Suicide Screening and Referral

This course offers a comprehensive review of suicide as well as elucidates its complex nature and offers best practices in assessment, management, and prevention.

After completing this continuing education course, the participant will be able to meet the following objectives.

• Identify five terms that describe suicidal thinking and behavior.
• List 3 protective factors relating to suicide.
• Identify five high-risk risk characteristics for suicide.
• Differentiate a suicide risk screening and a suicide assessments.
• Identify two screening instruments for children and adolescents.
• Identify the 5 components of a comprehensive suicide assessment.
• Identify and select the appropriate referral for those at risk for suicide.
• Define the 6 key components of the management of suicidal behavior.
• Given a scenario of a patient who is at risk for suicide, identify the appropriate level of care to which the patient should be referred.

Latin for “self-murder,” suicide is a psychiatric emergency that claims over 42,000 lives every year in the United States¹. It is a fatal act that represents a person’s desire to die. Suicide is almost always the result of mental illness, usually depression, and it is preventable when recognized early and treated effectively.

Suicide is ranked as the 10th overall cause of death in the United States (Table 1). Suicide accounts for over 42,000 deaths per year while homicide accounts for around 20,000.² Estimates suggest that there is a 25:1 ratio of suicide attempts to completed suicides. Over the past century, these rates have remained constant, averaging 12 per 100,000 persons.²

Suicide is the deliberate act of taking one's own life; however, there are a variety of terms used to classify the range of suicidal-type behaviors (Table 2).¹ Suicide not only ends a patient’s life, but it also can leave a devastating legacy to the patient’s loved ones and result in litigation against the provider.

Clinicians should understand both protective and risk factors for suicide. Protective factors buffer individuals from both suicidal ideation and suicidal behaviors. Risk factors, on the other hand, encompass individual, relationship, community, and societal factors that increase a person's likelihood of attempting suicide.

The Centers for Disease Control (CDC) notes that protective factors have not been studied extensively, but it is still important for clinicians to understand them.³ Protective factors include:

• Effective clinical care for mental, physical, and substance abuse disorders
• Easy access to a variety of clinical interventions and support for help-seeking
• Family and community support
• Skills in problem-solving, conflict resolution, and nonviolent ways of handling disputes
• Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

Risk factors for suicide can be divided into two categories: high-risk and low-risk characteristics. High-risk characteristics include older than 45 years, male gender, alcohol dependence, violent behavior, previous suicidal behavior, previous psychiatric hospitalization.¹ Low-risk characteristics include younger than 45 years, female gender, married, employed, and lack of previous mental health disorder or suicide attempt.¹ Table 3 compares high and low-risk characteristics.

Suicide risk is evaluated through two means: screens and assessments. Suicide screening refers to the use of a standardized instrument or protocol used to identify those at risk for suicide.⁷ These screens can be completed as part of a comprehensive suicide assessment or separately. Suicide screens may be conducted orally (the screener asking questions), on paper, or on a computer.⁷

Suicide assessment describes a comprehensive evaluation usually completed by a clinician to determine suicide risk and course of treatment.⁷ Sometimes assessments include screens but they may also include an open-ended interview and broader conversations with the individual’s friends, family, or other healthcare providers. Assessments encompass detailed evaluations of a person’s thoughts, behaviors, risk factors, protective factors, and medical and psychiatric history.⁷

A suicide assessment is a specific type of psychiatric evaluation aimed at determining a person’s suicidal risk and creating a specialized treatment plan. The five domains of suicide assessment include the current presentation of suicidality, psychiatric illness, history, psychosocial situation, individual strengths and weaknesses.¹⁶ These domains are summarized in Table 4.

During a suicide assessment, clinicians should also conduct a thorough psychiatric evaluation. This information should be obtained from either the patient or their family members and friends. The clinician must approach the situation with empathy and compassion. In the context of a suicide assessment, the purpose of the psychiatric evaluation is to¹⁶:

• Identify specific psychiatric signs and symptoms
• Assess past suicidal behavior
• Review past treatment history and treatment relationships
• Identify family history of suicide and mental illness
• Identify current psychosocial situation and the nature of the crisis
• Evaluate current substance misuse
• Appreciate psychological strengths and vulnerabilities

Clinicians should begin by assessing current signs and symptoms of psychiatric disorders.¹⁶ They should pay close attention to signs of a depressive disorder and make note of any high-risk characteristics (Table 3). Clinicians should document previous psychiatric hospitalizations along with prior treatment for substance use disorders.¹ Specific psychiatric symptoms that increase a person's risk of suicide include aggression, violence toward others, impulsiveness, hopelessness, agitation, psychic anxiety, anhedonia, global insomnia, and panic attacks.

Clinicians should obtain and document a thorough history of the patient’s previous suicide attempts, aborted suicide attempts, and self-harming behaviors.¹ Do not forget, a previous suicide attempt is one of the strongest risk factors for another attempt. When possible, clinicians should contact the patient’s current primary care or psychiatric provider.¹⁶

Clinicians should also inquire about the patient’s family history. Family dysfunction is linked to suicide and other self-harming behaviors.¹ Clinicians must assess for a family history of suicide or psychiatric disorders. Clinicians should also document a history of familial conflict or separation, parental legal trouble, family substance abuse, domestic violence, and physical or sexual abuse.

Next, the clinicians should assess the patient’s current psychosocial situation.¹⁶ What are their current stressors? Have they experienced any recent interpersonal losses, financial difficulties, or changes in socioeconomic status? The clinician should document acute crises, chronic stressors, employment status, living situation, family constellation, and cultural or religious beliefs about suicide.¹⁶

Substance abuse may contribute to suicide. When suspecting substance use disorder, please consider:

• Ask first about socially acceptable substances such as caffeine or tobacco products. This helps to establish a level of comfort for the rest of the interview. Always ask “how many” and “how often” – e.g.,” You mentioned you drink the occasional latte, how many of those during the course of a week?” “So you have three, 4 shot, Grande lattes, six days a week, is that correct?”
• Next, inquire about alcohol use. Be sure to ask specifically about beer, wine, and spirits as many cultures do not consider beer to be alcohol.
• Next, inquire about over the counter substances, including diet aids, cough and cold preparations, herbal supplements.
• Ask about the misuse of prescription items such as sleep medications, pain preparations, medications for attention deficit disorder or weight loss.
• Next ask about marijuana, which is legal for use in some states or settings. Be sure to quantify how much, how often.
• Next, ask about illicit drugs. Be sure to be consistently non-judgmental and focus on the information needed for accurate health assistance. Street drugs such as heroin, cocaine, hallucinogens, methamphetamine and inhalants should be asked about here.
• Remember to ask how much, how often, length of use pattern, and the last time each substance was used. Route of administration is also important and be sure to ask whether the person has shared substances, especially injected drugs and needles.
• If prior substance use disorders are mentioned, ask about participation in Alcoholics Anonymous (AA), Narcotics Anonymous (NA), other twelve-step programs, addiction treatments, detoxifications or periods of abstinence from the substance. Of special interest is the length of the longest period without the substance without using other illicit substances or alcohol to help maintain.
• Ask the person what benefits they obtain from their substance of choice. This will be very helpful information when treatment for their substance use disorder begins.
• And finally, ask what negative consequences have arisen from their substance use. Should they need coaching look for items in each of these three key areas;
• Physical risks or illnesses – sickness, accidents, fractures, burns, car wrecks
• Psychiatric problems – focusing problems, anxiety, depression, suicidal thoughts, psychosis
• Relationship problems – work, social relationships, legal difficulties, financial worries

Finally, clinicians must appreciate the patient’s psychological strengths and weaknesses. These may include coping skills, personality traits, thinking style, and development needs. Patients who are at an increased risk of suicide exhibit polarized thinking, closed-mindedness, perfectionism, and excessively high self-expectations.¹⁶

Healthcare providers must directly ask patients about suicidal thoughts, plans, and behaviors; however, cultural and religious beliefs about death and suicide may present a patient from speaking openly about his or her thoughts. In this case, clinicians must seek out collateral sources such as spouses, friends, family members, clergy, or other healthcare providers.¹⁶

Table 5 includes a list of questions that clinicians can use when inquiring about different aspects of suicide. Clinicians should follow these steps¹⁶:

• Elicit the presence or absence of suicidal ideation
• Elicit the presence or absence of a suicide plan
• Assess the degree of suicidality including intent and lethality

During and after conducting a suicide screen or assessment, the clinician should develop a strategy for treatment and management of potential suicidal behaviors. In their publication Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, the American Psychiatric Association defines six key components of the management of suicidal behavior¹⁶:

• Therapeutic Alliance
• Patient Safety
• Determine Treatment Setting
• Treatment Plan
• Care Coordination
• Patient & Family Education

First, the healthcare provider must focus on developing a strong therapeutic alliance with the patient¹⁶. The clinicians should begin by building trust and establishing mutual respect. Only within a trusting relationship will patients feel comfortable discussing and addressing their suicidal ideation and behaviors. The ultimate goal of the patient-provider relationship is reducing the risk of suicide.¹⁶

Next, the clinician must attend to the patient’s safety¹⁶. Throughout the suicide assessment, the clinician may need to intervene directly in order to prevent the patient from harming him or herself. For example, the clinician may need to search the patient’s belongings for weapons, lighters, matches, medications, or other toxic substances. The healthcare provider may also determine that the patient needs constant observation by either another clinician or closed-circuit television.¹⁶

After developing a therapeutic alliance and attending to the patient’s safety, the clinician must select the most appropriate treatment setting. The patient should always be treated in the least restrictive yet safest most effective setting.¹ Table 6 provides the guidelines for determining when a patient needs inpatient psychiatric treatment.¹⁶

Admission to an inpatient psychiatric hospital is usually indicated after a suicide attempt or an aborted suicide attempt.¹⁶ Admission may be necessary if the patient expresses suicidal ideation, has previous attempts, and has a diagnosed psychiatric disorder. Outpatient treatment is most beneficial for those with chronic suicidal ideation or who have a stable, supportive living situation.¹⁶

Next, clinicians must develop a plan of treatment.¹⁶ The treatment plan begins by ensuring the patient’s safety and selecting the appropriate treatment setting. After acute treatment, the patient should be referred to a psychiatric specialist such as a psychiatrist or a psychiatric nurse practitioner. These specialized clinicians will continue the patient’s care and ensure timely diagnosis and management of any underlying mental health conditions.

In the early phases of treatment, specialists will monitor the patient closely and prescribe specific treatments for symptoms such as anxiety, insomnia, and hopelessness. During the early stages of recovering from a suicide attempt, patients will be encouraged to undergo education and supportive psychotherapy.

Psychiatric specialists and primary care providers must coordinate their care to offer the best treatment to patients with suicidal behaviors. These patients are often complex, requiring an interdisciplinary team of healthcare professionals such as social workers, case managers, and psychiatric nurses.

When the patient agrees, education should be provided to his or her involved family members. It is important for family members to understand that psychiatric disorders are real and difficult illnesses that require special treatment. Friends and family should also learn about the role of psychological and social stressors that can precipitate or worsen suicidal behaviors.

Jack is a 47-year-old Caucasian male. He has a history of major depressive disorder without psychosis beginning in his early 20s that has been controlled with various antidepressants. He and his wife separated two months ago. Last week he lost his job after repeatedly arriving late. He currently resides in a hotel and is out of contact with his friends and family. Earlier in the evening, his wife called the police after receiving a text message from Jack where he said he wanted to kill himself. The police brought Jack to the emergency room stating that they found him in his hotel room with a gun and bottle of vodka. Jack appears disheveled, depressed, and withdrawn. He tells you his life is not worth living and he wants to end his life. He does express some desire to seek treatment but fears his situation is hopeless.

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