Because risk occurs on a continuum, assessment, management, and referrals are different for each situation. Identifying 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 (Stone et al., 2017).
For people who survive a suicide attempt, the period after an emergency department visit is a time of high risk. Subsequent suicide attempts can be reduced by engaging patients in treatment and providing followup services. 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).
Actions and Referrals for Various Levels of Risk
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 in this state of mind, external controls may be needed to prevent a suicidal act. Some intervention may become necessary, such as restricting access to the means of completing a suicidal act. This may prevent a fatal act but does not necessarily resolve the suicidal impulse or crisis (DVA/DOD, 2019).
- 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/DOD, 2019).
If a plan is present, the plan is general or vague, and 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 using appropriate coping strategies and are willing and able to utilize a safety plan in a crisis situation (DVA/DOD, 2019).
Low acute risk patients can be managed in primary care. Outpatient mental health treatment may also be indicated, particularly if suicidal ideation and co-occurring conditions exist (DVA/DOD, 2019).
Essential Features of Acute Risk
Risk of suicide attempt
High acute risk
Intermediate acute risk
These individuals may present similarly to those at high acute risk, sharing many of the 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.
Low acute risk
Individuals may have suicidal ideation, but it will be with little or no intent or specific current plan. If a plan is present, the plan is general and/or vague, and 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 will be capable of engaging appropriate coping strategies, and willing and able to utilize a safety plan in a crisis situation.
Although suicidal ideation with serious intent to die is a clinical emergency, there is little or no evidence-based treatment on how to manage it. Interprofessional clinical practice guidelines for suicide prevention, assessment, and management of suicidal thoughts and behaviors show tremendous variations from one guideline to the next (Harmer et al., 2022).
A gap in all the guidelines—except the DOD/DVA guideline—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.
Improving Access to Mental Health Services
Effective management of mental health conditions (particularly major depression) can reduce the risk of suicide. Intervention and treatment should be direct and specific and include improving access to mental health services, counseling, and other psychosocial services, encouraging use of crisis lines, and pharmacologic interventions. (DVA/DOD, 2019).
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.
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. Chemical dependency services have been available under managed care since 2016 (WSDOH, 2016).
In Washington State, Apple Health offers managed care plans in all regions statewide. The plan coordinates physical health, mental health, and substance use disorder treatment services to provide whole-person care under one health plan (WSHCA, 2022).
Apple Health offers Behavioral Health Services Only (BHSO) plans in all regions with integrated managed care. In addition to integrated managed care plans, clients in integrated regions have access to a regional Behavioral Health—Administrative Services Organization (BH-ASO). These organizations administer services such as:
- 24/7 regional crisis hotline for mental health and substance use disorder crises
- Mobile crisis outreach teams
- Short-term substance use disorder crisis services for individuals who are intoxicated or incapacitated in public
- Application of behavioral health involuntary commitment statutes, available 24/7 to conduct Involuntary Treatment Act (ITA) assessments and file detention petitions
- Regional Ombuds services (WSHCA, 2022)
Within available funding, a Behavioral Health/Administrative Services Organization also has the discretion to provide outpatient behavioral health services or voluntary psychiatric inpatient hospitalizations for individuals who are not eligible for or enrolled in Apple Health (WSHCA, 2022).
Continuity of Care
Because a variety of healthcare providers, friends, and family members may be associated with the care of a person at risk for suicide, continuity of care is critical. Maintaining continuity across facilities and providers may be helped by electronic medical records; however, not everyone has access to this information. A confounding factor is that mental health information has higher levels of consent for accessing records.
Continuity of care is often interrupted when patients who are or have been at risk for suicide transition between care facilities or between other health systems or provider organizations. Patients have reported frustration with seeing multiple providers, both within a treatment facility due to provider availability and across locations due to frequent travel, resulting in decreased continuity of care (DVA/DOD, 2019).
Potential discontinuities can occur when a patient transitions from:
- Primary care to behavioral health
- Emergency department to ambulatory care
- Inpatient units to other settings such as nursing homes, rehabilitation, or other residential treatment settings
- Nursing homes and residential care units to ambulatory services
Continuity of care is improved during transitions when providers directly contact other providers and schedule followup appointments. Transition support services (such as telephone or telehealth contact with behavioral health providers) can improve continuity of care and prevent delays in followup services (DVA/DOD, 2019).
Continuity of care following a suicide attempt should leave the patient with a feeling of connectedness. Strategies may include telephone reminders of appointments, providing a “crisis card” with emergency phone numbers and safety measures, and sending a letter of support. Motivational counseling and case management can also be used to promote adherence to the recommended treatment (HHS, 2012, latest available).