Sign Up
For the best experience, choose your profession & state.
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Suicide Screening and Referral Training - 3 Hours

3.00 Contact Hours

AOTA Classification Code: CAT 1: Client Factors; CAT 2: Intervention
Education Level: Intermediate
AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9575.

A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Melissa DeCapua (DNP, PMHNP-BC)

Outcomes

This course offers a comprehensive review of suicide as well as elucidates its complex nature and offers best practices in assessment, management, and prevention. This course meets the Washington state suicide prevention training requirement for health professionals

Objectives

After completing this course, the learner will:

  • Define four terms that describe suicidal thinking and behavior.
  • Recognize five suicide risk factors
  • Recognize three protective factors.
  • Differentiate suicide risk screening and assessments.
  • Recognize when and how to screen children and adults for suicide risk.
  • List the components of a comprehensive suicide assessment.
  • Determine how to appropriately use the information gathered from suicide risk screening and assessments.
  • Given a scenario of an individual at risk for suicide, select the appropriate referral plan for the patient.
  • Recognize the importance of continuity of care when making referrals.
  • Identify one key point in best practices for connecting a patient to a referral.

Introduction

Latin for “self-murder,” suicide is a psychiatric emergency that claims over 42,000 lives every year in the United States [1]. 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 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].

Table 1: Top 15 Leading Causes of Death in the United States [2]
Cancer591,6999 deaths
Chronic lower respiratory diseases147,101 deaths
Accident136,053 deaths
Stroke133,103 deaths
Alzheimer’s disease93,541 deaths
Diabetes76, 488 deaths
Influenza and Pneumonia55,227 deaths
Kidney Disease48,146 deaths
Suicide42,773 deaths
Septicemia38,940 deaths
Liver Disease38,170 deaths
Hypertension30,221 deaths
Parkinson’s disease26,150 deaths
Pneumonitis due to solids and liquids18,792 deaths

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, it also can leave a devastating legacy to the patient’s loved ones and result in litigation against the provider.

Table 2: Terms Describing Suicidal Thinking and Behavior [1]
Aborted suicide attemptPotentially self-injurious behavior with explicit or implicit evidence that the person intended to die but stopped the attempt before physical damage could occur.
Deliberate self-harmWillful self-inflicting of painful, destructive, or injurious acts without the intent to die.
Lethality of suicidal behavior
Objective danger to one's life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual's expectation of what is medically dangerous.
Suicidal ideationThought of serving as the agent of one’s own death. The seriousness of suicidal ideation may vary depending on the specificity of suicidal plans and the degree of suicidal intent.
Suicidal intentSelf-injurious behavior with a nonfatal outcome accompanied by explicit or implicit evidence that the person intended to die.
SuicideSelf-inflicted death with explicit or implicit evidence that the person intended to die.

Suicide Risk & Protective Factors

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.

Table 3: Comparison of high-risk and low-risk characteristics [1]
CharacteristicHigh-riskLow-risk
Age>45 years<45 years
SexMaleFemale
Marital StatusDivorced or widowedMarried
EmploymentUnemployedEmployed
Interpersonal relationshipsConflictualStable
Family backgroundChaoticStable
Physical HealthChronic illness, hypochondriac, excessive substance intakeGood health, feels healthy, low substance use
Mental HealthSevere depression, psychosis, severe personality disorder, substance abuse, hopelessnessMild depression, neurosis, normal personality, social drinker, optimism
Suicide attemptMultiple, planned, rescue unlikely, specific wish to die, self-blaming, available lethal methodFirst attempt, impulsive, rescue inevitable, wish for change rather than wish to die, external anger, low lethality method
Personal resourcesPoor achievement, poor insight, unstable affectGood achievement, insightful, controllable affect
Social resourcesPoor rapport, socially isolated, unresponsive familyGood rapport, socially integrated, concerned family

Geographic Location

In the United States, suicide rates are lowest in New Jersey for both genders; Montana and Wyoming have the highest for men, and Alaska and Idaho have the highest for women [1]. International suicide rates range from 25 per 100,000 in Lithuania, South Korea, and Russia to 10 per 100,000 in Portugal and Australia [1]. The Golden Gate Bridge, located in San Francisco, California, is the most common suicide site in the world. Over 1,600 suicides have been completed there since it was built in 1937.

Gender

Men are four times more likely to commit suicide compared with women, regardless of age, race, religion, or marital status [1]. On the other hand, women experience suicidal thoughts and attempt suicide three times as often as men. The reason for this disparity appears to be related to the different ways men and women attempt suicide.

Age

The rate of suicide increases as a person ages [1]. Prior to puberty, suicide is extremely rare. For men, suicide rates are highest at age 45; for women they are highest after age 55. Elderly persons attempt suicide less often than younger persons, but they are typically more successful. Unfortunately, the suicide rate is rising quickly in younger populations. Today suicide is the third leading causes of death for those aged 15 to 24 years, followed by accidents and homicides [1].

Race and Religion

Caucasian men and women are three times more likely to commit suicide than African American men and women. Native American and Alaskan Native youth experience suicide rates much higher than the national average [4]. Rates among immigrant are higher than those among citizens [5]. In the United States, Protestants and Jews have higher suicide rates than both Catholics and Muslims. Overall, the level of orthodoxy and integration with society is a more accurate predictor of suicide than religion alone [1].

Marital Status

Married individuals with children are much less likely to commit suicide than single persons. Single, never-married individuals experience double the suicide rate compared with married persons [4]. Divorce increases the risk of suicide; divorced men are three times more likely to commit suicide than divorced women. Homosexual men and women have higher rates than heterosexual persons whether married or single. Some individuals commit “anniversary suicides” on the day their family member or loved one died [1].          

Occupation

The risk of suicide increases as a person's socioeconomic status increases. In general, employment serves as a protective factor against suicide; however, certain occupations increase a person’s risk. High-risk occupations include healthcare provider, artist, mechanic, lawyer, and insurance agent. Unemployed persons are more likely to commit suicide than their employed counterparts. Suicide rates increase during economic recessions and decreased during economic booms [1].

Physical Health

Over 30 percent of people who commit suicide have seen a healthcare professional within the previous six months. Physical illness, in general, is a significant contributing factor in half of all suicides. Factors that specifically contribute to suicide include loss of mobility, disfigurement, and chronic pain. Especially when these impact personal relationships and occupational status. Persons on hemodialysis are at an increased risk as well [1].

Mental Illness

Nearly 95 percent of those who commit or attempt suicide have a diagnosed mental health disorder. Major depression and other depressive disorders account for 80 percent of suicides; those with delusional depression are at the highest risk [6]. Furthermore, schizophrenia accounts for 10 percent, and dementia or delirium account for the remaining five percent. Over one-quarter of those who commit suicide are dependent on alcohol at the time [1].

Screening & Assessing for Suicide Risk

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

Screening for Suicide Risk

Although screening scales can help facilitate conversation between patients and providers; expert panels have determined that they have limited value. The following panels have independently reviewed the value of screening for suicide risk [7]:

  • The Department of Veterans Affairs/Department of Defense (VA/DoD) Assessment of Risk for Suicide Working Group
  • The U.S. Preventive Services Task Force
  • The American Academy of Pediatrics Committee on Adolescence
  • The American Psychiatric Association Work Group on Suicidal Behaviors

In their publication, Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide, the VA/DoD) wrote, “suicide risk assessment remains an imperfect science, and much of what constitutes best practice is a product of expert opinion, with a limited evidence base” [8]. In addition, the U.S. Preventive Service Task Force concluded that suicide screens often elicit a high rate of false positives, rendering them ineffective when used independent from a comprehensive assessment conducted by a professional [9].

During their work group on suicidal behaviors, the American Psychiatric association determined that “although suicide assessment scales have been developed for research purposes, they lack the predictive validity necessary for use in routine clinical practice. Therefore, suicide assessment scales may be used as aids to suicide assessment but should not be used as predictive instruments or as substitutes for a thorough clinical evaluation [10].”

Furthermore, in their report, Suicide and Suicide Attempts in Adolescents, the American Academy of Pediatrics stated, “no specific tests are capable of identifying a suicidal person” and “scales…tend to be oversensitive and under specific and lack predictive value [11].”

Even though screening for suicide using questionnaires has low predictive value, they can be useful when used in additional to a comprehensive suicide assessment. When choosing a suicide screen, consider the following [7]:

  • Has this screen been researched and evaluated?
  • How much does the screen cost?
  • What age group is this screen designed for?
  • How long does it take to administer this screen?
  • Who can conduct this screen (i.e. healthcare providers, mental health providers, or lay persons)? 

Screens for Children and Adolescents

In their publication, Assessment of Suicidal Behaviors and Risk Among Children and Adolescents, the National Institute of Mental Health recommends four suicide screening instruments for children and adolescents [12]:

  1. Beck Scale for Suicide Ideation (BSI)
  2. >Harkavy Asnis Suicide Scale (HASS)
  3. Suicide Ideation Questionnaire (SIQ)
  4. Suicidal Behaviors Questionnaire for Children (SBQ-C)

The Beck Scale for Suicide Ideation (BSI) is a 21-question self-report questionnaire that is best used to detect and measure the severity of suicidal thoughts. The authors of this screen emphasize that if a person endorses any item on the BSI than a suicide assessment should immediately be initiated. The BSI is more thorough than other screens asking questions about the desire to live, suicidal ideation, duration and frequency of suicidal thoughts, and suicidal plan [12].

The Harkavy Asnis Suicide Scale (HASS) is a 21-item questionnaire used to gather information about a child's current and past suicidal behavior. This screen gathers demographic information, previous suicidal acts, the frequency of suicide-related behaviors in the previous two weeks, and recent substance misuse. The HASS is used most commonly in high school students and includes questions like, “Have you ever thought about killing yourself but did not actually try?” [12]

The Suicide Ideation Questionnaire (SIQ) is used to determine the severity of suicidal ideation. There is a 30-item and 15-item version, both designed for younger adolescents. The SIQ asks individuals to rate the severity of their suicidal ideation on a 7-point Likert scale. This screen is based on a hierarchy of seriousness of suicidality ranging from thoughts to death to attempting suicide. This screen does not assess previous or recent suicide attempts and should almost always be supplemented by a comprehensive suicide assessment [12].

The Suicidal Behaviors Questionnaire for Children (SBQ-C) is a 14 question screen designed to assess suicidal thoughts and behaviors in children and adolescents. It is a self-report tool designed to be easily understood by children and adolescents. Very little psychometric data is available for this questionnaire [12]. 

Screens for Adults

There are various suicide risk screens available for adults; however, it is important to remember screens do not replace a comprehensive suicide assessment conducted by a professional. Commonly used suicide screens for adults include:

  1. Beck Scale for Suicidal Ideation (SSI)
  2. Columbia Suicide Severity Rating Scale (C-SSRS)
  3. Nurses’ Global Assessment of Suicide Risk/li>

Aaron Beck developed the Scale for Suicide Ideation (SSI) in 1979 to evaluate the intensity of suicidal thoughts. It includes 19 questions each scored 0, 1, or 2 based on severity. It places individuals into three categories: active suicidal desire, preparation, and passive suicidal desire. This scale was later revised and named the Modified Scale for Suicide Ideation (MSSI). This screen used a scale 0 to 3 increasing the ability to discriminate between those who are thinking about suicide and those who are likely to attempt [13].

The Columbia-Suicide Severity Rating Scale (C-SSRS) used primarily in primary care settings, and it is available in over 100 different languages. The C-SSRS does not require mental health training to effectively administer and it provides criteria for next steps (e.g. referral to a psychiatric provider) based on the score [14].

The Nurses’ Global Assessment of Suicide Risk includes 15 items that help assess a person’s risk of attempting suicide. It allows clinicians to quickly evaluate high and low-risk characteristics. Each item on the screen is supported by research; however, the screen as a whole has not been empirically tested [15].

Assessing for Suicide Risk

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. 

Table 4: Domains of Suicide Assessment [16]
Current Presentation of Suicidality
  • Suicidal or self-harming thoughts, plans, behaviors, and intent.
  • Specific methods considered for suicide, including their lethality and the patient’s expectation about lethality, as well as whether firearms are accessible.
  • Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety.
  • Reasons for living and plans for the future.
  • Alcohol or other substance use associated with the current presentation.
  • Thoughts, plans, or intentions of violence toward others.
Psychiatric Illness
  • Current signs and symptoms of psychiatric disorders with particular attention to depressive disorders.
  • Previous psychiatric diagnoses and treatments, including illness onset and course and psychiatric hospitalizations, as well as treatment for substance use disorders
History
  • Previous suicide attempts, aborted suicide attempts, or other self-harming behaviors.
  • Previous or current medical diagnoses and treatments, including surgeries or hospitalizations.
  • Family history of suicide or suicide attempts or a family history of mental illness, including substance abuse.
Psychosocial Situation
  • Acute psychosocial crises and chronic psychosocial stressors, which may include actual or perceived interpersonal losses, financial difficulties or changes in socioeconomic status, family discord, domestic violence, and past or current sexual or physical abuse or neglect.
  • Employment status, living situation (including whether or not there are infants or children in the home), and presence or absence of external supports.
  • Family constellation and quality of family relationships
  • Cultural or religious beliefs about death or suicide.
Individual strengths and weaknesses 
  • Coping skills
  • Personality traits
  • Past responses to stress
  • Capacity for reality testing
  • Ability to tolerate psychological

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 to [16]:

  • 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 [55].

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 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 at an increased risk of 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 steps [16]:

  • 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
Table 5: Questions during a suicide assessment [16]
Opening questions 
  • Have you ever felt that life was not worth living? 
  • Did you ever wish you could go to sleep and just not wake up?
Follow-up questions
  • Is death something you’ve thought about recently?
  • Have things ever reached the point that you’ve thought of harming yourself?
Thoughts of self-harm and suicide 
  • When did you first notice such thoughts?
  • What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitation, psychosis)?
  • How often have those thoughts occurred (including frequency, obsessional quality, controllability)?
  • How close have you come to acting on those thoughts?
  • How likely do you think it is that you will act on them in the future?
  • Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to edge of bridge but not jumping)?
  • What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reactions of others)?
  • Have you made a specific plan to harm or kill yourself? (If so, what does the plan include?)
  • Do you have guns or other weapons available to you?
  • Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)?
  • Have you spoken to anyone about your plans?
  • How does the future look to you? 
Previous suicide attempts
  • Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)?
  • What thoughts were you having beforehand that led up to the attempt?
  • What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)?
  • Were other people present at the time?
  • Did you seek help afterward yourself, or did someone get help for you?
  • Had you planned to be discovered, or were you found accidentally?
  • How did you feel afterward (e.g., relief versus regret at being alive)? 
  • Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)?
  • Has your view of things changed, or is anything different for you since the attempt?
  • Are there other times in the past when you’ve tried to harm (or kill) yourself?

Repeated suicidal thoughts and attempts

  • About how often have you tried to harm (or kill) yourself?
  • When was the most recent time?
  • Can you describe your thoughts at the time that you were thinking most seriously about suicide?
  • When was your most serious attempt at harming or killing yourself?
  • What let up to it, and what happened afterward?
Psychosis  
  • Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus non-recognizable)?
  • What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the remarks are commands,
  • determine if they are for harmless versus harmful acts; ask for examples)?
  • How do you cope with (or respond to) the voices?
  • Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult?)
  • Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?)
  • Are you worried about having a serious illness or that your body is rotting?
  • Are you concerned about your financial situation even when others tell you there’s nothing to worry about?
  • Are there things that you’ve been feeling guilty about or blaming yourself for?
Harm to others
  • Are there others who you think may be responsible for what you’re experiencing (e.g., persecutory ideas, passivity experiences)?
  • Are you having any thoughts of harming them?
  • Are there other people you would want to die with you?
  • Are there others who you think would be unable to go on without you?

 Strategies for screening and appropriate use of information gained through screening.

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 behavior [16]:

  • 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 patient [16]. 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 safety [16]. 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. 

Case Study

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. 

Referral

Levels of Care

How to identify and select an appropriate resource

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) [17]. 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 different times during their treatment depending on the severity of their symptoms or degree of occupational or social impairment [17]. Levels of care in the mental health system include:

  • Inpatient
  • Residential
  • Partial Hospital
  • Intensive Outpatient
  • Outpatient

Inpatient treatment is the highest, most acute level of nursing and medical services. It is provided in a structured environment 24-hours a day. Patients have full and immediate access to healthcare providers, and they undergo extensive and comprehensive psychiatric treatment. Inpatient treatment may be sought voluntarily by patients or deemed medically necessary by a healthcare provider. Inpatient treatment generally lasts three to seven days [1].

Residential treatment is one level down from inpatient, and it is considered sub-acute. These patients have access to 24-hour skilled nursing care, and they often live on site through their recovery. They usually undergo treatment that combines medication with group and individual psychotherapy [1].

Partial hospitalization refers to an intensive, non-residential settings where patients receive care during the day but return to their home at night. They undergo structured medical and nursing care with services similar to inpatient psychiatric hospitals. Usually, in these settings, the patient receives medication treatment and participant in group psychotherapy [1].

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 [1]. Outpatient care, on the other hand, is the least restrictive form of mental health care. Patients often meet with their mental health provider in an office setting to undergo psychotherapy sessions and medication management [1].

Determining Treatment Setting

After completing a suicide assessment, a qualified mental health clinician can determine the most appropriate level of care [16]. Table 6 offers guidelines for determining the best treatment setting for a particular patient.

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 expresses regret surviving or a persistent internet 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 [16].

Furthermore, inpatient psychiatric hospitalization may also be necessary for the presence of suicidal ideation [16, 17]. If a patient expresses suicidal thoughts and they have a history of previous attempts, the presence of another psychiatric disorder, and limited social support, they may require inpatient treatment. If the patient describes a specific plan with a high lethality, they almost always need hospitalization [17].

Partial hospitalization is appropriate for patients who do not require inpatient treatment but require more intensive services than available in outpatient settings [17]. Because partial hospitalization is highly structured with both nursing and medical services, it is best 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 step-down from inpatient treatment to help patients transition to outpatient treatment [16, 17].

Outpatient mental health services are appropriate if patients are experiencing transient or mild suicidal ideation without a specific plan or intent to attempt [17]. These patients should also have a stable and supportive living situation and be willing to cooperate with recommendations for follow-up. 

Table 6: Guidelines for Determining Treatment Setting [16]

Inpatient treatment recommended

After a suicide attempt or aborted suicide attempt if:

  • The patient is psychotic
  • 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 condition
  • 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:

  • Psychosis
  • Major psychiatric disorder
  • Past attempts
  • Lack of response to or inability to cooperate with 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/or social support, including lack of 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 situation has changed since coming to emergency department
  • Plan/method and intent have low lethality.
  • Patient has stable and supportive living situation.
  • Patient is able to cooperate with recommendations for follow-up.
  • Patient has chronic suicidal ideation without prior medically serious attempts and has a safe and supportive living situation

Involuntary Treatment

After a person has attempted suicide, they often require inpatient psychiatric treatment. Sometimes patients will agree to this treatment, while others will not. The Involuntary Treatment Act governs the psychiatric detainment against the will of the patient in the state of Washington. This law can be found under Title 71.05 of the Revised Code of Washington [65].

In Washington State, anyone who possesses first-hand knowledge of the patient can refer him or her for involuntary psychiatric treatment. A county designated mental health professional such as a psychiatric nurse practitioner or a psychiatrist must see the patient and complete a thorough evaluation. The criteria for commitment include [19]:

  1. The person has a diagnosable mental disorder where mental disorder is defined as any organic, mental, or emotional impairment that has substantial adverse effects on an individual's cognitive or volitional behavior.
  2. The person presents as a danger to self, other, or property, or the person is gravely disabled such that they cannot provide for their basic needs or health.

If the county designated mental health professional determines that a person meets these criteria, they can authorize a 72-hour involuntary detention. The person will be sent to a psychiatric hospital. At a psychiatric hospital, the patient maintains their individual rights and are not presumed incompetent, meaning their information remains strictly confidential. The patient will receive the appropriate treatment.

After 72 hours, the patient can request legal counsel and a court evaluator if he or she remains unwilling to accept treatment on a voluntary basis. The court evaluator is usually a psychologist who will perform an independent assessment as to whether the patient meets the criteria for involuntary commitment. The patient's legal counsel will meet with the patient to represent his or her wishes during a formal hearing, called the Probable Cause Hearing.

During the Probable Cause Hearing, a judge will determine if there is enough evidence to warrant further involuntary treatment. This hearing can result in one of four decisions [19]:

  1. The involuntary treatment petition can be dropped and the patient can be released.
  2. The judge can dismiss the case and the patient can be released.
  3. The judge can maintain the involuntary commitment and the patient can be kept at a psychiatric facility for 14 more days.
  4. The patient can change his or her mind and agree to treatment voluntarily.

If the judge maintains the involuntary commitment, the patient will return to the psychiatric facility for at most 14 more days. If a county designated mental health professional determines the patient needs to remain at the facility even longer, they can file a 90-day petition, and the process starts over. If the judge rules in favor of a 90-day commitment, the patient is transferred to the Western State Hospital (adults) or Fairfax Hospital (children) [65].

Continuity of Care

Continuity of care when making referrals

In 2011, the Suicide Prevention Resource Center (SPRC) collaborated with the Substance Abuse and Mental Health Services Administration (SAMHSA) to review the research on suicide attempts occurring following a patient’s discharge from an emergency department or inpatient psychiatric hospital [20]. They published their findings in a report titled, Continuity of Care for Suicide Prevention and Research.

In their report, both SPRC and SAMHSA found that many lives could be saved by improving the continuity of care between emergency department and psychiatric services [20]. After patients are discharged from the emergency room and inpatient psychiatric hospitals, they must be effectively transitioned to outpatient psychiatric services. Continuity of care refers to linking providers in one setting to providers in another and ensuring that all clinical information is transferred correctly and smoothly [20].

Best practices for connecting a client or patient to a referral

Discharge plans for patients with suicidal thoughts or a recent suicide attempt should include making contact with their outpatient providers. This approach increases the patient's access to follow-up care and reduces their risk of relapse. As discharge plans are established, always consider the particular patient’s barriers to treatment such as financial or transportation challenges. Best practices for connecting a patient to a referral include [20]:

  1. Scheduling the follow-up appointment within one to seven days.
  2. Give the patient crisis contract information such as the phone number for the local crisis center and the National Suicide Prevention website (http://www.suicidepreventionlifeline.org).
  3. Facilitate a phone call between the other provider and the patient, especially if this will be a new provider for the patient.
  4. Create a safety plan that consists of a list of the patient’s coping strategies and their sources of social support. Safety planning is not the same as “Contracts for Safety” or “No-Suicide Contracts,” which have limited research supporting their effectiveness. A safety plan, on the other hand, helps create a dialogue between the patient and clinician to discuss their transition.
  5. Reinforce to the patient the importance of follow-up care. Speak directly to his or her social support so that they know the plan as well.
  6. If you cannot make an appointment with a psychiatric provider refer the patient back to the primary care provider. With the patient’s consent, transmit all clinical information to the primary care provider directly. 

References

[1] Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Synopsis of psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

[2] Centers for Disease Control and Prevention. (2016). Leading Causes of Death. Retrieved from (Visit Source).

[3] Centers for Disease Control and Prevention. (2016). Suicide: Risk and Protective Factors. Retrieved from (Visit Source).

[4] Centers for Disease Control and Prevention. (2016). National Suicide Statistics. Retrieved from (Visit Source).

[5] World Health Organization. (2015). Suicide data. Retrieved from (Visit Source).

[6] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

[7] Suicide Prevention Resource Center. (2014). Suicide Screening and Assessment. Retrieved from (Visit Source).

[8] Department of Veterans Affairs/Department of Defense. (2013). Assessment and Management of Risk for Suicide Working Group. Retrieved from (Visit Source).

[9] U.S. Preventive Service Task Force. (2014). Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care. Retrieved from (Visit Source).

[10] American Psychiatric Association. (2003). Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors. Retrieved from (Visit Source).

[11] American Academy of Pediatrics. (2011). Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System. Retrieved from (Visit Source).

[12] Goldston, D. B. (2000). Assessment of suicidal behaviors and risk among children and adolescents. Bethesda, MD: National Institute of Mental Health.  Retrieved from (Visit Source).

[13] Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The scale for suicide ideation. Washington, DC: American Psychological Association.

[14] Posner, K., Brent, D., Lucas, C., Gould, M., Stanley, B, Brown, G.,... & Mann, J. (2008). Columbia-suicide severity rating scale (C-SSRS). New York, NY: The Research Foundation for Mental Hygiene.

[15] Cutfliffe, J. R. (2004). The nurses’ global assessment of suicide risk: Developing a tool for clinical practice. Journal of Psychiatric and Mental Health Nursing, 11(4): 393-400.

[16] Jacobs, D.G., Baldessarini, R. J., Conwell, Y., Fawcett, J. A., Horton, L., Meltzer, H., … Simon, R. R. (2010). Practice Guideline for the assessment and treatment of patients with suicidal behaviors. American Psychiatric Association:  Arlington, VA.

[17] Gabbard, G. O. (2014). Gabbard’s treatments of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Association.

[18] National Action Alliance for Suicide Prevention. (2012). National Strategy for Suicide Prevention: Goals and Objectives for Action. Retrieved from (Visit Source) [18]

[19] Washington State Legislature. (2015). Revised Code of Washington Title 71.05. Retrieved from (Visit Source).

[20] Suicide Prevention Resource Center. (2011).  Continuity of Care for Suicide Prevention and Research. Retrieved from (Visit Source). 


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Registered Nurse (RN)

Topics:

CPD: Preserve Safety, CPD: Prioritize People, Medical Surgical, Psychiatric


Last Updated: