the likelihood of a person with Major Depressive Disorder (MDD), particularly adolescents, attempting suicide. It is carried out by healthcare professionals using structured interviews and assessment tools.


The purpose of a suicide risk assessment is to identify individuals at high risk of self-harm or suicide, allowing for timely intervention and support. The goal is to prevent suicide by addressing the risk factors and providing appropriate care and resources.


  • Symptoms of severe depression
  • Expressed thoughts of self-harm or suicide
  • Behavioral changes indicating a potential for self-injury
  • Diagnosis of MDD in adolescents
  • Past history of suicide attempts


  • No specific preparation needed for the patient.
  • Patients may be advised to bring a list of current medications and past medical history.
  • Health professionals might use diagnostic tools such as the Columbia-Suicide Severity Rating Scale (C-SSRS).

Procedure Description

  1. Initial Interview: The healthcare professional will conduct a structured interview with the patient.
  2. Questionnaires: Standardized tools like the C-SSRS are administered to gauge the severity of suicidal thoughts and behaviors.
  3. Risk Factors: Identification of risk factors such as previous attempts, mental health history, family history, substance abuse, and life stressors.
  4. Protective Factors: Identification of factors that could mitigate risk, such as strong support systems and coping mechanisms.
  5. Clinical Judgment: Based on gathered information, the healthcare professional makes an informed judgment about the level of risk and necessary interventions.


Approximately 30 to 60 minutes.


Performed in various settings such as hospitals, outpatient clinics, or primary care offices.


  • Psychiatrists
  • Psychologists
  • Pediatricians
  • Licensed Clinical Social Workers
  • Mental Health Nurses

Risks and Complications

  • Emotional distress during the assessment
  • Misinterpretation of patient responses if not carefully analyzed No physical risks are associated; however, timely interpretation and intervention are critical.


  • Early identification of suicide risk
  • Timely intervention can prevent suicide attempts
  • Development of a safety plan
  • Connection to mental health resources and support networks
  • Improved patient outcomes


  • Immediate emotional support provided if distress is identified.
  • Follow-up appointments scheduled for ongoing assessment.
  • Implementation of a safety plan and connection to counseling services.


  • Standard mental health evaluation without a specific focus on suicide risk.
  • Crisis hotline intervention.
  • Emergency services if imminent risk is identified. The structured suicide risk assessment is generally considered more thorough and specific compared to these alternatives.

Patient Experience

  • Patients might feel distressed discussing sensitive topics.
  • Assurance of confidentiality and empathetic communication by healthcare providers helps in easing the process.
  • Pain management is not required as the procedure is non-invasive.
  • Comfort can be provided through a supportive and non-judgmental approach by the care team.

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