Table 2. Risk Stratification Essential Features
Level of Risk
Essential Features
Actions
Acute Risk High acute risk
● Suicidal ideation with intent to die by suicide ● Inability to maintain safety, independent of external support/help ● Common warning signs include: ○ A plan for suicide ○ Recent attempts and/or ongoing preparatory behaviors ○ Acute major mental illness (e.g., major depressive episode, acute mania, acute psychosis, recent/current drug relapse) ○ Exacerbation of personality disorder (e.g., increased borderline symptomatology) ● Suicidal ideation ● Ability to maintain safety, independent of external support/ help ● These individuals may present similarly to those at high acute risk. ○ The only difference may be a lack of intent, based upon an identified reason for living (e.g., children), and the ability to abide by a safety plan and maintain their safety. ○ Preparatory behaviors are likely to be absent.
● Typically requires psychiatric hospitalization to maintain safety and aggressively target modifiable factors ● May need to be directly observed until they are transferred to a secure unit and kept in an environment with limited access to lethal means (e.g., keep away from sharps, cords or tubing, and toxic substances) ● During hospitalization, cooccurring conditions should also be addressed. ● Consider psychiatric hospitalization if related factors driving risk are responsive to inpatient treatment (e.g., acute psychosis). ● Outpatient management of suicidal thoughts and/or behaviors should be intensive and include frequent contact, regular reassessment of risk, and a well- articulated safety plan. ● Mental health treatment should also address cooccurring conditions. ● These individuals are considered to be at chronic risk for becoming acutely suicidal, often in the context of unpredictable situational contingencies (e.g., job loss, loss of relationships, and relapse on drugs). ● These individuals typically require: ○ Routine mental health follow-up ○ A well-articulated safety plan, including lethal means safety (e.g., no access to guns, limited medication supply) ○ Routine suicide risk screening ○ Coping skills building ○ Management of co-occurring conditions These individuals typically require: ● Routine mental health care to optimize psychiatric conditions and maintain/enhance coping skills and protective factors ● A well-articulated safety plan, including lethal means safety (e.g., safe storage of lethal means, medication disposal, blister packaging) ● Management of co-occurring conditions ● Appropriate for mental health care on an as-needed basis; some may be managed in primary care settings ● Others may require mental health follow-up to continue successful treatment
Intermediate acute risk
Chronic Risk High chronic risk
● Common warning sign is chronic suicidal ideation ● Common risk factors include: ○ Chronic major mental illness and/or personality disorder
○ History of prior suicide attempt(s) ○ History of substance use disorders ○ Chronic pain ○ Chronic medical condition ○ Limited coping skills
○ Unstable or turbulent psychosocial status (e.g., unstable housing, erratic relationships, marginal employment) ○ Limited ability to identify reasons for living ● May feature similar chronicity as those at high chronic risk concerning psychiatric, substance use, medical and pain disorders ● Protective factors, coping skills, reasons for living, and relative psychosocial stability suggest enhanced ability to endure future crises without engaging in self-directed violence. ● May range from no or little in the way of mental health or substance use problems, to significant mental illness associated with relatively abundant strengths/ resources ● Stressors historically have typically been endured absent suicidal ideation ● Following factors generally missing: ○ History of self-directed violence ○ Chronic suicidal ideation ○ Tendency toward being highly impulsive ○ Risky behaviors ○ Marginal psychosocial functioning
Intermediate chronic risk
Low chronic risk
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Book Code: PYMA2024
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