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Brief Suicide Safety Assessment Guide

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What to do when a pediatric patient screens positive for suicide risk:

  • Use after a patient (10 - 24 years) screens positive for suicide risk on the asQ
  • Assessment guide for mental health clinicians, MDs, NPs, or PAs
  • Prompts help determine disposition
  1. Praise patient

    for discussing their thoughts

    “I’m here to follow up on your responses to the suicide risk screening questions. These are hard things to talk about. Thank you for telling us. I need to ask you a few more questions.”
  2. Assess the patient

    Review patient’s responses from the asQ

    (If possible, assess patient alone depending on developmental considerations and parent willingness.)

    Frequency of suicidal thoughts

    Determine if and how often the patient is having suicidal thoughts.

    Ask the patient: “In the past few weeks, have you been thinking about killing yourself?” If yes, ask: “How often?” (once or twice a day, several times a day, a couple times a week, etc.) “When was the last time you had these thoughts?”

    “Are you having thoughts of killing yourself right now?” (If “yes,” patient requires an urgent/ STAT mental health evaluation and cannot be left alone. A positive response indicates imminent risk.)

    Suicide plan

    Assess if the patient has a suicide plan, regardless of how they responded to any other questions (ask about method and access to means).
    Ask the patient: “Do you have a plan to kill yourself?” If yes, ask: “What is your plan?” If no plan, ask: “If you were going to kill yourself, how would you do it?”

    Note: If the patient has a very detailed plan, this is more concerning than if they haven’t thought it

    through in great detail. If the plan is feasible (e.g., if they are planning to use pills and have access to pills), this is a reason for greater concern and removing or securing dangerous items (medications, guns, ropes, etc.).

    Past behavior

    Evaluate past self-injury and history of suicide attempts (method, estimated date, intent).
    Ask the patient: “Have you ever tried to hurt yourself?” “Have you ever tried to kill yourself?”
    If yes, ask: “How? When? Why?” and assess intent: “Did you think [method] would kill you?” “Did you want to die?” (for youth, intent is as important as lethality of method) Ask: “Did you receive medical/psychiatric treatment?”

    Note: Past suicidal behavior is the strongest risk factor for future attempts.

    Symptoms

    Ask the patient about:

    Depression:
    “In the past few weeks, have you felt so sad or depressed that it makes it hard to do the things you would like to do?”
    Anxiety:
    “In the past few weeks, have you felt so worried that it makes it hard to do the things you would like to do or that you feel constantly agitated/on-edge?”
    Impulsivity/Recklessness:
    “Do you often act without thinking?”
    Hopelessness:
    “In the past few weeks, have you felt hopeless, like things would never get better?”
    Anhedonia:
    “In the past few weeks, have you felt like you couldn’t enjoy the things that usually make you happy?”
    Isolation:
    “Have you been keeping to yourself more than usual?”
    Irritability:
    “In the past few weeks, have you been feeling more irritable or grouchier than usual?”
    Substance and alcohol use:
    “In the past few weeks, have you used drugs or alcohol?” If yes, ask: “What? How much?”
    Sleep pattern:
    “In the past few weeks, have you had trouble falling asleep or found yourself waking up in the middle of the night or earlier than usual in the morning?”
    Appetite:
    “In the past few weeks, have you noticed changes in your appetite? Have you been less hungry or more hungry than usual?”
    Other concerns:
    “Recently, have there been any concerning changes in how you are thinking or feeling?”

    Social Support & Stressors

    (For all questions below, if patient answers yes, ask them to describe.)

    Support network:
    “Is there a trusted adult you can talk to? Who? Have you ever seen a therapist/counselor?” If yes, ask: “When?”
    Family situation:
    “Are there any conflicts at home that are hard to handle?”
    School functioning:
    “Do you ever feel so much pressure at school (academic or social) that you can’t take it anymore?”
    Bullying:
    “Are you being bullied or picked on?”
    Suicide contagion:
    “Do you know anyone who has killed themselves or tried to kill themselves?”
    Reasons for living:
    “What are some of the reasons you would NOT kill yourself?”
  3. Interview patient & parent/guardian together

    If patient is ≥ 18 years, ask patient’s permission for parent/guardian to join.

    Say to the parent: “After speaking with your child, I have some concerns about his/her safety. We are glad your child spoke up as this can be a difficult topic to talk about. We would now like to get your perspective.”

    • “Your child said… (reference positive responses on the asQ). Is this something he/she shared with you?”
    • “Does your child have a history of suicidal thoughts or behavior that you’re aware of?” If yes, say: “Please explain.”
    • “Does your child seem:
      • Sad or depressed?”
      • Anxious?”
      • Impulsive? Reckless?”
      • Hopeless?”
      • Irritable?”
      • Unable to enjoy the things that usually bring him/her pleasure?”
      • Withdrawn from friends or to be keeping to him/herself?”
    • “Have you noticed changes in your child’s:
      • Sleeping pattern?”
      • Appetite?”
    • “Does your child use drugs or alcohol?”
    • “Has anyone in your family/close friend network ever tried to kill themselves?”
    • “How are potentially dangerous items stored in your home?” (e.g. guns, medications, poisons, etc.)
    • “Does your child have a trusted adult they can talk to?” (Normalize that youth are often more comfortable talking to adults who are not their parents)
    • “Are you comfortable keeping your child safe at home?”

    At the end of the interview, ask the parent/guardian:
    “Is there anything you would like to tell me in private?”

  4. Make a safety plan with the patient

    Include the parent/guardian, if possible.

    Create a safety plan for managing potential future suicidal thoughts. A safety plan is different than making a “safety contract”; asking the patient to contract for safety is NOT effective and may be dangerous or give a false sense of security.

    Say to patient:
    “Our first priority is keeping you safe. Let’s work together to develop a safety plan for when you are having thoughts of suicide.”
    Examples: “I will tell my mom/coach/teacher.” “I will call the hotline.” “I will call               .”
    Discuss coping strategies to manage stress (such as journal writing, distraction, exercise, self-soothing techniques).
    Discuss means restriction (securing or removing lethal means):
    “Research has shown that limiting access to dangerous objects saves lives. How will you secure or remove these potentially dangerous items (guns, medications, ropes, etc.)?”
    Ask safety question:
    “Do you think you need help to keep yourself safe?” (A “no” response does not indicate that the patient is safe; but a “yes” is a reason to act immediately to ensure safety.)
  5. Determine disposition

    After completing the assessment, choose the appropriate disposition plan. If possible, nurse should follow-up with a check-in phone call (within 48 hours) with all patients who screened positive.

    • Emergency psychiatric evaluation: Patient is at imminent risk for suicide (current suicidal thoughts). Send to emergency department for extensive mental health evaluation (unless contact with a patient’s current mental health provider is possible and alternative safety plan for imminent risk is established).
    • Further evaluation of risk is necessary: Review the safety plan and send home with a mental health referral as soon as patient can get an appointment (preferably within 72 hours).
    • Patient might benefit from non-urgent mental health follow-up: Review the safety plan and send home with a mental health referral.
    • No further intervention is necessary at this time.

    For all positive screens, follow up with patient at next appointment.

  6. Provide resources to all patients

    • 24/7 National Suicide Prevention Lifeline 1-800-273-TALK (8255) En Español: 1-888-628-9454
    • 24/7 Crisis Text Line: Text “HOME” to 741-741