Patient Management Tools

Many concrete and easy-to-use tools are available to assist you and your staff in preventing suicide. This
section includes pocket-sized tools to facilitate assessment and intervention with at-risk patients in the
office, as well as templates for helping to ensure the patients’ safety outside of your office.

In This Section
Primary Care Pocket Guide
The Pocket Guide for Primary Care Professionals provides a summary of important risk and protective
factors for suicide, questions you can use in a suicide assessment, and a decision tree for managing the
patient at risk for a suicide attempt. The card is designed to be printed on both sides and folded in quarters
to fit easily in the pocket. Hard copies are available for purchase through the WICHE Mental Health
Program at mentalhealthemail@wiche.edu or by calling 303-541-0311.

SAFE-T Pocket Card

http://www.sprc.org/resources-programs/suicide-assessment-five-step-evaluation-and-triage-safe-t-pocket-
card
This pocket card, designed by mental health experts for mental health professionals, provides a brief
overview on conducting a suicide assessment using a five-step evaluation and triage plan. The website
above will direct you to the SAMHSA Publications Ordering website where the card can be downloaded or
ordered free of charge. https://store.samhsa.gov/product/SAFE-T-Pocket-Card-Suicide-Assessment-Five-Step-
Evaluation-and-Triage-for-Clinicians/SMA09-4432 . SAMHSA’s free suicide prevention app, Suicide Safe, is
based on the SAFE-T card and can be downloaded for iOS and Android devices. More information about
Suicide Safe is available at: https://store.samhsa.gov/apps/suicidesafe/index.html.

Safety Planning Guide

http://www.sprc.org/resources-programs/safety-planning-guide-quick-guide-clinicians
The pocket-sized safety planning guide reminds clinicians of the most important points to cover in
collaboratively developing a safety plan with a patient. The guide was adapted from content developed by
the Department of Veterans Affairs.

Patient Safety Plan Template

http://www.sprc.org/resources-programs/patient-safety-plan-template
The Patient Safety Plan Template is filled out collaboratively by the clinician and the patient and then used
independently by the patient to help ensure their safety in their day-to-day lives. The Safety Planning Guide
(listed above) can be used as a source of questions to ask to facilitate development of the Safety Plan.

Crisis Support Plan

The Crisis Support Plan is used by the patient and the clinician to enlist social support from a trusted friend
or relative should a suicide crisis recur. It explains roles that supportive individuals can take to help protect
the person at risk for suicide and serves as an informal contract that the designated support person will
fulfill these roles. Active support of a friend or loved one is among the strongest protective factors against
suicide.

47
 2 Endnotes:
Screening: uncovering suicidality 1 A Pocket Guide
Assess suicide ideation and plans3 SAFE-T pocket card. Suicide Prevention Resource Center & Mental
Transition Question: Confirm Suicidal Ideation fAssess suicidal ideation – frequency, duration, and intensity Health Screening. (n/d).
2 for Primary Care
Have you had recent thoughts of killing yourself? Is there other • When did you begin having suicidal thoughts? Caring for Adult Patients with Suicide Risk: A Consensus Guide for
evidence of suicidal thoughts, such as reports from family or • Did any event (stressor) precipitate the suicidal Emergency Departments. Suicide Prevention Resource Center. Newton,
friends? (Note: the transitional question is not part of scoring.) thoughts?
0$KWWSZZZVSUFRUJVLWHVGHIDXOWÀOHV('*XLGHBTXLFNYHUVLRQSGI Professionals
3
Gliatto, M.F., & Rai, K.A. Evaluation and treatment of patients with
1. Thoughts of carrying out a plan. Recently, have you been • How often do you have thoughts of suicide? suicidal ideation. American Family Physician, 59 (1999), 1500-1506.
thinking about how you might kill yourself? If yes, consider • How strong are the thoughts of suicide?
the immediate safety needs of the patient. • What is the worst they have ever been?
• What do you do when you have suicidal thoughts?
2. Suicide intent. Do you have any intention of killing yourself?
fAssess suicide plans
3. Past suicide attempt. Have you ever tried to kill yourself? • Do you have a plan or have you been planning to end
4. 6LJQLÀFDQWPHQWDOKHDOWKFRQGLWLRQ Have you had your life? If so, how would you do it? Where would Call the Colorado Crisis Services 24/7 Hotline at
treatment for mental health problems? Do you have a mental you do it? 1-844-493-TALK (8255) for mental health crisis
health issue that affects your ability to do things in life? • Do you have the (drugs, gun, rope) that you would
use? Where is it right now? services including mobile crisis response.
5. Substance use disorder. Have you had four or more (female) • Do you have a timeline in mind for ending your life?
RUÀYHRUPRUHPDOHGULQNVRQRQHRFFDVLRQLQWKHSDVW Is there something (an event) that would trigger
month or have you used drugs or medication for non-medical the plan?
reasons in the past month? Has drinking or drug use been a Development of this pocket guide was supported by
problem for you? the Federal Office of Rural Health Policy, Assessment and
6. Irritability/agitation/aggression. Recently, have you been Health Resources and Services Administration (HRSA),
feeling very anxious or agitated? Have you been having Assess suicide intent Public Health Services, Grant Award, U1CRH03713 Interventions
FRQÁLFWVRUJHWWLQJLQWRÀJKWV",VWKHUHGLUHFWHYLGHQFHRI fWhat would it accomplish if you were to end your life?
irritability, agitation, or aggression. fDo you feel as if you’re a burden to others? with Potentially
Scoring: Score 1 point for each of the Yes responses on fWhat have you done to begin to carry out the plan? For
questions 1-6. If the the answer to the transition question and instance, have you rehearsed what you would do (e.g., Suicidal Patients
any of the other six items is “Yes”, further intervention, including held pills or gun, tied the rope)?
assessment by a mental health professional, is needed. fHave you made other preparations (e.g., updated life Western Interstate Commission for Higher Education
insurance, made arrangements for pets)? 3035 Center Green Drive, Suite 200 Boulder, CO 80301-2204
fWhat makes you feel better (e.g., contact with family, use of 303.541.0200 (ph) 303.541.0291 (fax)
substances)? www.wiche.edu/mentalhealth/
fWhat makes you feel worse (e.g., being alone, thinking Copyright 2017 by Education Development Center, Inc., and the Western Interstate Commission for
about a situation)? Higher Education
WICHE Mental Health Program. All rights reserved. SPRC

48
Assessment and Interventions with Potentially Suicidal Patients Suicide Risk and Protective Factors1
RISK FACTORS
Patient has suicidal ideation or any past attempt(s) within the past two months. See right for risk factors and back for assessment questions. fSuicidal behavior: history of prior suicide attempts, aborted
suicide attempts or self-injurious behavior.
fFamily history: of suicide, attempts, or psychiatric diagnoses,
High Risk Moderate Risk
Moderate Risk Low Risk especially those requiring hospitalization.
fCurrent/past psychiatric disorders: especially mood disorders
Patient has a suicide plan with preparatory or Patient has suicidal ideation, but limited suicidal intent and Patient has thoughts of death only; (e.g., depression, Bipolar disorder), psychotic disorders,
rehearsal behavior no clear plan; may have had previous attempt no plan or behavior alcohol/substance abuse, TBI, PTSD, personality disorders (e.g.,
Borderline PD).
Co-morbidity with other psychiatric and/or substance abuse
Patient has severe Patient has good social disorders and recent onset of illness increase risk.
psychiatric symptoms and/ support, intact judgment;
fKey symptoms: anhedonia, impulsivity, hopelessness, anxiety/
or acute precipitating event, psychiatric symptoms, panic, insomnia, command hallucinations, intoxication.
access to lethal means, poor if present, have been For children and adolescents: oppositionality and conduct
social support, impaired addressed problems.
Evaluate for psychiatric disorders, stressors, and additional risk factors
judgement fPrecipitants/stressors: triggering events leading to humiliation,
Take action to prevent the plan VKDPHRUGHVSDLULHORVVRIUHODWLRQVKLSÀQDQFLDORUKHDOWK
Hospitalize, or call 911 or Safety planning status – real or anticipated).
Safety planning fChronic medical illness (esp. CNS disorders, pain).
local police if no hospital is
available. If patient refuses fHistory of or current abuse or neglect.
Consider (locally or via telemedicine):
hospitalization, consider 1) psychopharmacological treatment with psychiatric consultation
involuntary commitment if PROTECTIVE FACTORS
2) alcohol/drug assessment and referral, and/or
state permits 3) individual or family therapy referral to evidence based treatment 3URWHFWLYHIDFWRUVHYHQLISUHVHQWPD\QRWFRXQWHUDFWVLJQLÀFDQW
acute risk.
fInternal: ability to cope with stress, religious beliefs, frustration
Encourage social support, involving family members, close friends and community resources. If patient has therapist, call him/her in presence of patient. tolerance.
fExternal: responsibility to children or pets, positive therapeutic
Record risk assessment, rationale, and treatment plan in patient record. Continue to monitor patient status via repeat interviews, follow-up contacts, and collaboration with other providers. relationships, social supports.
RESOURCES

Q

Q
Download this card and additional resources at IUUQXXww.sprc.org
XXww.sprc.org SAFE-T
Resource for implementing The Joint Commission 2007 Patient
Safety Goals on Suicide
IUUQXww.sprc.org/library/jcsafetygoals.pdf
Q SAFE-T drew upon the American Psychiatric Association Suicide Assessment Five-step
Evaluation and Triage
Practice Guidelines for the Assessment and Treatment of
Patients with Suicidal Behaviors IUUQXww.psychiatryonline.com/
pracGuide/pracGuideTopic_14.aspx
Q
 Practice Parameter for the Assessment and Treatment of Children and
Adolescents with Suicidal Behavior. Journal of the American Academy 1
of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s IDENTIFY RISK FACTORS
Note those that can be
modified to reduce risk
ACKNOWLEDGMENTS
Q Originally conceived by Douglas Jacobs, MD, and developed as 2
a collaboration between Screening for Mental Health, Inc. and IDENTIFY PROTECTIVE FACTORS
the Suicide Prevention Resource Center. Note those that can be enhanced
Q This material is based upon work supported by the Substance
Abuse and Mental Health Services Administration (SAMHSA) under
Grant No. 1U79SM57392. Any opinions/findings/conclusions/ 3
recommendations expressed in this material are those of the CONDUCT SUICIDE INQUIRY
author and do not necessarily reflect the views of SAMHSA. Suicidal thoughts, plans,
behavior, and intent
National Suicide Prevention Lifeline
1-800-273-TALK (8255) 4
DETERMINE RISK LEVEL/INTERVENTION
Determine risk. Choose appropriate
intervention to address and reduce risk

IUUQwww.sprc.org 5
DOCUMENT
Assessment of risk, rationale,
intervention, and follow-up

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

((30UBLICATION.O3-!  s#-(3 .30  Substance Abuse and Mental Health Services Administration
Printed 2009 www.samhsa.gov

49
Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical
change; for inpatients, prior to increasing privileges and at discharge.
1. RISK FACTORS
 Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior
 Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality
disorders, conduct disorders (antisocial behavior, aggression, impulsivity)
Co-morbidity and recent onset of illness increase risk
 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations
 Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization
 Precipitants/Stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real
or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation
 Change in treatment: discharge from psychiatric hospital, provider or treatment change
 Access to firearms

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk
 Internal: ability to cope with stress, religious beliefs, frustration tolerance
 External: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent

 Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever
 Plan: timing, location, lethality, availability, preparatory acts
 Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions
 Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious.
Explore ambivalence: reasons to die vs. reasons to live
* For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition
* Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above

4. RISK LEVEL/INTERVENTION
 Assessment of risk level is based on clinical judgment, after completing steps 1–3
 Reassess as patient or environmental circumstances change

RISK LEVEL RISK/PROTECTIVE FACTOR SUICIDALITY POSSIBLE INTERVENTIONS

Psychiatric diagnoses with severe Potentially lethal suicide attempt or
Admission generally indicated unless a significant
High symptoms or acute precipitating event; persistent ideation with strong intent or
change reduces risk. Suicide precautions
protective factors not relevant suicide rehearsal
Admission may be necessary depending on risk
Multiple risk factors, few protective Suicidal ideation with plan, but no intent
Moderate factors or behavior
factors. Develop crisis plan. Give emergency/crisis
numbers
Modifiable risk factors, strong protective Thoughts of death, no plan, intent, or Outpatient referral, symptom reduction.
Low factors behavior Give emergency/crisis numbers
(This chart is intended to represent a range of risk levels and interventions, not actual determinations.)

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant
others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.

50
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Patient Safety Plan Template
Step 1. Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be
developing:

1. _________________________________________________________________________________________
2. _________________________________________________________________________________________
3. _________________________________________________________________________________________

Step 2. Internal coping strategies – things I can do to take my mind off my problems
without contacting another person (relaxation technique, physical activity):

1. _________________________________________________________________________________________
2. _________________________________________________________________________________________
3. _________________________________________________________________________________________

Step 3. People and social settings that provide distraction:

1. Name ________________________________________ Phone ____________________________________

2. Name ________________________________________ Phone ____________________________________
3. Place _________________________________________ 4. Place ___________________________________

Step 4. People whom I can ask for help:

1. Name ________________________________________ Phone ____________________________________

2. Name ________________________________________ Phone ____________________________________
3. Name ________________________________________ Phone ____________________________________

Step 5. Professionals or agencies I can contact during a crisis:

1. Clinician Name _________________________________ Phone ____________________________________

Clinician pager or emergency contact # ______________________________________________________
2. Clinician Name _________________________________ Phone ____________________________________
Clinician pager or emergency contact # ______________________________________________________
3. Local Urgent Care services _________________________________________________________________
Urgent Care services address _______________________________________________________________
Urgent Care services phone ________________________________________________________________
4. Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)

Step 6. Making the environment safe:

1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
Safety Plan Template ©2008 Barbara Stanley and Gregory K. Brown, is reprinted with the express permission of the authors. No portion of the Safety Plan Template may be reproduced
without their express, written permission. You can contact the authors at bhs2@columbia.edu or gregbrow@mail.med.upenn.edu.

The one thing that is most important to me and worth living for is:
___________________________________________________________________________________________

53
Crisis Support Plan
For: _________________________________________ Date: ________________________________________
I understand that suicideal risk is to be taken very seriously. I want to help ____________________________
find new ways of managing stress in times of crisis. I realize there are no guarantees about how crises
resolve, and that we are all making reasonable efforts to maintain safety for everyone. In some cases,
inpatient hospitalization may be necessary.
Things I can do:
f Provide encouragement and support
• ___________________________________________________________________________________
• ___________________________________________________________________________________
f Help ___________________________________ follow his/her Crisis Action Plan
f Ensure a safe environment:
1. Remove all firearms and ammunition
2. Remove or lock up:
• knives, razors, and other sharp objects
• prescriptions and over-the-counter drugs (including vitamins and aspirin)
• alcohol, illegal drugs, and related paraphernalia
3. Make sure someone is available to provide personal support and monitor him/her at all times
during a crisis and afterwards as needed.
4. Pay attention to his/her stated method of suicide/self-injury and restrict access to vehicle, ropes,
inflammables, etc. as appropriate.
5. Limit or restrict access to vehicle/car keys as appropriate.
6. Identify people who might escalate risk for the client and minimize their contact with the client.
7. Provide access to things client identifies as helpful and encourage healthful behaviors such as
good nutrition and adequate rest.
f Other ________________________________________________________________________________

If I am unable to continue to provide these supports, or if I believe that the Crisis Action Plan is not helpful
or sufficient, I will contact [name of therapist or therapy practice] immediately and express my concerns.
If I believe ____________________________________ is a danger to self or others, I agree to:
f Call [name of therapist or therapy practice and phone number]
f or call 911
f or help _________________________________ get to a hospital.

I agree to follow by this plan until ____________________. Support signature: ________________________

Client signature: _______________________________ Therapist signature: ____________________________

SPRC Mental Health Program

54