Assessing and Managing Suicide Risk

ASSESSING SUICIDE RISK

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When patients endorse item 9 on the PHQ, or when they report any thoughts of death or suicide, the provider must follow up with a series of questions around thoughts patients may be having in the past month. Risk levels range from:

• None
• Mild (wishes to be dead)
• Moderate (thoughts of suicide without a specific, detailed plan or intention; or currently wishes to be dead with lifetime history of a suicide attempt)
• High (specific, detailed plan or intention to end one’s life; or any suicidal behavior in the past 3 months).

A thorough and complete assessment of suicidal ideation involves inquiring into each of the below areas in sequential order:

1. Ask about wishes to be dead in the past month
2. Ask about thoughts of suicide or ending one’s life in the past month
3. If reports of any thoughts of suicide in the past month, ask about:
   • Specific detailed plan and intention
   • Suicidal behavior or preparation (over patient’s lifetime and also specifically in the past 3 months)
   • Context and stresses
   • Reasons for living and protective factors
4. Accurately categorize the suicide risk level of the patient

Ineffective or poor strategies to assess suicide risk include:

• Skip ahead, or move on prematurely
• Minimize patient feelings or experiences
• Convey disapproval or negative judgement about patient experience
• Ask questions that lead patient toward denying suicidal thoughts
• Do not inquire specifically about suicidal thoughts in the past month
• Do not ask about suicidal or preparation for both lifetime and past 3 months
• State that will seek out supervisor without completing full suicide risk assessment

MANAGING MILD TO MODERATE SUICIDE RISK

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Providers must take the appropriate actions after they determine suicide risk level to be mild to moderate

A thorough and complete action plan involves addressing each of the below areas:

• Convey that provider will inform Behavioral Health supervisor or PCP to discuss treatment
• State follow up appointment date and importance of regular sessions and ongoing monitoring of risk level
• Help patient identify self-management strategies in response to suicidal thoughts
• Help patient identify family or friends for support, including possible participation in conjoint sessions
• Provide care team numbers, hotline, 911, and 988 if thoughts become more severe
• Discuss importance of keeping environment safe by limiting access to firearms and medications

Ineffective or poor strategies to manage mild to moderate suicide risk include:

• Fail to communicate action plan or reasons for action plan to patient
• Call family member without patient permission
• Convey that patient is at high risk for suicide and will arrange emergency services

MANAGING SEVERE SUICIDE RISK

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Providers must take the appropriate actions after they determine suicide risk level to be high.

A thorough and complete action plan involves addressing each of the below areas:

• Communicate care and concern
• Convey that provider will consult with the Behavioral Health supervisor or PCP, or arrange emergency services to ensure patient safety
• Convey that a care team member will remain with the patient until emergency services arrive

Ineffective or poor strategies to manage severe suicide risk include:

• Convey disapproval or disrespect toward the patient
• Communicate unclear emergency services plan to patient
• Recommend any other action than immediately arranging consultation from the Behavioral Health supervisor or PCP, or emergency services