Suicide Risk

Assessing suicide risk from social media text is a small-data, high-stakes setting requiring not only severity prediction but also supporting evidence and clinically relevant risk and protective factors. Yet common NLP techniques, including model scaling, synthetic data, loss reweighting, ensembling, and threshold tuning, are often applied without testing whether their gains hold up under severe class imbalance, coupled outputs, and limited author-level data. We study 1,635 clinician-annotated posts and audit 31 pre-specified techniques from 7 methodological families through roughly 300 controlled experiments on author-disjoint partitions. We found no prior audit of this playbook in this regime. The findings guide a task-grounded system for three outputs: 4-level suicide risk, evidence spans, and 24 clinical risk and protective factors. Only 5 of 31 comparisons produced reliable gains. We reformulate factor prediction as entailment between each post and its codebook definitions, using an architecturally diverse ensemble with class-balanced training and score rescaling. Risk predictions condition a 7-model evidence tagger ensemble; evidence restricts symbolic risk rules; and a difficult risk class is routed separately. The factor predictor remains independent because risk evidence provides no additional factor signal. We also correct a mismatch between validation scores used for threshold fitting and test-time ensemble scores through deployment-consistent calibration, yielding the largest improvement to the factor system. The final system achieves 0.8203 for risk, 0.7953 for evidence, and 0.7045 macro-F1 for factors, with a 0.7781 composite, ranking third among 53 teams. We call the underlying principle task-conditioned technique selection: retain techniques only when task-specific knowledge, structure, or empirical evidence justifies them.

Crisis helplines assess suicide risk through structured interviews, a process that is slow and dependent on operator training and workload. Natural language processing could support risk assessment and call prioritization, but almost no work addresses Arabic-language helpline calls or operates within the privacy constraints of real helpline data. We analysed de-identified transcripts from Lebanon's National Lifeline for Emotional Support and Suicide Prevention. Audio never left the helpline: calls were transcribed on site with a speech recognition model for Levantine Arabic, and an Arabic named-entity recognition model removed identifying information locally. Only the de-identified transcripts were shared with the research team. Operators recorded the five suicidal ideation items of the Columbia Suicide Severity Rating Scale, which we combined into two binary outcomes: at-risk and high-risk. We also machine-translated the transcripts into English, giving a paired Arabic/English comparison. On each corpus, we fine-tuned five instruction-tuned large language models alongside six transformer encoder baselines (four Arabic, two English) and evaluated all models on a held-out test set. We included 383 calls: 373 for the at-risk task (52.3% positive) and 297 for the high-risk task (30.0% positive). The best Arabic model reached a macro-F1 of 81.19 and a ROC-AUC of 90.61 on high-risk; the best English model reached 85.00 and 92.59, identifying 88.9% of high-risk calls. In both languages, high-risk calls separated more cleanly than at-risk calls, and translation to English did not reduce the best observed performance. Suicide risk can be classified from de-identified Arabic transcripts without sending audio outside the helpline. The high-risk results support further testing as an operator-facing tool; lower-severity ideation proved the harder case.

AI tools are being increasingly adopted in policing in the UK and worldwide. Racial bias is a known and well-documented risk, yet representatives of affected communities are rarely included in decisions about AI adoption. We present results from a mixed-stakeholder deliberation workshop bringing together 30 community representatives, police officers, and academics to assess the risks of 13 AI use cases in policing, with an explicit focus on racial bias. We found that participants were broadly open to AI adoption, rejecting only three use cases outright, most notably recidivism risk assessment, where objections targeted the premise rather than the implementation. Our analysis reveals that foregrounding racial equity did not narrow the deliberation. Instead, discussions gravitated toward a fundamental set of questions: does this tool actually work, will it deliver genuine benefit, and will that benefit extend to everyone? This integrated reasoning, reminiscent of the curb-cut effect in inclusive design, highlights the benefit of incorporating the racial bias lens into the risk-benefit analysis of AI use cases from the outset.

The suicide is a terrifying act of a person who is misled by his own mental state. This problem arises across many countries. Sadly, Russia also has quite high number of persons who committed suicide. Luckily, a subset of these people writes their struggles in social media, allowing a way to find them and help. However, these valuable texts disappearing in many irrelevant texts which is considerably slowing down the decision process about person's suicidal risk. To tackle this problem, in this work we have presented a detailed methodology of building the dataset for detecting texts that describe presuicidal and anti-suicidal signals. This methodology describes the process of instruction and class table creation, the process of annotation, verification and post-annotation correction. Guiding by this methodology, we collect and annotate a large-scale Russian dataset with more than 50 thousand texts from social media. We provide a count statistic of the dataset as well as common problems in annotation. We also conduct basic experiments of building the classification models to show the on go performance on different levels of annotation. Furthermore, we make the dataset, code and all materials publicly available.

Self-harm content is particularly challenging to detect using NLP techniques, and is also a high-stakes task which requires the highest accuracy to enable timely intervention or flagging at-risk users. We therefore present an analysis of how LLMs represent such self-harm content, which has downstream applications in self-harm detection, LLM intervention and governance and policing. In this paper, we focus on two datasets and four models, and perform two main experiments: (1) We train and evaluate linear probes across all layers of each model on two self-harm datasets: X-Sensitive and SH-Detection. Across both corpora, self-harm information crystallizes in the final 3 - 7% of network layers (93 to 97% depth). (2) We extract contrastive self-harm directions and, after performing a normaliation step, we find that the most accurate probes are not necessarily the most linearly separable. In particular, we find Gemma-3-4B to represent this \textit{contrastive self-harm direction} in a slightly different, more intricate way than the other LLMs.

Objectives: To develop a codebook for self-stigma across cognitive, affective, and behavioral domains, and to estimate the prevalence, co-occurrence, and temporal patterns of these indicators in Reddit posts by people who use drugs. Methods: We developed a ten-indicator codebook through consensus-based abductive coding spanning cognitive (self-labeling, pessimism/self-defeatism, deservingness/worthlessness), affective (shame, guilt/self-blame, despair/hopelessness), and behavioral (concealment, anticipated rejection, desire to quit, ambivalence) domains; two coders reached substantial agreement (Cohen's k = 0.72). We then scaled classification with a large language model validated against expert coding (k = 0.73, F1 = 0.80), analyzing 72,115 thread-initiating posts from 1,660 English-language users (2006-2025). Results: 3,838 posts (5.3%) from 1,228 users (74.0%) contained self-stigma; all ten indicators discriminated self-stigma posts (RR 3.6 to 86.2), led by self-labeling (56.0%) and despair/hopelessness (48.5%). Self-stigma was integrated: core and behavioral indicators were strongly associated at the user level (OR = 4.65, 95% CI 3.12-6.94, p < 0.001), and 87.0% of posts with behavioral indicators also contained a core indicator. Contrary to progressive models, behavioral indicators emerged earlier than core ones (desire to quit at median position 0.08 vs. shame at 0.38). Nine of ten indicators were stable across posting trajectories; only pessimism increased (OR = 1.62, 95% CI 1.25-2.10). Conclusion: Among people who use drugs online, self-stigma is an integrated phenomenon in which behavioral indicators rarely appear without internalized ones and often precede them. Most expressions remain stable over time, but pessimism about change deepens, marking a target for early digital intervention and showing that progressive stage models do not map directly onto textual disclosure.

Large language models are increasingly proposed for mental-health applications such as detecting suicidal content, raising the question of what they rely on. We study this mechanistically and use it to ask a narrower question: how to make a causal claim about a model's internal features more trustworthy. Our validation-gated framework, with suicidality detection as a case study, interprets a behavior only after the model is shown to perform it: a concept is admitted only once the model ranks it above a simple lexical baseline, and each subsequent property is tested against a matched control. This discipline yields negative as well as positive results. The gate rules out one task at the outset: on DeepSuiMind (Li et al. 2025), Llama-3.1-8B-Instruct cannot separate implicit suicidal intent from ordinary distress, so we do not analyze it. We turn to binary suicide detection, which it does perform. There we find a mid-network feature that appears semantic rather than keyword-based, is causally implicated in the decision (ablating it degrades the judgment; a random direction does not), is low-rank, and recurs across three model families and three suicide datasets. A register-matched control (suicide versus depression) suggests it tracks suicidality more specifically than general distress. Steering raises the model's response, but for unrelated questions too, so we treat it as necessary but not sufficient. The clearest pattern separates encoding from use: smaller models already represent suicidality, yet only larger ones appear to act on it. The positive evidence is English Reddit text, which limits the clinical reading.

Clinical NLP increasingly relies on electronic health record (EHR) data to detect suicidal behaviors, treating clinical documentation as more reliable ground truth than social media. We argue that this framing obscures how EHR-based suicidality datasets encode a particular operationalization of suicidality, shaped by who authors the data, how episodes are bounded, and how ambiguity is resolved. We ground this argument in a case study of the ScAN dataset, built over MIMIC-III clinical notes. We show how governance constraints, ICD-based cohort selection, single-annotator labeling, and hospital-stay-level aggregation produce labels that reflect clinician-documented judgments, treat suicidality as a bounded episode, and assume that intent can be reliably inferred from documentation. A linguistic analysis demonstrates that identical labels subsume heterogeneous clinical framings differing in temporality, negation, and uncertainty. We argue that clinical NLP should examine the assumptions embedded in suicidality datasets before interpreting their labels as ground truth.

We investigate whether information about time-to-event risk estimated by a Cox proportional hazards model can be transferred into a generative large language model. We propose a text-based survival modelling pipeline in which structured clinical covariates are converted into text prompts and a Qwen-based large language model is fine-tuned to generate patient-specific survival risk using Cox model predictions as a training target. Across GBSG2, ACTG320, and WHAS500, the model achieves competitive held-out discrimination and calibration despite being trained as a text-generation task rather than with a conventional survival-analysis loss. We further analyse the geometry of the model's hidden states, where t-SNE visualisations reveal smooth risk gradients in latent space, suggesting that the model represents survival risk as a continuous structure rather than isolated risk categories. Together, these findings suggest that large language models can internalise survival-risk structure while supporting calibrated prediction, providing a route towards time-to-event reasoning in language models.

Suicide ideation detection models are typically evaluated using aggregate performance metrics, yet little is known about how they internally represent psychologically meaningful risk factors. In high-stakes mental health applications, understanding these internal representations is essential for safety, transparency, and responsible deployment. In this work, we move beyond accuracy and analyze how suicide detection models trained on original and topic-augmented datasets encode psychological risk factors in their internal representation space. Using visualization and geometric analysis, we examine the coherence and separability of topic-related features. Our results show that topic-aware augmentation increases the clarity and distinctness of underrepresented psychosocial risk factors such as immigration, family issues, and financial crisis. These findings suggest that augmentation not only improves model performance but also leads to more structured and interpretable internal representations.

Self-harm is a major public health concern, but current surveillance relying on hospital presentations is inadequate due to the low sensitivity of diagnostic codes. Emergency Department (ED) triage notes, recorded at the initial point of contact, provide a succinct summary of presentations and an opportunity to identify self-harm. We developed a three-stage approach, augmenting traditional machine learning with large language model-based screening and evidence extraction to detect self-harm in ED triage notes. We assessed model transferability across three Australian hospitals. Our approach showed AUPRCs of 0.887 +/- 0.016 and 0.884 +/- 0.012 during internal and external validation. Prospectively, it achieved AUPRC of 0.881 +/- 0.008 at the development site, and 0.879 +/- 0.012 and 0.816 +/- 0.015 at two external sites without site-specific retraining. A key advantage of the approach is that it enables identification of the primary self-harm method with an accuracy of 95%, supporting more granular surveillance beyond binary classification.

Suicide memes are memes used to express suicide-related thoughts or comment on suicide-related issues. Suicide memes are increasingly common on social media, yet remain poorly understood and potentially harmful. There is an urgent need to better understand their characteristics and to develop appropriate content moderation strategies that limits users' exposure to potentially harmful content. Currently, the absence of annotated datasets of suicide memes remains a key barrier to developing and evaluating automated moderation approaches. In this paper, we introduce FigSIM, the first dataset designed for fine-grained analysis of suicide memes. The dataset consists of 1049 memes, each annotated for (1) fine-grained suicide severity levels, (2) figurative phenomena (e.g., metaphors), and (3) suicide-related content (e.g., suicide method depiction). We benchmark 16 unimodal and multimodal models across three tasks: figurative language, suicide severity, and suicide-related content detection. Overall, FigSIM demonstrates that suicide memes pose unique challenges for both modeling and content moderation. Analysis revealed biases, such as underprediction of higher suicide severity levels, especially for figurative memes. The dataset (including splits used for analyses) is publicly available. Content Warning: This paper contains suicide-related content that may be triggering.

Recent evidence shows that people with eating disorders (EDs) are increasingly seeking guidance, advice, and emotional support from Large Language Model (LLM)-based chat systems. Although these systems are not designed to provide clinical advice, their perceived expertise, neutrality and accessibility make them a frequent, albeit risky, source of support. This paper investigates potential patterns of interaction between users with EDs and LLMs, focusing on the potential harms arising from models that uncritically adapt to, and facilitate unsafe or self-harming user requests. We find, in consultation with clinical ED experts, that specific linguistic cues in prompts increase the likelihood of unsafe responses and, through systematically varying the degree of potential risk present in the user prompt, report the extent to which LLMs uncritically adapt to problematic, and potentially dangerous user inputs.

Prediction tasks over individual futures, which are inherently noisy, often admit multiple similarly accurate models. When these models produce different predictions for the same individual, they raise concerns of arbitrariness in decision-making. How severe can this arbitrariness be, in theory and in practice? How can it be resolved to support high-stakes risk assessment? We address these questions through a study of a machine learning-based decision support system for recidivism risk assessment that has been in use for over 15 years. By translating complex legal rules into an algorithm for labeling post release outcomes (recidivist or non-recidivist), we first construct a dataset of thousands of inmate releases. Using this dataset, we learn interpretable models that improve predictive performance, reduce error-rate disparities between groups, and ensure that rehabilitative progress lowers risk scores. Next, we study predictive multiplicity, by first deriving a tight lower bound on the expected predictive agreement of any finite set of models over a dataset, and then by evaluating the extent to which structural diversity (e.g., different model coefficients) within this set translates to predictive multiplicity (i.e., different predictions for the same individual). Our experiments indicate that the existence of many similarly accurate models with comparable error-rate disparities does not necessarily translate into severe predictive multiplicity. Empirically, similarly performant models can exhibit substantially higher predictive agreement than worst-case theoretical guarantees suggest. We find that a simple policy that assigns each inmate the lowest risk among these models is effective for addressing predictive arbitrariness.

Self-harm presentations to emergency departments (EDs) are strongly associated with higher suicide risk. NLP models have shown robust performance in detecting self-harm from triage notes within single hospitals, yet performance often declines across institutions. To examine potential causes, we compare ED triage notes from two hospitals by analyzing lexical characteristics, highly associated predictive features, and salient topics. Our results reveal variation in lexical expression and feature importance related to self-harm across hospitals, despite consistent core themes such as self-poisoning and self-injury. These documentation differences are associated with reduced cross-site performance. Our findings provide insight into how institutional variation affects the identification of self-harm in clinical text and highlight potential methods to improve model generalisability.

Suicide is a critical global public health challenge, causing approximately 720,000 deaths each year and calling for timely, effective prevention strategies. Existing computational studies primarily focus on post-based social media platforms such as Twitter and Weibo, leaving instant messaging environments such as Telegram underexplored. Yet group chats pose distinct challenges: messages are short, fragmented, multi-party, and often rely on implicit or culturally specific expressions, making isolated post-level analysis insufficient. We introduce SuiChat-CN, a Chinese group-chat benchmark for contextual suicide risk assessment. We collect public Telegram group-chat data, construct coherent conversational segments through signal-word extraction and bidirectional context expansion, and annotate user risk levels with an expert-validated, LLM-assisted paradigm. SuiChat-CN contains 13,312 contextual segments from 1,406 users, covering 258,228 raw chat messages. Extensive experiments with PLMs and more than 40 LLMs demonstrate that contextual information is essential for reliable risk assessment, while fine-tuning and partial-context evaluation further reveal the challenges of early detection in multi-party conversations. Due to ethical and sensitivity concerns, the dataset is not publicly released but will be shared with accredited mental health and suicide-prevention research institutions upon reasonable request.

Recent advances in artificial intelligence (AI) and social media data have led to growing optimism about the ability to detect suicide risk at scale. However, the empirical foundations of this work remain unclear. This article provides a synthesis of current research on AI-based suicide detection in social media, drawing on a recent umbrella review of 22 systematic reviews covering studies up to 2022, alongside an ongoing literature review extending the analysis to more recent work. Across these sources, we identified 195 relevant studies, which are documented in a detailed supplementary dataset outlining their key characteristics and findings (see Supplementary Information). Analysis of these studies reveals consistent patterns, including rapid growth, concentration on a small number of platforms, reliance on textual and English-language data, and repeated use of similar datasets. Most importantly, the majority of studies rely on indirect labeling strategies that do not involve direct, individual-level validation of suicide risk. Instead, ground truth is typically inferred from observable features of online content, such as linguistic markers or community membership. As a result, the predictive task often shifts from identifying individuals at risk to classifying posts that contain suicidal or distress-related language, limiting the ability of current approaches to detect individuals who do not express such content explicitly online. These findings suggest that current advances in model performance should be interpreted with caution. Progress in this field is likely to depend less on improving model performance and more on ensuring that model predictions meaningfully correspond to suicide risk as it is experienced in real life.

Recommender systems generally optimises user engagement, but this approach is dangerous in mental health contexts. When vulnerable users show signs of suicidal ideation, standard algorithms often trap them in echo chambers of harmful content, worsening their psychological state. In response, we introduce RankAid, a re-ranking method that prioritises clinical safety alongside predictive relevance. It works as an add-on layer to existing models: it penalises risky items and boosts therapeutic content depending on the user's current level of vulnerability. We evaluated this approach using the MovieLens 1M dataset, where items were semantically annotated for clinical risk and therapeutic value using large language models. Our simulations show that our algorithm successfully blocks the recommendation of harmful content during crisis peaks, actively reshaping the feed to support emotional de-escalation. Furthermore, this safety intervention only causes a controlled, acceptable drop in standard accuracy metrics like NDCG. By using asymmetric hyperparameters, RankAid also gives system administrators the flexibility to tune the severity of the intervention based on specific clinical guidelines.

Understanding and monitoring human behavior in metro stations play an important role in supporting suicide prevention efforts, where early identification of high-risk situations can enable timely intervention. This requires assessing suicide risk from a surveillance video by jointly reasoning about the behavior of each passenger, his/her spatial context, and temporal dynamics. However, this assessment using videos captured by surveillance cameras is challenging, as it demands accurate perception of human motion, understanding of platform geometry, and aggregation of heterogeneous behavioral cues over time. In this work, we formalize the task of Suicide Risk Assessment (SRA) in metro stations and introduce the first interpretable framework that addresses this challenge. Unlike approaches that focus on isolated subtasks or attempt to infer intent directly, our formulation assesses suicide risk from accumulated evidence by incorporating person tracking, activity recognition, semantic segmentation of the platform, and trajectory-driven risk heatmap modeling. By formalizing SRA as a distinct task and benchmarking a complete operational pipeline achieving 83.2% ROC-AUC on real surveillance data, this work highlights the complexity of suicide risk assessment and opens new directions for research on interpretable AI systems for social good.

While large language models (LLMs) are increasingly being explored for mental health applications, recent studies reveal that they can exhibit stigma toward individuals with psychological conditions. Existing evaluations of this stigma primarily rely on multiple-choice questions (MCQs), which fail to capture the biases embedded within the models' underlying logic. In this paper, we analyze the intermediate reasoning steps of LLMs to uncover hidden stigmatizing language and the internal rationales driving it. We leverage clinical expertise to categorize common patterns of stigmatizing language directed at individuals with psychological conditions and use this framework to identify and tag problematic statements in LLM reasoning. Furthermore, we rate the severity of these statements, distinguishing between overt prejudice and more subtle, less immediately harmful biases. To broaden the reasoning domain and capture a wider array of patterns, we also extend an existing mental health stigma benchmark by incorporating additional psychological conditions. Our findings demonstrate that evaluating model reasoning not only exposes substantially more stigma than traditional MCQ-based methods but also helps identify the flaws in the LLMs' logic and their understanding of mental health conditions.

Emerging AI systems in behavioral health and psychiatry use multi-step or multi-agent LLM pipelines for tasks like assessing self-harm risk and screening for depression. However, common evaluation approaches, like LLM-as-a-judge, do not indicate when a decision is reliable or how errors may accumulate across multiple LLM judgements, limiting their suitability for safety-critical settings. We present a statistical framework for multi-agent pipelines structured as directed acyclic graphs (DAGs) that provides an alternative to heuristic voting with principled, adaptive decision-making. We model each agent as a stochastic categorical decision and introduce (1) tighter agent-level performance confidence bounds, (2) a bandit-based adaptive sampling strategy based on input difficulty, and (3) regret guarantees over the multi-agent system that shows logarithmic error growth when deployed. We evaluate our system on two labeled datasets in behavioral health : the AEGIS 2.0 behavioral health subset (N=161) and a stratified sample of SWMH Reddit posts (N=250). Empirically, our adaptive sampling strategy achieves the lowest false positive rate of any condition across both datasets, 0.095 on AEGIS 2.0 compared to 0.159 for single-agent models, reducing incorrect flagging of safe content by 40% and still having similar false negative rates across all conditions. These results suggest that principled adaptive sampling offers a meaningful improvement in precision without reducing recall in this setting.

Millions of people now use generative AI chatbots for psychological support. Despite their promise, the most pressing question in AI for mental health is whether these tools are safe. The field currently lacks a validated, automated benchmark for evaluating AI chatbot safety, particularly for users at risk of suicide. The Validation of Ethical and Responsible AI in Mental Health (VERA-MH) evaluation was recently proposed to address this need. This human validation study examined the alignment of VERA-MH safety ratings with expert clinician judgments. We simulated conversations between large language model (LLM)-based users spanning a range of suicide risk levels and disclosure styles and general-purpose AI chatbots. Licensed mental health clinicians from Spring Health independently rated chatbot safety using the VERA-MH scoring rubric. An LLM-based evaluator ("judge") applied the same rubric to the same conversations. We examined agreement among clinicians, between clinician consensus and the LLM judge, and across different judge LLMs. Clinicians also rated user-agent realism, suicide risk, and disclosure. Clinicians showed strong agreement in safety ratings (chance-corrected inter-rater reliability [IRR] = 0.77), establishing a reliable clinical consensus reference. The LLM judge was strongly aligned with this consensus (IRR = 0.81), and ratings were stable across judge models and repeated evaluations. Ratings of user-agent realism and fidelity to intended suicide risk and disclosure styles were mixed. These findings support the reliability of VERA-MH as an open-source, fully automated benchmark for evaluating AI chatbot suicide risk detection and response. Because these results reflect an earlier version of the benchmark, future work should validate updated versions, assess generalizability and robustness, and expand VERA-MH to additional domains of AI safety in mental health.

Ecological Momentary Assessment (EMA) studies enable the collection of high-frequency self-reports of suicidal thoughts and behaviors (STBs) via smartphones. Latent stochastic differential equations (SDEs) are a promising model class for EMA data, as it is irregularly sampled, noisy, and partially observed. But SDE-based models suffer from two key limitations. (a) These models often violate domain constraints, undermining scientific validity and clinical trust of the model. (b) Training is numerically unstable without ad hoc fixes (e.g. oversimplified dynamics) that are ill-suited for high-stakes applications. Here, we develop a novel class of expressive SDEs whose solutions are provably confined to a prescribed compact polyhedral state space, matching the domains of EMA data. In this work, (1) we show why chain-rule based constructions of SDEs on compact domains fail, theoretically and empirically; (2) we derive constraints on drift and diffusion for general and stationary SDEs so their solutions remain in the desired state space; and (3), we introduce a parameterization that maps arbitrary (neural or expert-given) dynamics into constraint-satisfying SDEs. On several real EMA datasets, including a large suicide-risk study, our parameterization improves forecasts and optimization dynamics over standard latent neural SDE baselines. These contributions pave the way for principled, trustworthy continuous-time models of suicide risk and other clinical time series and extend applications of SDE-based methods (e.g. diffusion models) to domains with hard state constraints.

Real-world crisis intervention is inherently conversational, yet existing research largely focuses on static texts. When applied to multi-turn dialogues, current models exhibit significant performance degradation, struggling to track risk signals that emerge as context evolves. To address this gap, we introduce CRADLE-Dialogue, a clinician-annotated benchmark for turn-level crisis detection in conversational settings. The dataset features 600 dialogues with multi-label annotations across clinically grounded risks, including suicide ideation, self-harm, and child abuse, distinguishing past from ongoing risk. We further propose an Alert-Confirm evaluation protocol that distinguishes early warning signals (Alert) from turns where a specific crisis becomes explicitly identifiable (Confirm), reflecting the clinical need to intervene before risk becomes explicit. Experiments show that identifying when risk emerges is much harder than recognizing that it exists: models achieve only mid-40% to high-60% Micro F1. Additionally, we release a synthetic training corpus and a 32B-parameter model that substantially outperforms existing open-source models and achieves competitive or superior results against proprietary models across turn-level, dialogue-level, and confirm-only evaluation settings.