Within the mental health system, there are varying levels of care. These levels range from not at all restrictive (e.g., outpatient care) to very restrictive (e.g., acute inpatient care) (WHO, 2021). The more restrictive services are reserved for the most acute cases, whereas the less restrictive services are for less acute cases.
Individuals require different levels of care at various times during their treatment, depending on the severity of their symptoms or degree of occupational or social impairment (WHO, 2021). Levels of care in the mental health system include Inpatient, Residential, Partial Hospital, Intensive Outpatient, and Outpatient treatment.
Inpatient treatment is the highest, most acute nursing and medical services level. It is provided in a structured environment 24 hours a day. Patients have full and immediate access to healthcare professionals and undergo extensive and comprehensive psychiatric treatment. Inpatient treatment may be sought voluntarily by patients or deemed medically necessary by a healthcare professional. Inpatient treatment lasts anywhere from two to fourteen days, depending on the severity of the symptoms and the patient's response to treatment.
Residential treatment is one level down from inpatient and is considered sub-acute. These patients have access to 24-hour skilled nursing care and often live onsite throughout their recovery. They usually undergo treatment that combines medication with group and individual psychotherapy (Sadock et al., 2017).
Partial hospitalization refers to an intensive, non-residential setting where patients receive care during the day but return to their homes at night. They undergo structured medical and nursing care with services similar to inpatient psychiatric hospitals. Usually, the patient receives medication treatment in these settings and participates in group psychotherapy (Sadock et al., 2017).
Intensive outpatient treatment offers patients regular contact with mental health professionals, often multiple days per week. Patients in intensive outpatient programs receive care more often than those in general outpatient services but less often than those in partial hospital programs (Sadock et al., 2017). On the other hand, outpatient care is the least restrictive form of mental health care. Patients regularly meet with their mental health provider in an office setting to undergo psychotherapy sessions and medication management (Sadock et al., 2017).
After completing a suicide assessment, a qualified mental health clinician can determine the most appropriate level of care. Table 2 offers guidelines for determining the best treatment setting for a particular patient.
Table 2: Guidelines for Determining Treatment Setting
(Jacobs et. al., 2010)
|Inpatient Treatment Recommended||After a suicide attempt or aborted suicide attempt if:|
- The patient is psychotic
- The attempt was violent, near-lethal, or premeditated
- Precautions were taken to avoid rescue
- Persistent plan or intent
- The patient regrets surviving
- The patient is male, older than 45 years, with new-onset suicidal thinking
- The patient has limited family and social support
- The patient lacks a stable living situation
- Current impulsive behavior and severe agitation
- The patient is refusing help
- In the presence of suicidal ideation with a specific plan with high lethality
|Inpatient Treatment Might Be Necessary||In the presence of suicidal ideation with:|
- Major psychiatric disorder
- History of past attempts
- Lack of response to or inability to cooperate with a partial hospital or outpatient treatment
- Need for supervised setting for medication trial or ECT
- Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting
- Limited family and social support, including a lack of a stable living situation
- Lack of access to timely outpatient follow-up
|Outpatient Treatment Recommended||After a suicide attempt or in the presence of suicidal ideation/plan, when:|
- Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient's view of the situation has changed since coming to the emergency department
- Plan/method and intent have low lethality
- The patient has a stable and supportive living situation
- The patient can cooperate with recommendations for follow-up
- The patient has chronic suicidal ideation without prior medically serious attempts and has a safe and supportive living situation
Following a suicide attempt, inpatient psychiatric treatment is recommended. Following an aborted suicide attempt, inpatient psychiatric treatment is most likely recommended, especially if the patient regrets surviving or has a persistent intent to end their life. If the patient has minimal family or social support, is psychotic, or is declining any type of mental health care, they most likely require inpatient treatment (Jacobs et al., 2010).
Furthermore, inpatient psychiatric hospitalization may also be necessary for the presence of suicidal ideations (Jacobs et al., 2010; Sadock et al., 2017). If a patient expresses suicidal thoughts, has a history of previous suicide attempts, the presence of a psychiatric disorder, and limited social support, they may require inpatient treatment. If the patient describes a specific plan with high lethality, they almost always need hospitalization (Sadock et al., 2017).
Partial hospitalization is appropriate for patients who do not require inpatient treatment but require more intensive services than available in outpatient settings (Sadock et al., 2017). Because partial hospitalization is highly structured with both nursing and medical services, it is advocated for those experiencing suicidal ideation without a specific plan and with some social support. Importantly, when choosing partial over inpatient hospitalization, consider whether the patient has the capacity for reliable attendance. Partial hospitalization is also used as a step-down from inpatient treatment to help patients transition to outpatient treatment (Jacobs et al., 2010; Sadock et al., 2017).
Outpatient mental health services are appropriate if patients experience transient or mild suicidal ideation without a specific plan or intent to attempt suicide (Sadock et al., 2017). These patients should also have a stable and supportive living situation and be willing to cooperate with follow-up recommendations.
Continuity of care refers to the link between providers from one setting to another. Care transition, the period following hospitalization to a lower level of care, is a high-risk time for patients (SAMHSA, 2022). Doupnik et al. (2020) completed a meta-analysis to review the research on suicide prevention interventions with subsequent suicide attempts and how follow-up care impacted outcomes. They published their findings in a paper titled Association of Suicide Prevention Interventions with Subsequent Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms for Acute Care Settings: A Systemic Review and Meta-analysis.
The meta-analysis showed that "brief suicide prevention interventions were associated with reduced subsequent suicide attempts and increased linkage to follow-up but were not associated with reduced depressive symptoms" (Doupnik et al., 2020). The results solidified the theory that continuity of care through brief interventions leads to more consistent follow-up encounters, thus reducing subsequent suicide attempts. Risks can be mitigated through a number of interventions, including coordination between inpatient and outpatient services, safety planning before inpatient discharge, immediate involvement of family, friends, and social support, maintaining continuity of care best practices, and follow-up with the patient within 24 hours after discharge (SAMHSA, 2022).
The Suicide Prevention Resource Center and the Joint Commission both recommend safety planning as a standard of care for individuals identified as at risk for suicide-related behaviors. Safety planning is a brief intervention to help an individual survive suicidal crises by having the individual develop a set of steps to reduce the likelihood of engaging in suicidal behavior. It includes cognitive-behavioral interventions for suicide prevention and is usually used in collaboration with a referral for mental health treatment (Moscardini et al., 2020).
Safety plans typically include ways that the individual can identify that he/she is at increased risk for suicide (e.g., suicidal thoughts, looking for ways to commit suicide, changes in mood and behaviors, etc.). The safety plan will help the individual identify coping strategies to employ when these urges arise and the people or resources the individual can access during the crisis. It also helps the individual identify one or two things worth living for as a means to arrest the movement towards committing suicide.
Providing the individual with resources to access help is paramount to successful discharge planning. Crisis contact information, such as the phone number for the local crisis center and the National Suicide Prevention website, is considered best practice. Ensuring the patient has a follow-up appointment with an outpatient provider and reviewing the appointment with the patient helps ensure follow-through.