Because risk occurs on a continuum, assessment, management, and referrals will be 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).
The suicide continuum begins 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 presents an opportunity to intervene and prevent the act of self-directed violence. Often, the first opportunity to assess an individual’s suicide risk occurs because of warning signs that are identified by a caregiver, gatekeeper, or loved one. However, all too often a patient’s risk is identified after a suicide attempt is made (VA/DOD, 2013).
For people who survive a suicide attempt, the period after an emergency department (ED) visit is a time of high risk. Reductions in subsequent suicide deaths have occurred by engaging patients in timely treatment and providing followup 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. The ED provides an important opportunity to assess the patient's mental health needs and provide followup resources at a particularly critical juncture (Crane, 2016).
Importance of Secondary Suicide Risk Screening
In a multicenter study of 1,376 emergency department patients with recent suicide attempts or ideation, an intervention consisting of secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls resulted in a 5% absolute decrease in the proportion of patients subsequently attempting suicide and a 30% decrease in the total number of suicide attempts over a 52-week followup period.
Source: Coyne, 2017.
Levels of Risk
High acute risk for suicidal ideation and behavior includes patients with warning signs, serious thoughts of suicide, a plan or intent to engage in lethal self-directed violence, a recent suicide attempt, or those with prominent agitation, impulsivity, or psychosis. In such cases, clinicians should ensure constant observation and monitoring before arranging for immediate transfer for psychiatric evaluation or hospitalization (DVA/DOD, 2013).
A person with high risk may be in danger of crossing a threshold and 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 thinking, external controls may be needed to prevent a suicidal act. Some intervention may become necessary to interfere with the trajectory toward death, such as restriction of 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, 2013).
Intermediate acute risk includes patients with suicidal ideation and a plan but with no intent or preparatory behavior. A combination of warning signs and risk factors might include a history of self-directed violence or previous suicide attempt (DVA/DOD, 2013).
Patients at this level of risk should be evaluated by a behavioral health provider. The decision whether to urgently refer a patient to a mental health professional or ED depends on the patient’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 patient 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).
Low acute risk patients include those with recent suicidal ideation 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. These patients should be followed up for reassessment (DVA/DOD, 2013).
Those not at an elevated risk for suicide include patients that at some point in the past had reported thoughts about death or suicide, but currently don’t have any of these symptoms. There is no indication to consult with behavioral health specialists in these cases, and the patients 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).
†Modifiers that increase the level of risk for suicide of any defined level:
Level of Risk and Appropriate Action in Primary Care
Risk of suicide attempt
Indicators of suicide risk
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
Intermediate 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
- Treat presenting problems
- Address safety issues
- Document care and rationale for action
- 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).
Source: (VA/DOD, 2013).
Documentation is critical to promoting safety, coordinating care, and establishing a solid medical and legal record. Documentation includes providing a written summary of any steps taken, along with a statement of conclusions that shows the rationale for the plan. The plan should make good sense in light of the seriousness of risk (CSAT, 2015).
Documenting Fernando, Iraqi War Veteran
The following is from a progress note for Fernando, a 22-year-old Hispanic male and Iraq war veteran who was doing well in treatment for dependence on alcohol and opiates, but had missed his group therapy sessions and not returned phone calls for the past 10 days. This situation occurred in a substance abuse clinic within a hospital and required immediate supervision and interventions of high intensity.
Step One: Gather Information
Fernando came in, unannounced, at 10:30 a.m. today and reported that he relapsed on alcohol and opiates 10 days ago and has been using daily and heavily since. Breathalyzer was 0.08, and he reported using two bags of heroin earlier this morning. He reported that he held his loaded rifle in his lap last night while high and drunk, contemplating suicide.
Gathering information involves collecting relevant facts. Screening questions should be asked of all new clients when you note warning signs and any time you have a concern about suicide, whether or not you can pinpoint the reason. Inquiries about suicidal ideation and attempts should start with an open-ended question that invites the client to provide more information. Followup questions are then asked to gather additional, critical information. Routine monitoring of suicide risk should be a basic standard in all substance abuse treatment programs.
Step Two: Access Supervision or Consultation
Upon consultation with a supervisor, it was determined that emergency intervention was needed because of intense substance use, suicidal thoughts with a lethal plan, and access to a weapon.
Consultation is a formal process whereby information and advice are obtained from (a) a professional with clear supervisory responsibilities, (b) a multidisciplinary team that includes such people, and/or (c) a consultant experienced in managing suicidal clients who has been vetted by your agency for this purpose.
Immediate supervision or consultation should be obtained when clients exhibit direct suicide warning signs or when, at intake, they report having made a recent suicide attempt. Substance abuse relapse during treatment is also an indication for supervisory involvement for clients who have a history of suicidal behavior or attempts.
You should not make a judgment about the seriousness of suicide risk or try to manage suicide risk on your own unless you have an advanced mental health degree and specialized training in suicide risk management and it is understood by your agency that you are qualified to manage such risk independently.
Step Three: Take Responsible Action
At 11:00 a.m., a hospital security guard and this writer escorted Fernando to the ED, where he was checked in. He was cooperative throughout the process.
A useful guiding principle in taking responsible action is that your actions should make good sense in light of the seriousness of suicide risk. Seriousness is defined as the likelihood that a suicide attempt will occur and the potential consequences of an attempt. Judgments about the degree of seriousness of risk should be made in consultation with a supervisor or a treatment team, not by a healthcare provider acting alone.
In some instances, an immediate response is required. Examples of immediate actions include arranging transportation to a hospital ED for evaluation, contacting a spouse to have him or her arrange to remove a gun from the home and arrange safe storage, and arranging on the spot to have a mental health specialist further evaluate a client. Examples of non-immediate, but important, actions include making a referral for a client to an outpatient mental health facility for evaluation, scheduling the client to see a psychiatrist for possible medication management, and ordering past mental health records from another provider.
Step Four: Follow Up
Dr. McIntyre, the ED physician, determined that Fernando requires hospitalization. He is currently awaiting admission. This writer will follow up with the hospital unit after he is admitted and will raise the issue of his access to a gun.
Suicide prevention efforts are not one-time actions. They should be ongoing because suicidal clients are vulnerable to a recurrence of risk. A team approach is also essential, as it requires you to follow up on referrals and coordinate with other providers in an ongoing manner.
Source: CSAT, 2015.