_____________________________________________________________ Suicide Assessment and Prevention
DETERMINE LEVEL OF RISK FOR SUICIDE AND APPROPRIATE ACTION
Contributing Factors a
Risk of Suicide Attempt Indicators of Suicide Risk
Initial Action Based on Level of Risk Maintain direct observational control of the patient Limit access to lethal means Immediate transfer with escort to urgent/emergency care setting for hospitalization Refer to behavioral health provider for complete evaluation and interventions Contact behavioral health provider to determine acuity of referral Limit access to lethal means Consider consultation with behavioral health to determine need for referral and treatment Treat presenting problems Address safety issues Document care and rationale for action
High acute risk
Persistent suicidal ideation or thoughts Strong intention to act or plan Not able to control impulse Recent suicide attempt or preparatory behavior b
Acute state of mental disorder or acute psychiatric symptoms Acute precipitating event(s) Inadequate protective factors
Intermediate acute risk Current suicidal ideation or thoughts No intention to act Able to control the impulse No recent attempt or preparatory behavior or rehearsal of act
Existence of warning signs or risk factors b and limited protective factors
Low acute risk
Recent suicidal ideation or thoughts No intention to act or plan Able to control the impulse No planning or rehearsing a suicide act No previous attempt
Existence of protective factors and limited risk factors
a Modifiers that increase the level of risk for suicide of any defined level include acute state of substance use, access to means (e.g., firearms, medications), and existence of multiple risk factors or warning signs or lack of protective factors. b 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: U.S. Department of Veterans Affairs. VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Available at http://www.healthquality.va.gov/guidelines/MH/srb. Table 2
High Acute Risk Considering all the information gathered in the assessment, the clinician will formulate the level of risk in one of the fol- lowing categories: high acute risk, intermediate acute risk, low acute risk, not at elevated risk [79]. High acute risk patients include those with warning signs, serious thoughts of suicide, a plan and/or intent to engage in lethal self-directed violence, a recent suicide attempt, and/or those with prominent agitation, impulsivity, and/or psychosis. In such cases, clinicians should ensure constant observation and monitoring before arranging for immediate transfer for psychiatric evaluation or hospitalization [79]. Patients at high acute risk should be immediately referred for a specialty evalu- ation with particular concern for ensuring the patient’s safety and consideration for hospitalization.
Intermediate Acute Risk Intermediate acute risk patients include those with suicidal ideation and a plan but with no intent or preparatory behav- ior. Combination of warning signs and risk factors to include history of self-directed violence (suicide attempt) increases a person’s risk for suicide. Patients at intermediate risk should be evaluated by a behavioral health provider. The decision whether to urgently refer a patient to a mental health profes- sional or emergency department depends on that patient’s presentation. The patient who is referred may be hospitalized if further evaluation reveals that the level of illness or other clinical findings warrant it. The patient may be managed in outpatient care if patient and provider collectively determine that the individual is capable of maintaining safety by utilizing non-injurious coping methods and utilize a safety plan [79].
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