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and treatment of mental illnesses.

A Clinical Pathway for Suicide Risk Screening in Adult Primary Care

Suicide is a leading cause of death for adults in the United States, yet many people at risk for suicide go unrecognized and do not receive critical mental health care. However, most of these adults will have seen their primary care doctor in the year before their suicide attempt or death. For this reason, primary care doctors are ideally positioned to improve the identification and referral of people at risk for suicide.

A workgroup organized and supported by the National Institute of Mental Health (NIMH) developed an evidence-based suicide detection and prevention pathway to make it easier for primary care doctors to implement suicide risk screening in their practices. The pathway, intended for use in adult primary care settings, will serve as a resource to help doctors identify patients at risk for suicide and connect them to mental health services. It includes detailed information on how to conduct suicide risk screening and when and how to intervene. A similar pathway for suicide risk screening in pediatric emergency departments is also available. Both pathways were developed by NIMH and non-NIMH experts based on their research and experience, as well as an extensive review of the literature.

The workgroup designed the pathway to be both thorough and flexible. Clear steps guide primary care practitioners through the screening and assessment process and provide a standard set of recommendations to which doctors and other staff can refer. At the same time, a high degree of flexibility allows the pathway to be modified to fit the needs of individual practices and their existing workflows.

The guidance is delivered via three documents that introduce the pathway and its approach to suicide risk screening, visually depict action paths based on different risk levels, and outline how to conduct the screening in clinical practice. Practices are advised to review the documents carefully and identify staff for each pathway step and courses of action for each risk level.

The three steps of the pathway are the following:

  1. Suicide risk screening: New and existing patients are screened regularly for suicide risk using short, evidence-based survey tools to identify those who may need further evaluation.
     
  2. Suicide safety assessment: Patients with a positive risk screen receive a brief suicide safety assessment administered by a trained professional using an evidence-based risk assessment tool. This conversation with the patient helps determine next steps for their care based on current suicidal thoughts or plans and specific risk and protective factors.
     
  3. Course-of-action planning: Based on a patient’s level of risk (low, moderate, or high), doctors initiate a course of action. For patients at moderate or high risk, this can involve emergency psychiatric evaluation, immediate crisis management, further evaluation, follow-up care, safety planning or safety counseling, ongoing monitoring, and additional referral, as necessary.

Although the pathway is grounded in knowledge from research and experts in the field, there is not yet evidence on how well it works or how easy it is to implement. Studies evaluating the pathway will show whether its use increases the frequency and quality of suicide screening, improves the identification of people at risk for suicide, and connects at-risk people with critical services. Nonetheless, this pathway is a promising starting point for increasing access to suicide screening in adult primary care so people can be identified and referred to services earlier. Hopefully, with further testing and evaluation, it will be the first step in addressing a significant public health issue.

Reference

Ayer, L., Horowitz, L. M., Colpe, L., Lowry, N. J., Ryan, P. C., Boudreaux, E., Little, V., Erban, S., Ramirez-Estrada, S., & Schoenbaum, M. (2022). Clinical pathway for suicide risk screening in adult primary care settings: Special recommendations. Journal of the Academy of Consultation-Liaison Psychiatry. https://doi.org/10.1016/j.jaclp.2022.05.003

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