Positive screens result in a referral to a trained behavioral health expert for a comprehensive assessment. This may involve establishing relationships with local behavioral health providers, including crisis centers.

National Action Alliance for Suicide Prevention

Because risk occurs on a continuum, assessment, management, and referrals are different for each situation. Identifying and supporting at-risk individuals, accessing services, and relying on evidence-based care remain key challenges. Simply improving or expanding services does not guarantee that services will be used, nor will it necessarily increase the number of people who follow recommended referrals or treatment (CDC, 2022).

Washington State has a coordinated approach to suicide prevention, with multiple partners and state agencies utilizing guidance from the Action Alliance for Suicide Prevention (AASP). Formed in 2016, AASP is now the coordinated body that informs policy and programmatic change and makes recommendations for the Washington State Suicide Prevention Plan (WSDOH, 2021).

Any provider with an ethical duty to assess patient safety can initiate the referral process; however, the outcome is dependent on providers with the required legal and medical expertise. In extreme circumstances, if a patient is judged to meet the criteria as a “danger to self”, a legal process can be initiated whereby a patient can be held against their wishes in a locked facility for up to 72 hours. During this time a more in-depth medical assessment is completed, and medication management and other safety strategies are initiated.

If a patient indicates an intention to harm themself, a healthcare provider’s next act is to refer the patient to someone who is licensed to decide about an involuntary hold. In larger healthcare organizations, psychiatric services are directly available. Patients who agree to be hospitalized must be placed in the least restrictive environment. Depending on the level of risk, patients can be held against their wishes. Determining whether a patient is safe (and whether they can be held against their will) is left to providers who are legally licensed to make that determination.

4.1 Connecting Patients to Appropriate Referral Resources

Because many people only seek care when they are in crisis, behavioral health systems must provide 24-hour, 7-day a week availability to individuals trained in assessment, supportive counseling, and intervention. Crisis hotlines, online crisis chat/intervention services, self-help tools, crisis outreach teams and other services can ensure that individuals can obtain help when they need it—eliminating barriers related to cost, distance, and stigma.

National Action Alliance for Suicide Prevention

Screenings and referrals are different for each person and each situation. Although often lacking, specialized services are essential—particularly in situations of unique vulnerability, such as suicidal crises. When the risk of suicide and self-harm is acute, services must be offered in a compassionate manner that honors a person’s human dignity (Liljedahl et al., 2017).

4.2 Actions and Referrals by Level of Risk

For a patient who has recently attempted to harm themself, the period after discharge from an emergency department or acute psychiatric ward is a time of high risk. Support services are critical during this time and reductions in suicide deaths have occurred when patients receive timely treatment and referral services (Crane, 2016).

A range of evidence-based interventions exist that have been shown to reduce the risk of suicide. The interventions are most cost-effective when they target high-risk patients. Unfortunately, it is not clear if providers consistently and accurately identify patients at high risk of suicide based on a clinical interview alone (Nock et al., 2022).

4.2.1 High Acute Risk

High acute risk for suicidal ideation and behaviors means a patient has serious thoughts of suicide, a plan, a recent suicide attempt, preparatory behaviors, acute major mental illness, or exacerbation of a personality disorder. In such cases, direct observation and monitoring is critical before arranging immediate transfer for psychiatric evaluation or hospitalization (DVA, 2019).

A person with high risk may be in danger of acting on suicidal impulses when they experience some “last straw,” some unbearable insult or burden that seems to make life unlivable. When a person is in this state of mind, external controls may be needed to prevent a suicidal act. Some interventions, such as restricting access to the means of completing a suicidal act may be necessary. This may prevent a fatal act but does not resolve the suicidal impulse or crisis (DVA, 2019).

Transitions in care are particularly high-risk periods. These transitions include the initial diagnosis with a mental condition, initiation of psychotropic medication, discharge from the hospital, and having a recent life-changing event. Identifying who might be at high risk for self-harm or suicide is challenging; clinicians cannot foresee which patients will act upon suicidal thoughts (Balbuena et al., 2022).

A study of nearly 2,000 patients found that prediction of suicide attempts in the 1 month and 6 months after a patient visited an emergency department was significantly improved using machine learning models applied to data from a brief patient self-report scale, especially when supplemented with data from patients’ electronic health records and/or clinicians’ assessments. This study suggests that clinicians can improve their ability to identify patients at high risk of suicide by using data from a brief patient self-report scale and electronic health records (Nock et al., 2022).

4.2.2 Intermediate Acute Risk

Intermediate acute risk includes patients with suicidal ideation and a plan but with no intent. These individuals may present similarly to those at high acute risk and share many of the same features. The only difference may be lack of intent, based upon an identified reason for living (e.g., children), and ability to abide by a safety plan and maintain their own safety. Preparatory behaviors are likely to be absent (DVA, 2019).

Patients at this level of risk should be evaluated by a behavioral health provider and include treatment of co-occurring mental health conditions. Psychiatric hospitalization may be needed if related risk factors are responsive to inpatient treatment (e.g., acute psychosis). Outpatient management of suicidal thoughts or behaviors should be intensive and include frequent contact, regular re-assessment of risk, and a well-designed safety plan (DVA, 2019).

4.2.3 Low Acute Risk

Low acute risk patients are those with recent suicidal ideation who have no current suicidal intent, no current or specific suicidal plan, no recent preparatory behaviors, and high confidence that the patient and family can maintain safety. Individuals may have suicidal ideation, but it will be with little or no intent or specific current plan (DVA, 2019).

If a plan is present, the plan is usually general or vague, without any associated preparatory behaviors (e.g., “I’d shoot myself if things got bad enough, but I don’t have a gun”). These patients are capable of engaging appropriate coping strategies and are willing and able to utilize a safety plan in a crisis (DVA, 2019).

Low acute risk patients can usually be managed in primary care. Outpatient mental health treatment may be indicated, particularly if suicidal ideation and co-occurring conditions exist (DVA, 2019).

4.3 Challenges to Overcome

A gap in all many guidelines is the lack of inclusion of patient-driven safety plans to identify supports, resources, and coping strategies. Another gap in most guidelines is the omission of outpatient intervention safety strategies such as restricting access to lethal means (Harmer et al., 2022).

Continuity of care is a critical part of management and is often lacking. Effective clinical care includes monitoring patients for a suicide attempt after an ED visit or hospitalization and providing outreach, mental health follow-up, therapy, and case management.