RESOURCES „ Download this card and additional resources at http://www.sprc.org or at http://www.stopasuicide.org „ Resource for implementing The Joint Commission 2007 Patient Safety Goals on Suicide http://www.sprc.org/library/jcsafetygoals.pdf „ SAFE-T drew upon the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors http://www.psychiatryonline. com/pracGuide/pracGuideTopic_14.aspx „ Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s ACKNOWLEDGEMENTS „ Originally conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and the Suicide Prevention Resource Center. „ This material is based upon work supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) under Grant No. 1U79SM57392. Any opinions/ fi ndings/conclusions/recommendations expressed in this material are those of the author and do not necessarily refl ect the views of SAMHSA. National Suicide Prevention Lifeline 1.800.273.TALK (8255) COPYRIGHT 2009 BY EDUCATION DEVELOPMENT CENTER, INC. AND SCREENING FOR MENTAL HEALTH, INC. ALL RIGHTS RESERVED. PRINTED IN THE UNITED STATES OF AMERICA. FOR NON-COMMERCIAL USE. SuicideAssessment Five-step Evaluation and T riage for Mental Health Professionals 1 IDENTIFY RISK FACTORS Note those that can be modifi ed to reduce risk 2 IDENTIFY PROTECTIVE FACTORS Note those that can be enhanced 3 CONDUCT SUICIDE INQUIRY Suicidal thoughts, plans behavior and intent 4 DETERMINE RISK LEVEL/INTERVENTION Determine risk. Choose appropriate intervention to address and reduce risk 5 DOCUMENT Assessment of risk, rationale, intervention and follow-up eAssessment Five-step SAFE-T NATIONAL SUICIDE PREVENTION LIFELINE 1.800.273.TALK (8255) Suicide assessments should be conducted at fi rst contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change; for inpatients, prior to increasing privileges and at discharge. 1. RISK FACTORS D Suicidal behavior: history of prior suicide attempts, aborted suicide attempts or self-injurious behavior D 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 D Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, insomnia, command hallucinations D Family history: of suicide, attempts or Axis 1 psychiatric disorders requiring hospitalization D Precipitants/Stressors/Interpersonal: triggering events leading to humiliation, shame or despair (e.g., loss of relationship, fi nancial 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. D Change in treatment: discharge from psychiatric hospital, provider or treatment change D Access to fi rearms 2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract signifi cant acute risk D Internal: ability to cope with stress, religious beliefs, frustration tolerance D External: responsibility to children or beloved pets, positive therapeutic relationships, social supports 3. SUICIDE INQUIRY Specifi c questioning about thoughts, plans, behaviors, intent D Ideation: frequency, intensity, duration–in last 48 hours, past month and worst ever D Plan: timing, location, lethality, availability, preparatory acts D Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun), vs. non-suicidal self injurious actions D 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 D Assessment of risk level is based on clinical judgment, after completing steps 1-3 D Reassess as patient or environmental circumstances change 5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., setting, medication, psychotherapy, E.C.T., contact with signifi cant others, consultation); fi rearm instructions, if relevant; follow up plan. For youths, treatment plan should include roles for parent/guardian. RISK LEVEL RISK / PROTECTIVE FACTOR SUICIDALITY POSSIBLE INTERVENTIONS High Psychiatric disorders with severe symptoms, or acute precipitating event; protective factors not relevant Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal Admission generally indicated unless a signifi cant change reduces risk. Suicide precautions Moderate Multiple risk factors, few protective factors Suicidal ideation with plan, but no intent or behavior Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers Low Modifi able risk factors, strong protective factors Thoughts of death, no plan, intent or behavior Outpatient referral, symptom reduction. Give emergency/crisis numbers (This chart is intended to represent a range of risk levels and interventions, not actual determination