Table 8. Actions according to level of suicide risk
Acute
Chronic
High risk: Requires psychiatric hospitalization to maintain safety. These patients need to be observed on a secure unit and kept in an environment with limited access to lethal means. Intermediate risk: Consider psychiatric hospitalization if related risk factors are responsive to inpatient treatment (i.e., psychosis). If patients are treated in an outpatient setting, there should be increased contact; regular re-assessment of risk; a safety plan in place.
High risk: These individuals require a calculated risk assessment; routine mental health follow ups; a safety plan; routine suicide risk screening; coping skills building; management of co-occurring psychiatric disorders, and evidence-based treatment for suicide. Intermediate risk: These individuals require routine mental healthcare to maintain or enhance coping skills and protective factors; a safety plan; management of co-occurring psychiatric disorders, and evidence-based treatment for suicide.
Low risk: Outpatient treatment should include behavioral health services and a well-articulated safety plan. Low risk: These individuals may seek treatment on a regular or an as needed basis. Some may be managed in primary care. Note. Adapted from Zero Suicide. (2019). Therapeutic risk management – Risk stratification table. 49 https://zerosuicide.edc.org/sites/default/files/Risk%20 Stratification%20Table%20MCHGM.pdf
Case Study 4
Instructions: Spend 5-10 minutes reviewing the case below and considering the questions and discussion that follow. (Rationale and discussion is displayed at the bottom of this exercise) Mrs. B. is a 35-year-old married woman with two children (ages 10 and 15). She presents for an annual checkup at her primary care physician. She appears uncomfortable and refuses to make eye contact with the front desk nurse, with whom she is usually friendly. She has been seeing Dr. Duke, but she is scheduled to see his partner, Dr. Cook, this afternoon because Dr. Duke is on vacation. Dr. Cook’s nurse, Joan, notices that Mrs. B. is not her usual self and appears “out of it” today and is somewhat irritable. She seems to have burn marks on her arms but is wearing a long-sleeved shirt and dismisses the marks saying: “I burned myself on the oven.” When asked by the nurse, Mrs. B denies suicidal ideation; however, there was no additional follow-up with a screening or assessment tool to determine the appropriate level of risk. Mrs. B reports to the nurse that she has not been sleeping, doesn’t have much appetite, and is struggling to get her husband to understand her needs “since he is so busy with his job and an affair” and her parents have moved 500 miles away. Mrs. B. has a history of depression diagnosed as postpartum depression after her second child was born. Her second child is now 10 years old, and she has no documented depressive symptoms. Of note, during the postpartum period, she had one suicide attempt. Dr. Cook is extremely busy today, and when Joan brings up Mrs. B.’s apparent depressed mood to his attention, he is extremely dismissive and remarks that her history of depression and prior suicide attempt was a thing of the past. Two weeks later, Mrs. B. is found by her older son after attempting to hang herself. She was admitted to the intensive care unit at the local hospital.
1. Based on the information provided, Mrs. B. falls into the following category of risk: A. Low risk. B. Moderate risk. C. High risk. D. None of the above. 2. Which of the following is the strongest predictor of Mrs. B.’s current suicide attempt? A. Postpartum depression. B. Previous suicide attempt. C. Isolation. D. Being married.
3. Mrs. B. came to see her primary healthcare provider for her annual checkup. Based upon the previous reading, what percentage of individuals see their primary healthcare provider within one year of a suicide attempt?
A. 80%. B. 55%. C. 65%. D. 35%.
Rationale for Question 1: Patients at high risk most likely have a suicide plan with preparatory or rehearsal behavior.
Rationale for Question 2: While her history of postpartum depression and isolation are concerns that she may attempt suicide, the previous suicide attempt is the strongest predictor for the current suicide attempt. Rationale for Question 3: According Schreiber and Culpepper2, 80% of individuals who die by suicide have had at least one contact with their primary healthcare provider within one year of dying by suicide.
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