1. Identification

Identification of suicide risk typically refers to identification of suicidal ideation – that is, asking about a wish for death or thoughts about suicide. While many patients who attempted suicide (Richards, et al., 2018) and who died by suicide (Louzon, et al., 2016; Obegi, 2021) denied having suicidal thoughts, asking about suicidal ideation remains the standard entry point into a pathway of suicide care. Identification of suicidal behavior may also serve as an entry point.

Among the Joint Commission’s resources for evidence-based clinical tools to support identification of suicide risk, we recommend:

• Ask Suicide-Screening Questions (ASQ) Toolkit
• Columbia Suicide Severity Rating Scale (C-SSRS) – Triage Version

These clinical tools ask about lower levels of suicidal ideation – i.e., wishes for death – as well as actual thoughts about suicide and a history of suicidal behavior. When suicide risk is identified with a “yes” response to these screening questions, clinicians then proceed to further assessment.

Ask Suicide-Screening Questions (ASQ)

• ASQ Suicide Risk Screening Tool (NIH)
• How to Use the ASQ to Detect Patients at Risk for Suicide – Training Webinar (NIMH)

Columbia Suicide Severity Rating Scale (C-SSRS) – Triage Version

Many versions of the C-SSRS are available for different settings and clinical circumstances. The C-SSRS Triage version has good utility in outpatient settings.

• C-SSRS – Screener Recent with Triage for Outpatient/Ambulatory (The Columbia Lighthouse Project) 
• C-SSRS Screener Training (The Columbia Lighthouse Project)
• Assessment of Suicidal Risk using the C-SSRS (Center for Practice Innovations) 

On “The Columbia Protocol for Healthcare and Other Community Settings” site, scroll to find the C-SSRS Triage version listed as “SCREENER: Screener Recent With Triage For Outpatient/Ambulatory.” The YouTube online training linked above refer to this as the “C-SSRS Screener” in the title of the video and as the “C-SSRS screen version” in the content of the video. All of the “Triage and Risk Identification” C-SSRS versions share five questions on suicidal ideation and one question on suicidal behavior.

2. Assessment

When suicide risk, as expressed as suicidal ideation or behavior, has been identified, the next step is further assessment. Assessment of suicide risk is the process of reviewing risk factors that increase suicide risk and protective factors that decrease suicide risk. Typically, assessment will include a review of general risk factors and protective factors – such as demographic characteristics, life stressors, psychiatric symptoms, and reasons for living – and a suicide inquiry into suicide-specific risk factors – such as the extent of suicidal ideation, presence of suicidal behavior, and access to lethal means for suicide.

Suicide risk assessment may be performed in a conversational, narrative manner, with the assistance of structured assessment tools, or a combination of approaches. The purpose of suicide risk assessment is to provide information on the presence or absence of risk and protective factors and the patient’s experience of these to be used in formulation of risk. Modifiable risk and protective factors identified during assessment will become targets for management and treatment.

Among TJC’s resources for evidence-based clinical processes to support assessment of suicide risk, we suggest one of two combinations of tools:

• the C-SSRS Risk Assessment checklist to be used with the C-SSRS Lifetime Recent version
• the SAFE-T Protocol with C-SSRS (Columbia Risk and Protective Factors) Lifetime/Recent.

Either of these combinations of clinical tools support the clinician in assessing for general risk and protective factors as well as suicide-specific risk factors.

On the Columbia Lighthouse Project website, scroll to find each of the suggested tools by looking for the name we have included in parentheses.

• C-SSRS Risk Assessment checklist (SUPPORT DOCUMENT: Risk and Protective Factors Page)
• C-SSRS Lifetime Recent version (FULL SCALE: Full Scale Lifetime/Recent)
• SAFE-T Protocol with C-SSRS (ILLUSTRATION DOCUMENT: SAFE-T with C-SSRS Lifetime and Recent)

Online training for the C-SSRS Lifetime/Recent version may be found here.

3. Formulation

Formulation of suicide risk is the process of integrating findings from a suicide risk assessment to guide subsequent interventions. In standard suicide care, formulation relies on clinical judgment in conjunction with consensus-based guidelines to make decisions about the importance and relevance of risk and protective factors identified during risk assessment. The outcome of formulation includes decisions about the overall level of risk, the setting of interventions (inpatient or outpatient) and the types of interventions (such as medication, referrals, safety planning, and psychotherapy, among others) to reduce suicide risk.

TJC refers to the need to document a patient’s “overall level of risk for suicide” (R3, TJC). SAMHSA’s SAFE-T includes guidelines on stratifying risk into categories of low, moderate, and high risk. For easier alignment with clinical decision-making, we suggest use of the Veterans Health Administration’s Therapeutic Risk Management Risk Stratification Table. The Risk Stratification Table formulates risk according to temporality and severity. Temporality refers to how acute (near-term) or chronic (longstanding or enduring) suicide risk is judged to be. Severity refers to the degree or extent of risk as stratified into categories of low, intermediate, and high risk.

• Rocky Mountain MIRECC Therapeutic Risk Management Risk Stratification Table
• Online training for the Risk Stratification Table may be found on YouTube here and on the VHA TRAIN website here.

Please note that while TJC and other guidelines in the United States set an expectation for stratifying risk into low, intermediate and high categories, this practice and expectation is not an international standard. Other countries such as the United Kingdom, Australia, and New Zealand specifically advise against formulating risk in this way, given its lack of evidence in predicting fatal or non-fatal suicidal behavior or in helping to guide follow-up care.

4. Interventions

Interventions for suicide risk include strategies to address risk and protective factors identified during assessment. We distinguish two categories of interventions: management of suicide risk and treatment of suicide risk.

Management refers to short and intermediate term interventions intended to reduce suicide risk. These strategies support the patient in staying alive and surviving crises without necessarily addressing underlying or longer-term problems.

Treatment refers to longer-term strategies focused on addressing emotional and psychological issues directly linked to the development of suicidal thoughts and behaviors. In an effective treatment process, patients develop capacities to self-recognize and self-manage suicide risk while building a life worth living.

5. Management

We identify four broad categories of interventions to manage suicide risk:

1. Addressing behavioral health concerns, including substance use
2. Facilitating connectedness
3. Safety or crisis response planning for high-risk periods
4. Reducing access to lethal means for suicide

These interventions may occur in an inpatient or outpatient setting and are optimally, though not necessarily, collaborative. Some management interventions might not require patient participation at all, such as addressing environmental risks in an inpatient psychiatry setting.

5.1 Addressing Behavioral Health Concerns

Suicide care guidelines differ on approaches to addressing behavioral health concerns, including substance abuse. For example, TJC does not include specific guidelines on psychiatric or substance use disorders, and the VA/DoD Clinical Practice Guideline suggests consideration of ketamine, lithium, or clozapine for specific diagnoses. Recognizing that mental health and substance use disorders are risk factors for suicide, we suggest following standard guidelines for addressing these diagnoses and related problems when these are present.

5.2 Facilitating Connectedness

For individuals identified to be at risk for suicide, TJC identifies a requirement for guidelines for follow-up assessment and monitoring without specifying particular resources for implementing this. Other guidelines focus on strategies for providing or facilitating follow-up behavioral healthcare such as the Zero Suicide Transition element and the VA/DoD Clinical Practice Guidelines for Post-Acute Care recommendations for Caring Contacts, Home visits, and the WHO Brief Intervention and Contact.

5.3 Safety or Crisis Response Planning for High-Risk Periods

Among TJC’s resources for safety planning upon discharge from care, we suggest the Safety Planning Intervention (SPI) and the related Patient Safety Plan Template (Stanley-Brown Safety Plan). We also suggest a comparable evidence-based intervention, Crisis Response Planning (Bryan, et al., 2017).

Safety Planning Intervention

• Safety Plan (Stanley-Brown)
• Training implementing the Safety Planning Intervention (Stanley-Brown)
• Safety Planning Intervention for Suicidal Individuals (New York State Office of Mental Health and Columbia University)

Crisis Response Planning

• An overview of the Crisis Response Plan may be found here
• Crisis Response Planning Training (VA/DoD Clinical Practice Guidelines)

5.4 Reducing Access to Lethal Means

For addressing access to lethal means, TJC recommends the Suicide Prevention Resource Center’s (SPRC) online training, Counseling on Access to Lethal Means (CALM).

• Counseling on Access to Lethal Means (Calm) (SPRC & Zero Suicide)

Clinicians who are unfamiliar with firearms or cultural factors associated with firearms ownership and use can benefit from training to support culturally-aligned lethal means counseling. A free self-guided course addressing this issue may be found here.

6. Treatment

Interventions that “treat suicidal thoughts and behaviors directly” (Zero Suicide) are psychosocial treatments targeting patterns of thoughts, emotions and behaviors that are believed to cause people to wish for death and act on suicidal urges. These treatments posit that thinking about suicide and acting on suicidal urges are not effective ways of coping with life problems and emotional distress. Treatment therefore targets aspects of the suicidal response itself rather than the related life problems and emotional distress. For example, suicidal urges to escape emotional pain might be targeted in treatment with emotion regulation skills to expand pain tolerance and reduce distress over time. Hopeless thoughts related to problems with no immediate solution might be targeted in treatment by exploring options for generating agency or purpose in the midst of a struggle. A pervasive belief about burdensomeness driving suicide as an option might be targeted in treatment with cognitive strategies to examine the validity of a belief that suicide is the only or optimal way to unburden others.

In contrast to management strategies, treatment strategies are necessarily collaborative. The clinician takes a consultative and collaborative stance relative to the patient to foster the patient’s own skills in self-recognition and self-management of suicide risk and resolution of underlying and longer-term issues to achieve recovery.

TJC’s guidelines do not specify treatment of suicide risk as a component of suicide care and do not list resources for this. The National Action Alliance for Suicide Prevention’s Recommended Standard Care for People with Suicide Risk(2018) lists Dialectical Behavior Therapy (DBT), Cognitive Therapy for Suicide Prevention (CT-SP), Collaborative Assessment and Management of Suicidality (CAMS) and Brief Cognitive Behavioral Therapy (BCBT) as resources for treatment.

7. Follow-up

Between outpatient appointments and after a course of care, patients will typically be discharged to their own care. To address risk during these periods of follow-up, safety planning strategies such as the Safety Planning Intervention and Crisis Response Planning include a review of people in a patient’s life who may offer support and clinical or crisis services that the patient can access if self-management strategies are insufficient. During follow-up, caring contacts, a management strategy to facilitate connectedness, may also be used to address suicide risk.

During a course of care, TJC specifies a requirement for policies and procedures that include guidelines for re-assessment of suicide risk and monitoring individuals at high risk for suicide (NPSG 15.01.01, EP 5). While TJC does not specify resources for meeting this requirement, we recommend use of a screening tool as noted above in “Identification” for patients returning for follow-up care, but a full risk assessment is not expected to be repeated. Instead, the screening information (along with follow-up questions, as relevant) and the previous risk assessment can be used to make the acute and chronic risk formulation. This is consistent with TJC’s screening requirement for all patients undergoing evaluation or treatment for behavioral health conditions.

For follow-up assessment of patients engaged in ongoing care such as counseling, psychotherapy or other treatment with frequent visits, we recommend a narrative approach to review life circumstances and psychiatric symptoms that may be contributing to suicide risk as well as a suicide-specific assessment of the extent of suicidal ideation and presence or absence of suicidal behavior. This could make use of a screening tool or a standardized monitoring process such as a diary card in DBT, the suicide status form in CAMS, or the PHQ-9 in depression interventions.

8. Recovery

In our story of suicide care, recovery refers to a process whereby patients become empowered to self-recognize and self-manage their own suicide risk and address the underlying and longer-term risk factors to build a life worth living.