About Suicide in Washington State, 3 unitsPage 6 of 11

4. Referral

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

Suicidal ideation and behavior occurs on a continuum, beginning with suicidal thoughts, evolving into a wish to die, consolidated into an intention to act, and resulting in a plan to end one’s life. The evolution of these steps can occur over minutes or years. Each step along the continuum provides an opportunity for intervention and referral. The first opportunity to intervene often occurs because of warning signs that are identified by a healthcare provider, caregiver, gatekeeper, or loved one (DVA/DOD, 2013).

Any provider with an ethical duty to assess client safety can initiate the referral process; however the outcome is dependent on providers with the legal and medical expertise required. If clients are referred for hospitalization and agree to be hospitalized, they must be placed in the least restrictive environment.

In extreme circumstances, if a client is judged to meet the criteria as a “danger to self,” a legal process can be initiated whereby a client can be held against his or her wishes in a locked facility for up to 72 hours. During this time a more thorough medical assessment is completed and medication management and other safety strategies are initiated.

For providers working in large healthcare organizations, psychiatric services are usually readily available. High-risk clients might be admitted to inpatient care; those at intermediate and low acute risk may be referred to an outpatient care setting. With appropriate support and safety plans, lower risk clients may be able to be followed up in the community (DVA/DOD, 2013).

Key Point

All health and behavioral health organizations should have specific written policies and procedures focused on the detection and response to persons presenting for care with suicide risk. Staff must be trained on how to employ the policies and procedures, with regular (eg, annual) scheduled refreshers.

Source: National Alliance for Suicide Prevention, 2011.

Connecting Clients to Appropriate Referral Resources

Because many persons seek care only when they are in crisis, behavioral health systems must provide 24-hour, 7-day 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

Screening and referral 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).

If you have clients (or are providing medications to clients) who have recently attempted to harm themselves, keep in mind that the period after discharge from an emergency department or acute psychiatric ward is a time of high risk when support services are critical. During this time, a client will likely come in contact with many outpatient service providers who do not have easy access to psychiatric services. For this reason, it is imperative that each organization or agency have policies and procedures in place outlining what to do if a screen indicates a client is at risk of self-harm.

Reductions in subsequent suicide deaths have occurred by engaging clients in timely treatment and referral services after discharge from the ED. Adults who receive medical care immediately after a suicide attempt are more likely to receive mental health treatment compared to those who did not receive medical care (Crane, 2016).

Following discharge from an ED, hospital, or mental health facility, a client typically comes in contact with a variety of outpatient healthcare providers. This can include pharmacists, physical therapists, psychologists, occupational therapists, and other healthcare providers. Each provider must be prepared to ask their client about suicide and be ready to refer if needed. At a minimum, providers must have contact information for local and national suicide hotlines.

Referrals by Level of Risk

The majority of identified suicidal patients are referred to acute or crisis settings (usually the nearest hospital emergency department) for assessment and care by mental health providers. In an urgent or emergent high-risk crisis situation, the primary purpose of clinical evaluation is to make a determination that balances risk and protective factors. Can the patient be discharged with an adequate safety plan? Does the patient require admission to a higher level of care, on either a voluntary or an involuntary basis (DVA/DOD, 2013)?

For high acute risk clients, providers should ensure constant observation and monitoring before arranging for immediate transfer for psychiatric evaluation or hospitalization. This may prevent a fatal act, but does not necessarily resolve the suicidal impulse or crisis (DVA/DOD, 2013).

Intermediate acute risk clients with suicidal ideation and a plan but with no intent or preparatory behavior should be evaluated by a behavioral health provider. The decision whether to urgently refer a client to a mental health professional or emergency department depends on the client’s presentation. If closer evaluation reveals that the level of illness or other clinical findings warrant a higher level of care, the patient may be hospitalized. If, in conjunction with the provider, a client feels he or she is capable of maintaining safety using non-injurious coping methods and a safety plan, the patient may be managed in outpatient care (DVA/DOD, 2013).

For low acute risk clients who have no specific plans or intent to engage in lethal self-directed violence and have no history of active suicidal behavior, consider consultation with a behavioral health specialist to determine the need for referral to treatment that will address symptoms and safety issues (DVA/DOD, 2013).

If a client is not at an elevated risk for suicide, there is no indication to consult with behavioral health specialists, and the client should be followed in routine care, continue to receive treatment for their disorder, and be re-evaluated periodically for thoughts and ideation (DVA/DOD, 2013).

Source: (VA/DOD, 2013).

Level of Risk and Appropriate Action in Primary Care

Risk of suicide attempt

Indicators of suicide risk

Contributing factors†

Initial action based on level of risk

High acute risk

  • Persistent suicidal ideation or thoughts
  • Strong intention to act or plan
  • Not able to control impulse or
  • Recent suicide attempt or preparatory behavior††

Acute state of mential disorder or acute psychiatric symptoms

  • Acute precipitating event(s)
  • Inadequate protective factors
  • Maintain direct observational control of the patient
  • Limit access to lethal means
  • Immediately transfer with escort to Urgent/ED care setting for hospitalization

Inter-mediate acute risk

  • Current suicidal ideation or thoughts
    • No intention to act
    • Able to contol the impulse
  • No recent attempt or prepratory behavior or rehearsal of act
  • Existence of warning signs or risk factors†† and
  • Limited protective factors
  • Refer to Behavioral Health provider for complete evaluation and interventions
  • Contact Behavioral Health provider to determine acuity of referral
  • Limit access to lethal means

Low acute risk

  • Recent suicidal ideation or thoughts
  • No intention to act or plan
  • Able to contol the impulse
  • No planning or rehearsing a suicide act
  • No previous attempt
  • Existence of protective factors and
  • Limited risk factors
  • Consider consultation with Behavioral Health to determine:
    • Need for referral
    • Treatment
  • Treat presenting problems
  • Address safety issues
  • Document care and rationale for action

†Modifiers that increase the level of risk for suicide of any defined level:

  • Acute state of substance use: Alcohol or substance abuse history is associated with impaired judgment and may increase the severity of the suicidality and risk for suicide act
  • Access to means: (firearms, medications) may increase the risk for suicide act
  • Existence of multiple risk factors or warning signs or lack of protective fact

††Evidence of suicidal behavior warning signs in the context of denial of ideation should call for concern (e.g., contemplation of plan with denial of thoughts or ideation).

Daniel Breaks His Sobriety

Daniel is a 42-year-old male who was referred to occupational therapy following a motor vehicle accident in which he broke his right femur and left clavicle. He is non-weight bearing on his right leg and is using a wheelchair to get around. Daniel is participating in OT in order to regain strength, for treatment of his left upper extremity, and for assessment of his activities of daily living (ADLs).

During the subjective evaluation, Daniel tells you that after the accident his work truck was impounded and he lost his driver’s license. He tells you that he was also arrested for driving under the influence. Additionally he struck another vehicle and the driver of the other car broke her hip and sustained a severe concussion.

Daniel expresses tremendous guilt because another person was injured. He expresses remorse for drinking after being sober for more than two years. He says he doesn’t know how he’ll be able to pay his bills and is worried about his health insurance. His says that his wife has asked for a divorce and is kicking him out of the house as soon as he is able to walk.

Daniel tells you that he feels depressed, hopeless, and angry and finds no pleasure in life. He is unable to work, has lost his truck, and (despite saying that he loves his 9-year-old daughter) says he wishes he had never impregnated his wife. He says he feels this way every day. He marks a 3 on both PHQ2 screening questions. He tells you “I’m not sure if it’s worth it anymore.”

He tells you he has thought about ending his life in the past but has never acted on this thought. In response to your question, “What stopped you from acting on these thoughts in the past?” He replies, “My daughter—I don’t want to hurt her.”

Screen Results

Your clinic screens all clients for suicide, knowing that injuries and illness increase the risk of depression, which can lead to an increased risk of suicidal ideation and behaviors. Your clinic uses a screening tool called the Patient Health Questionaire-2 (PHQ2). It is clinic policy to repeat this screening at the beginning of each of Daniel’s visits.

Your hospital-based clinic has an established protocol for identifying staff responsibilities and procedures for responding to PHQ2 scores. The results are reviewed by the team (primary care provider and behavioral health staff). This is then embedded into the electronic health record as part of the standard care delivery process.

What Action Should You Take?

Because Daniel provides a positive answer to both of the PHQ2 screening questions, you decide to:

  1. Make an appointment for him the next day to make sure he’s doing okay.
  2. Call social services and ask for a more thorough evaluation.
  3. Reassure him that he’s okay and send him home.
  4. Chart the results of the PHQ2 and continue with your treatment.

Answer: b


Your role is to screen your client and determine whether there is a need for immediate referral. You must be familiar with the resources available in your area. Your hospital has mental health services directly available so you make an immediate referral to social services. You assign an aide to sit with Daniel in a quiet room until a social worker arrives.

If Daniel is at immediate risk of harming himself, he can be held against his will. However, only police and mental health workers or providers with specialized training can detain Daniel against his will. Police can hold Daniel until a crisis worker arrives and can transport him to a psych facility, if needed. Because of Daniel’s expressed anger toward his wife, you decide that asking a family member to transport Daniel to the emergency department is not a good idea.

A social worker arrives and escorts Daniel to a quiet room. You follow up later in the day and learn that Daniel has voluntarily admitted himself to the hospital’s inpatient psych unit.

Referral Resources

Providers should be familiar with community agencies, mental health organizations, senior services, veterans support groups, and peer support programs. These programs foster a sense of connection and belonging and provide critically needed services, including employment and vocational help, housing assistance, and social interactions that are not focused on illness (HHS, 2012). Cooperation, collaboration, and communication are critical components of patient referral and recovery.

Recognition and referral training— also called gatekeeper training—plays a critical role in suicide prevention. It teaches educators, coaches, clergy, as well as emergency responders, primary and urgent care providers, pharmacists, allied health professionals, and others in the community how to identify and refer people who may be at risk of suicide (WSDOH, 2016).

Recognition and referral training can be a valuable training tool even for a provider who already has mental health training. It provides additional education, support, access to resources, and opportunities to practice assessment skills. Despite the comorbidity of mental health disorders and suicide, the vast majority of mental health professionals—a group that includes psychiatrists, psychologists, social workers, licensed counselors, and psychiatric nurses— do not typically receive routine training in suicide assessment, treatment, or risk management (AFSP, 2016).

Crisis lines provide immediate access, often 24 hours a day, to crisis intervention. They are an access point for emergency care, clinical assessment, referral, and treatment. When other providers are closed and personal support networks are unavailable, crisis lines can be a lifeline for people at risk of suicide (WSDOH, 2016).

image: National Suicide Prevention Lifeline logo


In an evaluation of the effectiveness of the National Suicide Prevention Lifeline to prevent suicide, more than a thousand suicidal individuals who called the hotline completed a standard risk assessment for suicide, and 38% of those completed a followup assessment between 1 and 52 days after the initial assessment (Stone et al., 2017).

Researchers found that over half of the initial sample was seriously considering suicide when they called, and they had a plan for their suicide. Among followup participants, there was a significant decrease in psychological pain, hopelessness, and intent to die between initiation of the call (time 1) to followup (time 3). Between time 2 (end of the call) to time 3, the effect remained for psychological pain and hopelessness, but was not significant for intent to die, suggesting that greater effort at outreach during and following the call is needed for callers with high levels of suicide intent (Stone et al., 2017).

The Veterans Crisis Line provides specially trained and experienced responders to help veterans of all ages and circumstances. Since its launch in 2007, the Veterans Crisis Line has answered nearly 2.8 million calls and initiated the dispatch of emergency services to callers in crisis nearly 74,000 times. An anonymous online chat service, added in 2009, has engaged in more than 332,000 chats. In November 2011, the Veterans Crisis Line introduced a text-messaging service to provide another way for veterans to connect with confidential, round-the-clock support, and since then has responded to more than 67,000 texts (DVA, nd).

banner for Veterans Crisis Line

Source: Department of Veterans Affairs.

New technologies have created new possibilities for suicide prevention and referral. For some mental health problems, such as depression, online tools and mobile applications provide resources for self-help, which can detect symptoms of distress and offer contact to hotlines or referral to other resources (Pauwels et al., 2017).

Online and mobile tools can be used along with traditional medical treatments and can be helpful for those who are reluctant or unable to find professional treatment. These tools provide an additional source of support and can lower the barrier to seeking professional help. Online tools and programs for suicide prevention create new possibilities due to their discretion, accessibility, availability, and low cost, which are important barriers for help seeking (Pauwels et al., 2017).

The Importance of Continuity of Care

Caring for suicidal persons requires that the suicidal risk be addressed directly, not merely as a symptom of an underlying disease. That care will most likely require multiple levels of services in a team environment. Discharge decisions from one level of care must incorporate linkages to other necessary levels of care. Organizations must recognize, accept, and implement shared service responsibilities both among various clinical staff within the organization and among providers in the larger community.

National Action Alliance for Suicide Prevention

Once a referral is made, care transitions and continuity of care are very important. The risk of suicide is 3 times as likely (200% higher) the first week after discharge from a psychiatric facility and continues to be high, especially within the first year and through the first four years after discharge (JC, 2016). The risk is particularly high in the weeks and months following the attempt, including the period after discharge from acute care settings and inpatient psychiatric units. Having survived a suicide attempt is one of the most significant risk factors for later death by suicide (HHS, 2012).

If a referral results in admission to an inpatient mental health unit, followup mental health services after discharge are important, as well as connections to community-based supports. Healthcare providers should seek to shorten the time between inpatient discharge and followup outpatient treatment. For example, EDs and others providing services should set a goal of ensuring that followup occurs within 48 hours or, at most, within a week of discharge (HHS, 2012).

If acute inpatient care is not needed, each at-risk client should be informed about risks and be referred to mental health services. Although referral is necessary, it may not be sufficient. There is increasing evidence that specific outreach programs are highly effective in increasing the proportion of patients who engage in mental health care after hospitalization (HHS, 2012).

Strategies to improve continuity of care may include telephone reminders of appointments, providing a “crisis card” with emergency phone numbers and safety measures, or sending a letter of support. Motivational counseling and case management can also be used to promote adherence to the recommended treatment (HHS, 2012). Unfortunately, many clients with high suicide risk are not referred for followup care, receive only limited mental health services, and may not receive adequate treatment for underlying mental health or substance use disorders.