STEP 2: ‘Protective’ factors. Discover and discuss internal and external factors that might help prevent the individual with suicidal thoughts from converting those thoughts into action (Table 2).2 When discussing these potentially protective effects, emphasize the patient’s:
- resilience during past personal crises
- family responsibilities
- religious or spiritual beliefs.
‘No-harm contracts.’ Suicide (or “no-harm”) contracts with patients might help open communication about factors that promote or mitigate suicide risk. Such contacts do not prevent suicide or lessen medicolegal risk in the event of a patient suicide, however.10
STEP 3: Suicide plans. Ask about suicide thoughts, plans, and behaviors (Table 3).11 Probe gently to allow the individual to discuss his or her feelings and to explore the next appropriate avenue of care.
In my experience, patients who reveal passive suicidal ideation (such as, “I sometimes wish I would just die in my sleep”) and strong deterrents to acting on thoughts of suicide (such as, “My children need me,” or “It’s against my religion”) should continue outpatient treatment. Those without deterrents or who discuss active and imminent thoughts and recent actions—writing suicide notes, buying a weapon, stockpiling pills—require emergent evaluation for psychiatric admission. Ask about thoughts of self-injury or mutilation (such as cutting or burning), as well as homicidal ideation.
Recognizing that patients with suicidal thoughts are almost always ambivalent about suicide to some extent—conflicted by simultaneous desires to live and to die—gives you the opportunity to intervene by allying with the part of the patient that wants to live. Creating a therapeutic connection also will help you determine the level of intervention required.
STEP 4: Intervention. Understanding why a patient feels suicidal—gathered in Steps 1 to 3—can help you choose the appropriate intervention. Among the 5 steps, Step 4 relies most heavily on clinical judgment:
- Is the suicidality acute or chronic?
- How great is the risk for suicide?
- To keep the patient safe, how urgent is the required intervention?
Acute risk. Suicidality related to Axis I psychiatric disorders tends to be acute, with prominent pain, anguish, and a desire to escape. Patients may describe a driven quality to the suicidality, which commands a treatment plan that maintains patient safety until suicidal feelings remit.
Hospitalization is often needed, plus focused treatments such as medication, psychotherapy, or electroconvulsive therapy. Intensive outpatient follow-up or partial hospitalization programs might be considered for patients:
- with whom you have a strong therapeutic alliance
- who have sturdy psychosocial support
- whose precipitating factors for suicidality have resolved.
Chronic risk. Suicide risk tends to be more chronic and has an impulsive quality for patients with suicidality related to personality disorders and environmental factors. Personality disordered patients may report feelings of anger, rage, or vengeance connected with their suicidal thoughts.
Hospitalization might become necessary, although multiple hospitalizations can be counter-therapeutic. Attempting in therapy to teach the patient to cope with suicidal thoughts and feelings might be a more effective intervention.
Malingering. Use your best judgment when patients make suicide threats that could represent malingering to achieve hospitalization.
Step 5: Documentation. Document your assessment of the suicidal patient and decision making to:
- clarify the treatment plan
- communicate to other caregivers
- manage medicolegal risk.
Include a brief summary (Box) that is timely, legible, and communicates the estimated degree of risk, known data, diagnosis, and planned interventions such as medications, tests, consultations, and follow-up reassessments.
Sample: How to document a suicide risk assessment
This 46-year-old, recently divorced man is experiencing his second episode of major depression associated with clear-cut panic attacks and suspected psychotic features. Although he denies current suicidal ideation, the treatment team believes he is at moderate to high risk for suicide because of known past history of serious suicide attempt with first depression, the presence of panic/anxiety, and possibly psychotic features. Additional risk is posed by loss of marital support and his inability to verbalize meaningful protective factors.
The plan is to convert from observation status on the inpatient unit to full admission, as the suicide risk precludes discharge at present. Further medication management and consideration for electroconvulsive therapy will take place, with daily reassessments. Suicide precautions ordered.
Table 1
Factors associated with potential for increased suicide risk