Suicide: Assessment and Management

Excerpt

Healthcare professionals have a key role in assessing the risk of suicide in patients. More than half of the individuals who died by suicide have seen a healthcare professional within the preceding year. Healthcare use by those who subsequently die by suicide is more common across all healthcare settings, including outpatient medical specialty clinics, primary care, inpatient hospitals, and emergency departments. Despite the awareness of suicide risk, assessing and managing this risk remains challenging for healthcare professionals, even though suicides are preventable using evidence-based interventions. However, "The estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment, since no study has identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior."

Suicide is a leading cause of death worldwide. According to the World Health Organization, Suicide Worldwide in 2019, Global Health Estimates, more than 700,000 people died by suicide in 2019, and suicide is the fourth leading cause of death among adolescents and young adults aged 15 to 29. Suicide is a global health issue affecting all ages, sexes, and regions. A significant barrier to screening for suicide risk is the dilemma of how to care for patients who screen positive; every patient care setting needs a plan to manage cases like this. The National Institute of Mental Health Ask Suicide Questions (ASQ) Toolkit website is a free resource that provides tools to help providers in various settings identify individuals at risk for suicide and provides evidence-based clinical pathways for further interventions.

Pathways for managing suicide risk can be described in 3 steps:

1. Brief screening for suicide risk

2. Brief suicide safety assessment for patients who screen positive

3. Determining a course of action for patients who screen positive

Brief Screening for Suicide Risk

The purpose of a brief screening for suicide risk is to identify patients at risk of suicide. Screening with evidence-based tools can be universal or targeted to higher-risk groups and may be incorporated into the electronic health record. Barriers to screening include concerns that asking about suicide risk can cause increased distress; worry about inordinate amounts of time to refer patients who screen positive to emergency or mental health services, causing disruptions in workflow; and negative patient reactions to screening. However, study results show that asking about suicide risk does not cause iatrogenic harm. Brief evidence-based interventions reduce immediate risk, and screening for suicide risk has broad support among patients and caregivers. Evidence-based screening tools include the Ask Suicide-Screening Questions, available in multiple languages; the Patient Safety Screener-3; and the Columbia-Suicide Severity Rating Scale, Screening Version, which are brief and easy to use. Depression screening alone is not adequate.

Brief Suicide Safety Assessment for Patients Who Screen Positive

Patients who screen positive should have a Brief Suicide Safety Assessment (BSSA) to clarify a patient's risk severity. This is not a full psychiatric assessment and takes 10 to 15 minutes; the BSSA, however, can help decide the next steps. The National Institute of Mental Health ASQ Toolkit website offers a toolkit that provides scripts and worksheets for BSSA of youths and adults in the emergency department, inpatient medical and surgical units, and outpatient settings, as well as a patient resource list. A 3-step process of screening, assessing, and disposition is effective in reducing the risk of patient suicide. Educational initiatives for primary care clinicians yield the most benefit since they encounter a significant portion of suicidal patients as the first point of contact.

Determining a Course of Action/Disposition

Clinicians across different healthcare settings can identify suicide risk and connect patients to further mental health care. BSSA has 3 possible scenarios that guide the next steps in caring for a patient who has revealed suicidal ideation or engaged in suicidal behavior:

1. Patients at imminent risk or with acute positive screens need emergency psychiatric and safety evaluations; clinicians are obligated to ensure the patient's safety.

2. Patients who are at moderate risk or require further evaluation need a prompt, comprehensive assessment from a mental health professional and interventions such as a safety plan, lethal means safety counseling, and access to crisis resources.

3. Patients at mild risk may not require further evaluation but could benefit from mental health follow-up and developing a safety plan, as well as receiving a list of resources, such as the 988 Suicide and Crisis Lifeline number.