ResouRces SAFE-T n Download this card and additional resources at http://wwww.sprc.org n Resource for implementing The Joint Commission 2007 Patient Safety Goals on Suicide http://www.sprc.org/library/jcsafetygoals.pdf S A F n sAFe-T drew upon the American Psychiatric Association uicide ssessment ive-step Practice Guidelines for the Assessment and Treatment of E T Patients with Suicidal Behaviors http://www.psychiatryonline.com/ valuation and riage pracGuide/pracGuideTopic_14.aspx n Practice Parameter for the Assessment and Treatment of Children and 1 Adolescents with Suicidal Behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s IDeNTIFY RIsK FAcToRs Note those that can be modified to reduce risk AcKNoWLeDGMeNTs 2 n Originally conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and IDeNTIFY PRoTecTIVe FAcToRs the Suicide Prevention Resource Center. Note those that can be enhanced n This material is based upon work supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) under 3 Grant No. 1U79SM57392. Any opinions/findings/conclusions/ 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 5 http://www.sprc.org DocuMeNT Assessment of risk, rationale, intervention, and follow-up U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES HHS Publication No. (SMA) 09-4432 • CMHS-NSP-0193 Substance Abuse and Mental Health Services Administration Printed 2009 www.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 Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization 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 2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk 3 Internal: ability to cope with stress, religious beliefs, frustration tolerance 3 external: responsibility to children or beloved pets, positive therapeutic relationships, social supports 3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent 3 Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever 3 Plan: timing, location, lethality, availability, preparatory acts 3 Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions 3 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 3 Assessment of risk level is based on clinical judgment, after completing steps 1–3 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 High symptoms or acute precipitating event; persistent ideation with strong intent or Admission generally indicated unless a significant change reduces risk. Suicide precautions protective factors not relevant suicide rehearsal Admission may be necessary depending on risk Moderate Multiple risk factors, few protective Suicidal ideation with plan, but no intent factors. Develop crisis plan. Give emergency/crisis factors or behavior numbers Low Modifiable risk factors, strong protective Thoughts of death, no plan, intent, or Outpatient referral, symptom reduction. 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.