Suicide Screening and Referral Training for Washington - 3 Hour

Men are four times more likely to die by suicide than women, regardless of age, race, religion, or marital status (Boland et al., 2021). 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.

The rate of suicide increases as a person ages. Before puberty, suicide is extremely rare. For men, suicide rates are highest at age 45; women 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 cause of death for those aged 15 to 24 years, followed by accidents and homicides (Boland et al., 2021).

Caucasian men and women are three times more likely to die by suicide than African American men and women. Native American and Alaskan Native youth experience suicide rates much higher than the national average (Suicide Prevention Resource Center, n.d.). Rates among immigrants are higher than those among citizens (WHO, 2021). 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 (Boland et al., 2021).

Married individuals with children are much less likely to die by suicide than single persons. Single, never-married individuals experience double the suicide rate compared with married persons (CDC, 2022). Divorce increases the risk of suicide; divorced men are three times more likely to die by 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 (Boland et al., 2021).

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 providers, artists, mechanics, lawyers, and insurance agents. Unemployed persons are more likely to die by suicide than their employed counterparts. Suicide rates increase during economic recessions and decrease during economic booms (Boland et al., 2021).

Over 30 percent of people who die by 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 (Boland et al., 2021).

Individuals who suffer from serious mental illness, including major depression, schizophrenia, and bipolar disorder, are at an increased risk for suicide (American Psychiatric Association, [APA] 2020; Boland et al., 2021). According to Serious Mental Illness (SMI) Adviser research data reviewed by the APA and the Suicide Prevention Resource Center, the rate of death by suicide for people with severe mood disorders, as mentioned above, is estimated to be 25 times higher than the rate for the general population (APA, 2020).

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 (Suicide Prevention Center, 2014):

• The Department of Veterans Affairs/Department of Defense (V.A./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 V.A./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.” (Department of Veterans Affairs/Department of Defense, 2019). Also, the U.S. Preventive Service Task Force concluded that suicide screens often elicit a high rate of false positives, rendering them ineffective when used independently from a comprehensive assessment conducted by a professional (U.S. Preventive Service Task Force, 2014).

Screening for suicide using questionnaires can be useful when used in addition to a comprehensive suicide assessment. When choosing a suicide screen, consider the following (American Psychiatric Association [APA], 2020; Roaten et al., 2018; Jacobs et al., 2010):

• Has this screen been researched and validated?
• 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 laypersons)?

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 (Jacobs et al., 2010). These domains are summarized in Table 4.

*Note: Although the aforementioned citation is from 2010, this clinical practice guideline is the most up-to-date practice guideline available for the assessment and treatment of patients demonstrating suicidal behaviors directly from the American Psychiatric Association (APA) as of February 2022.*

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: (Jacobs et al., 2010)

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

Clinicians should begin by assessing the current signs and symptoms of psychiatric disorders (Jacobs et al., 2010). They should pay close attention to signs of a depressive disorder and note any high-risk characteristics. Clinicians should document previous psychiatric hospitalizations along with prior treatment for substance use disorders (Boland et al., 2021). 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 (Boland et al., 2021). Do not forget that a prior 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 (Jacobs et al., 2010).

Clinicians should also inquire about the patient's family history. Family dysfunction is linked to suicide and other self-harming behaviors (Boland et al., 2021). 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 (APA, 2020).

Next, the clinicians should assess the patient's current psychosocial situation (Jacobs et al., 2010). 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 (Jacobs et al., 2010).

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 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 a week?" "So, you have three, four-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. The use of street drugs such as heroin, cocaine, hallucinogens, methamphetamine, and inhalants should be questioned.
• Remember to ask how much, how often, length of use pattern, and the last time each substance was used. Route of administration is also essential, 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 (A.A.), Narcotics Anonymous (N.A.), other twelve-step programs, addiction treatments, detoxifications, or periods of abstinence from the substance. Of particular 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 beneficial information when treatment for their substance use disorder begins.
• 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 are at an increased risk of exhibiting polarized thinking, closed-mindedness, perfectionism, and excessively high self-expectations (Jacobs et al., 2010).

Healthcare providers must directly ask patients about suicidal thoughts, plans, and behaviors; however, cultural and religious beliefs about death and suicide may prevent a patient from speaking openly about his or her thoughts. In this case, clinicians must seek collateral sources such as spouses, friends, family members, clergy, or other healthcare providers (Jacobs et al., 2010). Table 5 includes a list of questions that clinicians can use when inquiring about different aspects of suicide. Clinicians should follow these steps:

(Jacobs et al., 2010)

• 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 critical components of the management of suicidal behavior: (APA, 2020).

• 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 (Jacobs et al., 2010). 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 (Jacobs et al., 2010).

Next, the clinician must attend to the patient's safety (Jacobs et al., 2010). Throughout the suicide assessment, the clinician may need to intervene directly 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 another clinician or closed-circuit television (Jacobs et al., 2010).

After developing a therapeutic alliance and attending to the patient's safety, the clinician must select the most appropriate treatment setting. Patients should always be treated in the least restrictive yet safest, most effective setting (Boland et al., 2021). Table 6 provides the guidelines for determining when a patient needs inpatient psychiatric treatment (Jacobs et al., 2010).

Admission to an inpatient psychiatric hospital is usually indicated after a suicide attempt or an aborted suicide attempt (Jacobs et al., 2010). 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 (Jacobs et al., 2010).

Next, clinicians must develop a treatment plan (Jacobs et al., 2010). The 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 closely monitor the patient 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. Family members need to understand that psychiatric disorders are real and complex 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. Jack has a history of one suicide attempt in his 30s after the death of his mother. 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.

How should the health professional respond? In this scenario, Jack has expressed to both his wife and the clinician that he wants to kill himself. He also has a highly lethal means—a gun—and appears to have limited social support. Recent traumatic life experiences and a history of a suicide attempt also increase his risk. Collectively, his risk and history indicate a need for inpatient hospitalization.

Continue reading to learn more about referral and determining the level of care.

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). 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. Levels of care in the mental health system include:

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

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 providers and undergo extensive and comprehensive psychiatric treatment. Inpatient treatment may be sought voluntarily by patients or deemed medically necessary by a healthcare provider. It generally lasts three to seven days.

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 onsite throughout their recovery. They usually undergo treatment that combines medication with group and individual psychotherapy.

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 those of inpatient psychiatric hospitals. Usually, in these settings, the patient receives medication treatment and participates in group psychotherapy.

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. Outpatient care, on the other hand, 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.

After completing a suicide assessment, a qualified mental health clinician can determine the most appropriate level of care (Jacobs et al., 2010). 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 for 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 (Jacobs et al., 2010).

Furthermore, inpatient psychiatric hospitalization may also be necessary for the presence of suicidal ideation (Jacobs et al., 2010; Gabbard, 2014). If a patient expresses suicidal thoughts and has 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 high lethality, they almost always need hospitalization (Gabbard, 2014).

Partial hospitalization is appropriate for patients who do not require inpatient treatment but require more intensive services than available in outpatient settings (Gabbard, 2014). 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 a step-down from inpatient treatment to help patients transition to outpatient treatment (Jacobs et al., 2010, Gabbard, 2014).

Outpatient mental health services are appropriate if patients experience transient or mild suicidal ideation without a specific plan or intent to attempt (Gabbard, 2014). These patients should also have a stable and supportive living situation and be willing to cooperate with follow-up recommendations.

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 (Washington State Legislature, 2015).

Anyone who possesses first-hand knowledge of the patient can refer him or her for involuntary psychiatric treatment in Washington State. 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: (National Action Alliance for Suicide Prevention, 2012)

1. The person has a diagnosable mental disorder where a mental disorder is defined as any organic, mental, or emotional impairment that has substantial adverse effects upon an individual's cognitive or volitional behavior.
2. The person presents as a danger to self, others, 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 this criterion, they can authorize 72-hour involuntary detention. The person will be sent to a psychiatric hospital. At a psychiatric hospital, patients maintain their 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 voluntarily. The court evaluator is usually a psychologist who will independently assess 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: (National Action Alliance for Suicide Prevention, 2012)

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 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).

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 (Suicide Prevention Resources Center, 2011). 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 the emergency department and psychiatric services (Suicide Prevention Resources Center, 2011). 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 (Suicide Prevention Resources Center, 2011).

Best practice for contacting patients

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 the 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: (The Joint Commission, 2019; Suicide Prevention Resources Center, 2011)

1. Scheduling the follow-up appointment within one to seven days.
2. Give the patient crisis contact information, such as the phone number for the local crisis center and the National Suicide Prevention website.
3. Facilitate a phone call between the other provider and the patient, especially if this is the patient's first provider.
4. Create a safety plan that includes a list of the patient's coping strategies and 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. On the other hand, a safety plan 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 directly to the primary care provider.