Identify

Every new client or patient is screened for suicidal thoughts and behaviours when health and behavioural health care organisations are committed to safer suicide care.

The purpose of the screening is not to predict suicide but rather to plan effective suicide care. Once a screening shows some risk for suicide, further information is gathered with the aim of producing a “risk formulation” based on the patient’s specific context.¹

In a Zero Suicide approach:

  • All persons receiving care are screened for suicidal thoughts and behaviours at intake.
  • Whenever a patient screens positive for suicide risk, a full risk formulation is completed for the client.

To Implement Zero Suicide

Screening for Suicide Risk

  • Policies and procedures clearly describe screening patients for suicide risk, including:
    • The frequency of screening
    • Documenting risk screenings
    • Screening and identification workflows
    • How staff will be alerted when their patients screen positive for suicide risk
  • A written policy and procedure specifies that patients are provided timely access to clinically trained staff after screening positive for suicide risk.
  • A standardised screening measure is used by all staff.
  • Staff receives formal training on suicide screening and documentation.

In inpatient treatment, in addition to the above:

  • Patients are screened prior to discharge.

For more discussion about the use of standardised screening tools and information about specific tools, go to the Screening Options section below.

Formulating a Risk Assessment

  • A written policy and procedure states that a comprehensive suicide risk formulation is completed during the same visit whenever a patient screens positive for suicide risk.
  • All staff use the same risk formulation model.
  • The comprehensive risk formulation is conducted by a trained clinician.
  • All clinical staff receive formal training on risk formulation and documentation.
  • Information for risk formulation is taken from multiple sources, including treatment professionals, case workers, and people who are significant in the patient’s life.
  • Risk formulation decisions are based on observations by multiple staff members.
  • The risk formulation is re-evaluated and documented in the patient’s record at every client visit.

In addition to the above, in inpatient settings:

  • Risk formulation and reassessment are based on multiple, continuous observations, supported by:
    • Timely psychiatric consult
    • Family member input
    • Means-restricted environment
    • Up to line-of-sight supervision (or other environmental safety precautions)
    • Timely clinical team consultation when increased risk may be present
    • Reassessment at discharge and completion of a follow-up post-discharge referral and contact plan
  • Multiple observations of reduced risk are required to formally reduce risk status.
  • Risk formulation is repeated at discharge, with articulated follow-up post-discharge referral and contact plan.

It’s important to supplement a suicide screening with additional information and a complete risk formulation to inform treatment planning. See the Risk Formulation section below to see an example of a risk formulation model developed by suicide prevention researchers and practitioners.

Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2016). Reformulating suicide risk formulation: From prediction to prevention. Academic Psychiatry 40(4), 623–629.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26667005

Readings

Suicide Screening and Assessment -http://www.sprc.org/sites/default/files/migrate/library/RS_suicide%20screening_91814%20final.pdf

Patient Health Questionnaire 9 (PHQ-9) Depression Scale http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/PHQ-9_English.pdf

SAFE-T Suicide Assessment Five-Step Evaluation and Triage – This assists clinicians in conducting a suicide assessment using a five-step evaluation and triage plan to identify risk factors and protective factors, conduct a suicide inquiry, determine risk level and potential interventions, and document a treatment plan. http://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-and-Triage-SAFE-T-/SMA09-4432#sthash.aQ4yO46j.dpuf

Columbia Suicide Severity Rating Scale (C-SSRS) http://cssrs.columbia.edu/

National Suicide Prevention Lifeline Suicide Risk Assessment Standards – The Suicide Risk Assessment Standards focus on four core principles: Suicidal Desire, Suicidal Capability, Suicidal Intent and Buffers along with the subcomponents for each. https://suicidepreventionlifeline.org/wp-content/uploads/2016/08/Suicide-Risk-Assessment-Standards-1.pdf

Patient Safety Plan Template – A fill-in-the-blank template for developing a safety plan with a patient who is at increased risk for a suicide attempt.
http://www.sprc.org/sites/default/files/Brown_StanleySafetyPlanTemplate.pdf

Screening

In a Zero Suicide organisation, all patients are screened for suicide risk on their first contact with the organisation and at every subsequent contact. All staff members use the same tool and procedures to ensure that clients at suicide risk are identified.

The standard of care in suicide risk assessment requires that clinicians conduct thorough suicide risk assessments when patients screen positive for suicide risk and then make reasonable formulations of risk.¹

One barrier to ensuring that staff are consistently screening and assessing risk is mistaken beliefs about suicide and its causes. The activity Attitudes and Beliefs about Suicide to the right demonstrates how these beliefs might produce resistance to screening and presents ideas for responding to and overcoming that resistance.

When standardised procedures are in place to assess patients for suicide risk, staff are able to use the same language, which is understood by all, to discuss a patient’s status and make plans for appropriate care.

Full Assessment

There are three aspects of creating a full assessment of suicide risk and providing a foundation for treatment planning:
  • Gather complete information about past, recent, and present suicidal ideation and behaviour
  • Gather information about the patient’s context and history
  • Synthesise this information into a prevention-oriented suicide risk formulation anchored in the patient’s life context²

The purpose of assessment is not to predict which patient might take his or her own life but, rather, to do the best job we can to increase safety, reduce risk, and promote wellness and recovery.

The following sections address the gathering of information about suicidal ideation and behaviour. You’ll find more information about gathering information on the patient’s context and history and synthesising a risk formulation at the section Risk Formulation.

Gather Information about Suicidal Thoughts and Behaviours

Different kinds of organisations and settings may use different tools, based in part on whether the organisation itself will provide the comprehensive care after a patient is found to be at risk. Examples include:

PHQ

For example, once patients are found to be at risk for suicide in a primary care setting, they would often be referred for behavioural health care. In this case, a brief, basic screening tool such as a Patient Health Questionnaire (PHQ) may be used to identify at-risk patients.

The PHQ-9 is used extensively in primary care. The PHQ-9 contains nine items, and item 9 asks, “Over the past two weeks, have you been bothered by … thoughts that you would be better off dead or of hurting yourself in some way.”³

Many primary care practices use a shorter version called the PHQ-2, which contains two items asking about depression symptoms. If a patient answers ‘yes’ to either of the PHQ-2 questions, then the PHQ-9 is administered.

One concern about this approach is that a patient could answer ‘no’ to the PHQ-2 questions and still be having suicidal thoughts. In addition, the wording of item 9 is somewhat indirect—it does not directly ask about suicidal thoughts and behaviours.

Organisations should consider adding a more direct question about suicide to the PHQ-2 and substituting that same question for question 9 in the PHQ-9 if the PHQ-9 is the only screen used. For example, a possible very brief screening for suicide risk might be:

Over the past two weeks, have you been bothered by:

  • Little interest or pleasure in doing things?
  • Feeling down, depressed, or hopeless?
  • Thoughts that you want to kill yourself, or have you attempted suicide?³

Medical providers may be able to use procedure codes for screening and assessment. For example, medical providers are able to use procedure codes for a 15-minutes screen for depression for Medicare patients.

The SAMHSA-HRSA Centre for Integrated Health Solutions offers a set of state billing and financial worksheets to help clinic managers, integrated care project directors, and billing/coding staff at community mental health centres and community health centres identify the available current procedural terminology codes they can use in their state to bill for services related to integrated primary and behavioural health care. The worksheets can be found in the Tools below.

Once it is established that a patient is having suicidal thoughts or has attempted suicide, a complete assessment of suicidal thinking and behaviour, including the nature and extent of the risk, should be done immediately.

SAFE-T

It may make sense in a different setting, such as outpatient behavioural health care clinic, to use the SAFE-T or another tool that offers a thorough assessment of the nature and extent of suicidal thoughts and behaviours.

The more extensive items contained in the SAFE-T interview are likely to yield the detailed information needed to develop a full picture of a patient’s suicide risk. The items explore:

  • Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever
  • Plan: timing, location, lethality, availability, preparatory acts
  • Behaviours: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self-injurious actions
  • Intent: extent to which the patient, one, expects to carry out the plan and, two, believes the plan/act to be lethal vs. self-injurious. Explore ambivalence: reasons to die vs. reasons to live

C-SSRS

The Columbia-Suicide Severity Rating Scale (C-SSRS) is another tool that can be used in outpatient behavioural health care setting. The C-SSRS looks at identified suicide attempts and also assesses the full range of evidence-based ideation and behaviour. It can be used in initial screenings or as part of a full assessment. More information about the C-SSRS is in Tools and Readings at the bottom of this page and a training module is available to the right.

Inpatient

In inpatient behavioural health treatment, the assessment process will also be unique to that setting. Even if the admission is due to suicide risk, the admission process should include a suicide risk assessment. Policies should specify not only when to physically check on a patient but also when to complete a full reassessment. Inpatient organisations may use the C-SSRS or SAFE-T questions to guide these assessments.

How to Choose a Screening Tool?

Whatever screening tool is used, it should be given to all patients, either before they come in for a first appointment or at that first appointment.

The Patient in the Information-Gathering Process

Health and behavioural health organisations implementing screening and assessment should attend to more than just what tool or set of questions is used. The staff person conducting the patient interview should:

  • Adopt a collaborative stance, reflecting empathy and genuineness
  • Express an understanding of the ambivalence in the patient’s desire to die to relieve intolerable pain
  • Engender confidence that there’s an alternative to alleviating that pain and that the patient can be empowered to use care and services to do so
  • Treat the interview as an exploration of what has happened to the patient, not as a task to complete or an examination of what’s wrong with the patient. As one person with lived experience has stated,  “Don’t treat it like a checklist on a clipboard.”

The Joint Commission. (2016). Detecting and treating suicide ideation in all settings. Sentinel Event Alert, (56).
Retrieved from http://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf

Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2016). Reformulating suicide risk formulation: From prediction to prevention. Academic Psychiatry 40(4), 623–629.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26667005

a. b. Spitzer, R. L., Williams, J. B. W., Kroenke, K., et al. (2001) Patient health questionnaire-9 (PHQ-9).
Retrieved from http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/PHQ-9_Engli…

Kroenke K., Spitzer R. L., & Williams J. B. (2003). The patient health questionnaire-2: Validity of a two-item depression screener. Medical Care, 41(11), 1284–1292.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/14583691

U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2016). Medicare preventive services.
Retrieved from https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-Q…

Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2009). SAFE-T (HHS Publication No. [SMA] 09-4432).
Retrieved from http://store.samhsa.gov/shin/content//SMA09-4432/SMA09-4432.pdf

Research Foundation for Mental Hygiene, Columbia Lighthouse Project. (2008). Columbia suicide severity rating scale.
Retrieved from http://cssrs.columbia.edu/

Risk Formulation

Clinicians are often faced with having to make judgment calls about suicide risk with insufficient or contradictory information. Information obtained in a suicide screen is just one part of what is needed to fully assess risk and develop the best care plans to engage clients. Establishing a collaborative and shared perspective is essential to obtaining a comprehensive understanding of the client’s suffering and strengths.

One prevalent method of assessment attempts to put people into predictive categories such as a low, medium, or high risk. Despite many efforts to define these terms, definitions were usually difficult to apply, and the terms lack predictive validity, cross-clinician consistency, and clinical utility in treatment planning.

The high-medium-low model of formulating risk also was not anchored in a context. One could ask, “high compared to what?” or “low compared to when?” In newer, contextual risk formulation methods, the primary purpose is planning rather than the prediction of suicide.

A well-documented risk formulation can demonstrate that clinical decisions were sound and aid in communication with the client, other clinical staff, and important people in the client’s life. Clear documentation also helps to show the rationale behind your formulation, discussions with the client about your risk formulation, and treatment decisions. As new information becomes available and circumstances change, the assessment of risk also should be reconsidered and possibly modified.

 

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