Suicide Assessment and Prevention _ ____________________________________________________________
ADDITIONAL OPTIONS FOR CONTINUITY OF CARE It is important to ensure that the patient has follow-up con- tact even after discharge to another provider. At the point of discharge, information should be provided on crisis options (referred to as “crisis cards”) and free, universally available help, such as hotlines. There is evidence that follow-up out- reach in the form of letters or postcards expressing care and concern and continuing for up to three years may be helpful in suicide prevention [75]. These letters should generally be non-demanding, allowing the opportunity but not the require- ment for patients to respond. Alternatively, patients may be followed-up with phone calls from a mental health professional or suicide crisis volunteer [75]. If phone follow-up is preferred, calls should be made weekly or biweekly, in some cases supplemented with a home visit, and should continue for a period of three to six months. In many cases, partnering with a community crisis center can be helpful [66]. Crisis call centers are a crucial resource in linking patients to services and providing emotional support. According to the Suicide Prevention Lifeline, crisis center follow-up before a service appointment is associated with improved motivation, a reduction in barriers to accessing ser- vices, improved adherence to medication, reduced symptoms of depression, and higher attendance rates [64]. SAFETY PLANNING The VA recommends establishing an individualized safety plan for all persons who are at high acute risk for suicide as part of discharge planning, regardless of inpatient or outpatient status [79]. The safety plan is designed to empower the patient, manage the suicidal crisis, and engage other resources. Safety should also be discussed with patients at intermediate and low risk, with appropriate patient education and a copy of a safety plan handout [79]. Stressful events, challenging life situations, mental/substance use disorders, and other factors can precipitate a crisis of suicidal thoughts and behaviors leading directly to self-injury. Advance anticipation of challenging situations and envision- ing how one can identify and break a cycle of suicidal crises can reduce risk of self-injury and enhance a patient’s sense of self-efficacy. Open dialogue between patients and clinicians to establish a therapeutic alliance and develop strategies and skills supporting the patient’s ability to avoid acting on thoughts of suicide (including minimizing access to lethal means) is an essential component of suicide prevention in clinical settings. Putting this thinking-through process in writing for the antici- pation of a suicidal crisis and how to manage it constitutes a patient’s safety (action) plan [79].
the clinician should explain to the patient the reason for the referral and help alleviate patient anxiety over stigma and psy- chotropic medications. It is also important to help the patient understand that pharmacologic and psychologic therapies are both effective and to emphasize to the patient that referral does not mean “abandonment.” The referring clinician should also arrange an appointment with the mental health professional, allocate time for the patient following the initial appointment with the therapist or psychiatrist, and ensure the ongoing relationship with the patient [59; 60]. REFERRAL TO BE HOSPITALIZED Some indications for immediate hospitalization include recur- rent suicidal thoughts, high levels of intent of dying in the immediate future (the next few hours or days), the presence of agitation or panic, or the existence of a plan to use a violent and immediate suicide method [59; 60]. When hospitalizing a patient, she or he should not be left alone; the hospitaliza- tion and transfer of the patient by ambulance or police should be arranged and the family, and any appropriate authorities should be informed [59; 60].
The Department of Veterans Affairs recommends choosing the appropriate care setting that provides the patient at risk of suicide maximal safety in the least restrictive environment. Despite insufficient evidence to demonstrate the effectiveness
of acute hospitalization in the prevention of suicide, hospitalization is indicated in suicidal patients who cannot be maintained in less restrictive care settings. (https://www.healthquality.va.gov/guidelines/MH/srb. Last accessed March 24, 2023.) Level of Evidence : Expert Opinion/Consensus Statement A patient may be discharged to a less restrictive level of care from an acute setting (emergency department/hospital/acute specialty care) after a behavioral health clinician evaluated the patient, or a behavioral health clinician was consulted, and all three of the following conditions have been met [79]: • Clinician assessment indicates that the patient has no current suicidal intent. • The patient’s active psychiatric symptoms are assessed to be stable enough to allow for reduction of level of care. • The patient has the capacity and willingness to follow the personalized safety plan (including having available support system resources).
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