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    ResouRces

    n

    n

    n

    n

    Download this card and additional resources at http://wwww.sprc.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

    AcKNoWLeDGMeNTs

    n Originally conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and the Suicide Prevention Resource Center.

    n 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/recommendations expressed in this material are those of the author and do not necessarily reflect the views of SAMHSA.

    National Suicide Prevention Lifeline

    1-800-273-TALK (8255)

    http://www.sprc.org

    HHS Publication No. (SMA) 09-4432 • CMHS-NSP-0193Printed 2009

    SAFE-TSuicide Assessment Five-step

    Evaluation and Triage1

    IDeNTIFY RIsK FAcToRs

    Note those that can be modified to reduce risk

    2IDeNTIFY PRoTecTIVe FAcToRs

    Note those that can be enhanced

    3coNDucT suIcIDe INQuIRY

    Suicidal thoughts, plans,behavior, and intent

    4DeTeRMINe RIsK LeVeL/INTeRVeNTIoN

    Determine risk. Choose appropriateintervention to address and reduce risk

    5DocuMeNT

    Assessment of risk, rationale,intervention, and follow-up

    U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services Administrationwww.samhsa.gov

    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 3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior

    3 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

    3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations

    3

    3 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

    3 change in treatment: discharge from psychiatric hospital, provider or treatment change

    3 Access to firearms

    Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization

    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

    3

    3

    3

    3

    3

    3

    * 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

    3

    3

    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

    HighPsychiatric diagnoses 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 significant change reduces risk. Suicide precautions

    ModerateMultiple 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

    LowModifiable 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 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.

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