About Suicide in Washington State, 6 unitsPage 7 of 13

5. Management of Suicide Risk

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Effective management of mental health conditions (particularly major depression) can reduce the risk of suicide and may decrease suicide rates. This includes improving access to mental health services, counseling and other psychosocial services, encouraging use of crisis lines, and pharmaceutical treatments (discussed in Module 6). It is important that intervention and treatment be direct and specific to address potential risk factors (DVA/DOD, 2013).

Because suicide attempts are known to be a strong predictor of future attempts and deaths by suicide, continuity of care is critical. Effective clinical care should include monitoring patients for a suicide attempt after an ED visit or hospitalization and providing outreach, mental health followup, therapy, and case management.

In response to the high incidence of suicides, recent attention has focused on prevention. In the United States, suicide prevention strategies include physician education, lethal means restriction, pharmacotherapy, gatekeeper education, and psychotherapy. The success of these strategies has varied considerably. Physician education, lethal means restriction, and gatekeeper education have had the greatest impact on decreasing suicide rates (Hassamal et al., 2015).

Improving Access to Mental Health Services

Unfortunately, although most Washingtonians have some form of health insurance, nearly half of the population faces barriers to healthcare services because of geography and income challenges. Limited access to transportation as well as difficulty accessing physical and behavioral healthcare services increases risk and reduces community integration and wellbeing (WSDOH, 2016).

Mental Health Professional Shortage Areas

About 75% of Washington State is considered a Mental Health Professional Shortage Area by federal standards. More than 90% of the state is eligible for federal funding to recruit and retain primary care providers.

Affordable and accessible mental and general healthcare is critical to reducing suicide and must be taken into account.

Source: WSDOH, 2016.

The way behavioral healthcare is provided in Washington is changing rapidly under the Healthier Washington Initiative. Legislation has been passed directing the state to integrate the payment and delivery of physical and behavioral health services under Medicaid by 2020. Chemical dependency services have been available under managed care since 2016 (WSDOH, 2016).

Psychosocial Interventions

Many types of psychosocial interventions are beneficial for individuals who are experiencing suicidal ideation or behaviors. Psychotherapy is one type of psychosocial intervention that has been shown to reduce suicide risk. It can help people learn new ways of dealing with stressful experiences, recognize patterns of thinking, and identify alternative actions when thoughts of suicide arise (NIH, 2017).

Psychotherapy usually takes place in a one-on-one or group format and can vary in duration from several weeks to ongoing therapy, as needed. Treatment that employs collaborative and integrated care can engage and motivate patients, increasing retention in therapy and decreasing suicide risk (Stone et al., 2017). Other psychosocial interventions are described in the following case.

The Importance of Therapy: Terry


On the morning of December 25, 2000, Terry Wise tried to kill herself by taking an overdose of Tylenol. She awoke two days later in the intensive care unit.

Assessment in the ICU

In the ICU, Terry received an evaluation from a social worker. Terry reported that the death of her husband from Lou Gehrig’s disease was a trigger for her suicide attempt. She said she felt lost, didn’t know what to do, and found no joy in living. During this initial assessment, Terry admitted that her attempt was the culmination of years of depression and other problems that started in her childhood. She said she was overwhelmed by an intense emotional pain that had been building for years, and when her husband died the pain became unbearable.


Certain groups have higher suicide attempt or completion rates than the general population. Terry has likely been living with clinical depression most of her adult life. Along with this suicide attempt, the death of her husband and her stated history of depression, Terry may be at increased risk for self-harm.

What Actions Should You Take?

Because suicide attempts are known to be a strong predictor of future attempts and deaths by suicide, continuity of care is critical.

Test Your Learning

Once Terry is ready to be released from the ICU, what will help her the most?

  1. Encouraging her to start dating again.
  2. Admitting her to a psychiatric hospital for a short time against her will.
  3. Making sure she doesn’t have access to a gun.
  4. Referral to mental health services, counseling, and pharmaceutical treatments.

Correct answer: d

Mental Health Services

Terry agreed to start therapy, and ultimately it changed her life. By working with a counselor, Terry realized that the trauma she experienced when she was younger still affected her emotions as an adult. Her counselor helped her find ways to cope with her feelings. Therapy also allowed her to see how others would have reacted to her death by suicide. Most important, Terry’s therapist trusted her and respected her and, for Terry, her therapist’s compassion made a huge difference.

Bottom Line

It is important that Terry’s intervention and treatment be direct and specific to address potential risk factors. Effective management of mental health conditions (particularly major depression) can reduce the risk of suicide and may decrease suicide rates.

Terry’s recovery was a process. It took time and hard work. She recalls: “And that is really the first step, to go from feeling that life is an endurance test to being able to tolerate being alive. And then you hope that the unendurable becomes bearable. Then you hope the bearable becomes manageable. Then you hope the manageable becomes pleasurable. And so it’s a process. It evolved over time.”

Source: Adapted from SAMSHA, 2015b.

Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP)

Cognitive Behavior Therapy for Suicide Prevention (CBT-SP) is a therapeutic approach aimed at preventing re-attempts. It uses a risk-reduction, relapse prevention approach that includes an analysis of risk factors and stressors (eg, relationship problems, school or work-related difficulties) leading up to and following the suicide attempt; safety plan development; skill building; and psycho-education (Stone et al., 2017).

CBT-SP also has family skill modules focused on family support and communication patterns as well as on improving the family’s problem-solving skills. A randomized controlled trial utilizing CBT-SP found that 10-session outpatient cognitive therapy designed to prevent repeat suicide attempts resulted in a 50% reduction in the likelihood of a suicide re-attempt relative to treatment as usual among adults who had been admitted to an emergency department for a suicide attempt (Stone et al., 2017).

Dialectical Behavioral Therapy (DBT)

Dialectical Behavioral Therapy (DBT) is a multi-component therapy for individuals at high risk for suicide and who may struggle with impulsivity and emotional regulation issues. DBT includes individual therapy, group skills training, between-session telephone coaching, and a therapist consultation team. In a randomized controlled trial of women with recent suicidal or self-injurious behavior, those receiving DBT were half as likely to make a suicide attempt at the two-year followup than women receiving community treatment. The women also required less hospitalization for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined (Stone et al., 2017).

DBT has been shown to reduce the rate of suicide among people with borderline personality disorder, a mental illness characterized by unstable moods, relationships, self-image, and behavior. A therapist trained in DBT can help a person recognize when his or her feelings or actions are disruptive or unhealthy, and teach the skills needed to deal better with upsetting situations (NIH, 2017).

Improving Mood—Promoting Access to Collaborative Treatment (IMPACT)

TheImproving Mood—Promoting Access to Collaborative Treatment (IMPACT) program aims to prevent suicide among older primary care patients by reducing suicide ideation and depression. IMPACT facilitates the development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, as well as proactive followup (biweekly during an acute phase and monthly during continuation phase) by a depression care manager. The program has been shown to significantly improve quality of life, and to reduce functional impairment, depression and suicidal ideation over 24 months of followup relative to patients who received care as usual (Stone et al., 2017).

Collaborative Assessment and Management of Suicidality (CAMS)

Collaborative Assessment and Management of Suicidality (CAMS), is a therapeutic approach for suicide-specific assessment and treatment. The program’s flexible approach involves the clinician and patient working together to develop patient-specific treatment plans. Sessions involve constant patient input about what is (and is not) working with the goal of enhancing the therapeutic alliance and increasing treatment motivation in the suicidal patient (Stone et al., 2017).

CAMS has been tested and supported in six correlational studies, in a variety of inpatient and outpatient settings, and in one randomized controlled trial (RCT) with several additional RCTs under way. A feasibility trial with a community-based sample of suicidal outpatients randomly assigned to CAMS or enhanced care as usual (intake with a psychiatrist or psychiatric nurse practitioner followed by 1 to 11 visits with a case manager and medication as needed) found better treatment retention among the CAMS group and significant improvements in suicidal ideation, overall symptom distress, and feelings of hopelessness at the 12-month followup (Stone et al., 2017).

Attachment-Based Family Therapy (ABFT)

Attachment-Based Family Therapy (ABFT) is a program for adolescents aged 12 to 18 designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety. An RBT using ABFT found that suicidal adolescents receiving ABFT experienced significantly greater improvement in suicidal ideation over 24 weeks of followup than did adolescents assigned to enhanced usual care. Additionally, a significantly higher percentage of ABFT participants reported no suicidal ideation in the week prior to assessment at 12 weeks and again at 24 weeks than did adolescents receiving enhanced usual care (Stone et al., 2017).

Gatekeeper Training

Gatekeeper training—also called “recognition and referral training”—helps people without formal psychosocial training play a critical role in suicide prevention. It teaches educators, coaches, clergy, emergency responders, primary and urgent care providers, and others in the community to identify people who may be at risk of suicide. It provides information on how to respond, including encouraging the at-risk person to seek treatment and support services. Research shows that many at-risk people turn to family or friends for help. They often show warning signs that family and friends may notice first. An at-risk person benefits from an informed support network ready to connect them to the right help (WSDOH, 2016).

A Note on Language

Training on recognizing a person at risk and connecting them to an appropriate resource is often called gatekeeper training. In some communities, the word gatekeeper is a reminder of people and systems that create barriers to getting help. Instead, the Washington State Department of Health recommends the term Recognition and Referral (R&R) training.

Source: WSDOH, 2016.

One closely studied gatekeeper program, Applied Suicide Intervention Skills Training (ASIST), helps hotline counselors, emergency workers, and other gatekeepers identify and connect with suicidal individuals and direct them to available resources. In an RCT, researchers evaluated the training across the National Suicide Prevention Lifeline network of hotlines during 2008–2009. Using data from 1,410 suicidal individuals who called 17 Lifeline centers, researchers found that callers who spoke with ASIST-trained counselors were significantly more likely to feel less depressed, less suicidal, less overwhelmed, and more hopeful by the end of their call, compared to callers who spoke to non-ASIST trained counselors. Counselors trained in ASIST were also more skilled at keeping callers on the phone longer and establishing a connection with them (Stone et al., 2017).

Gatekeeper training has been a primary component of the Garret Lee Smith (GLS) Suicide Prevention Program, which has been implemented in 50 states and 50 tribes. A multi-site evaluation assessed the impact of community gatekeeper training on suicide attempts and deaths by comparing the change in suicide rates and nonfatal suicidal behavior among young people aged 10 to 24 in counties implementing GLS trainings, with the trajectory observed in similar counties that did not implement these trainings. Counties that implemented GLS trainings had significantly lower youth suicide rates one year following the training implementation. This finding equates to a decrease of 1 suicide death per 100,000 youth ages 10 to 24, or the prevention of approximately 237 deaths in the age group, between 2007 and 2010 (Stone et al., 2017).

Counties implementing GLS program activities also had significantly lower suicide attempt rates among youth ages 16 to 23 in the year following implementation of the GLS program than did similar counties that did not implement GLS activities. More than 79,000 suicide attempts may have been prevented during the period examined (Stone et al., 2017).

Crisis Lines

Crisis intervention programs provide support and referral services, typically by directing a person in crisis (or a friend or family member of someone at risk) to trained volunteers or professional staff via telephone hotline, online chat, text messaging, or in person. Crisis intervention approaches impact key risk factors for suicide, including feelings of depression, hopelessness, and subsequent mental healthcare utilization. Crisis interventions can put space or time between an individual who may be considering suicide and harmful behavior (Stone et al., 2017).

image: NSPL logo (suicidepreventionlifeline.org)

Source: CDC.

In an evaluation of the effectiveness of the National Suicide Prevention Lifeline to prevent suicide, 1,085 suicidal individuals who called the hotline completed a standard risk assessment for suicide, and 380 of those completed a followup assessment between 1 and 52 days after the initial assessment. Researchers found that over half of the initial sample had a plan for their suicide when they called. Researchers also found that 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).

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. Crisis lines are heavily used. From October 1, 2014 to September 30, 2015, almost 50,000 calls to the National Suicide Prevention Lifeline originated in Washington. Close to half of those calls were from people who selected the Veterans Crisis Line for help (WSDOH, 2016).

Source: Stone et al., 2017.

Preventing suicide: Protective factors

Strengthen economic supports

  • Strengthen household financial security
  • Housing stabilization policies

Strengthen access and delivery of suicide care

  • Coverage of mental health conditions in health insurance policies
  • Reduce provider shortages in underserved areas
  • Safer suicide care through systems change

Create protective environments

  • Reduce access to lethal means among persons at risk of suicide
  • Organizational policies and culture
  • Community-based policies to reduce excessive alcohol use

Promote connectedness

  • Peer norm programs
  • Community engagement activities

Teach coping and problem-solving skills

  • Social-emotional learning programs
  • Parenting skill and family relationship programs

Identify and support people at risk

  • Gatekeeper training
  • Crisis intervention
  • Treatment for people at risk of suicide
  • Treatment to prevent re-attempts

Lessen harms and prevent future risk

  • Postvention
  • Safe reporting and messaging about suicide