Crisis Intervention: Triage to
Prevent Suicide and Suicide
Attempts
Major risk factors
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Death of a loved one
Chronic pain – physical or psychiatric
Social isolation
Loneliness
Substance abuse, especially alcohol
Changes in social roles
Intense humiliation / loss of face (more
likely in Asian patients)
Clues / Risk factors
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Changes in eating or sleeping habits
Unexplained fatigue or apathy
Trouble concentrating or being indecisive
Crying for no apparent reason
Inability to feel good about themselves or
unable to express joy
• Behavior changes or are just "not
themselves"
More clues / risk factors
• Withdrawal from family, friends or social
activities
• Talk about or seem preoccupied with
death
• Give away prized possessions
• Take unnecessary risks
• Have had a recent loss or expect one
• Increase their use of alcohol, drugs or
other medications
More clues / risk factors
• Failure to take prescribed medicines or follow
required diets
• Acquire a weapon
• Prolonged sad mood (more than just a few days)
• Impulsive nature
• Loss of interest in hobbies, work, etc.
• Loss of interest in personal appearance
• Male sex
• Older male sex, alcoholic, alone in life, no
friends
Somewhat lower risk factors
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Transient sad mood
Female sex
No substance abuse
Family members and friends
Reactive mood
Can think of something that would help
him/her feel better
• Roman Catholic
Assessment
• ASK!
– You cannot prevent a suicide if you don’t ask
the patient
– You will not “suggest” suicide by asking the
patient (a common ‘myth’)
How to ask: – some suggestions
• Build rapport
– Let the patient tell his/her own story
– Can you tell me more about what has been
happening to you?
• Give empathy and sympathy
– It sounds like life has really been difficult for
you
– I’m sorry things have not been going well. I
hope I can help you
How to ask: more suggestions on
what to say
• People often ashamed to tell what they
have been thinking
• Create commonality
– Other people, like you, who have been having
a really rough time, have told me that they
feel life is no longer worth living
– Have you had such thoughts?
– Can you tell me more about those thoughts?
How to ask: more suggestions on
what to say
• Have you had thoughts about ending your
life?
• How long have you been feeling this way?
• If “yes,” consider asking the following:
– Do you have a plan?
– How would you do it?
– Do you have the means to do it?
• Pills, gun
– Who would be upset if you died?
How to ask: more suggestions on
what to say
– Have you ever made a suicide attempt in the
past?
• Past history of suicide attempt is often thing of any
true predictive value
– How many times have you attempted to end
your life?
– When did you do this?
– How did you try to end your life?
How to ask: more suggestions on
what to say
– How likely are you to do it (1 = unlikely, 10 =
highly likely)?
– Do you have any spiritual orientation?
– What do you feel about the meaning of your
life?
– What could happen that would stop you from
trying to end your life?
– What could happen to help you feel better?
Further elements of a risk
assessment
– Current suicidal thoughts, intent, and plan
– History of suicide attempts (eg. lethality of method,
circumstances)
– Family history of suicide
– History of violence (eg. weapon use, circumstances)
– Intensity of current depressive symptoms
– Current treatment regimen and response
– Recent life stressors (eg, marital separation, job loss)
– Alcohol and drug use patterns
Further elements of a risk
assessment
• Psychotic symptoms
• Current living situation (eg, social supports, availability of
weapon)
• Patients with altered perceptions of reality, such as those
caused by intoxication or psychosis
• Obtain a complete history of alcohol and drug use.
• Note whether suicidal thoughts occur during intoxication
or sobriety, or both.
• The presence of psychotic symptoms in a depressed
patient with suicidal ideation is an ominous sign.
Diagnostic / symptomatic
categories for patients at high risk
• Depression
• Alcoholism
• Chronic non-psychiatric medical illness
(demoralization)
• Chronic psychiatric medical illness
• Mourning / grief
• Personality disorders with impulsiveness
Diagnostic / symptomatic
categories for patients at high risk
• Three types of psychotic symptoms are
particularly worrisome and could push a patient
to commit suicide:
– Auditory hallucinations commanding suicidal acts
– Thoughts of external control (feeling that an outside
force controls one's actions)
– Religious preoccupation.
• Patients may not readily report these symptoms;
collateral interviews with family members can
help confirm psychosis.
Differential features
• Is the patient talking about being discouraged
with life because of chronic illness?
• Is the patient talking about end of life issues?
• Is the patient talking about loss of meaning to
life?
• Does the patient have a reactive mood?
• Is the patient attempting to upset someone with
whom they are angry?
• Does the patient have true major depression?
Sad Persons Scale
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S ex (male)
A ge (elderly or adolescent)
D epression
P revious suicide attempts
E thanol abuse
R ational thinking loss (psychosis)
S ocial supports lacking
O rganized plan to commit suicide
N o spouse (divorced > widowed > single)
S ickness (physical illness)
Differential features
• Has the patient lost the ability to control
his/her life (physically or emotionally)
• Has the patient lost a sense of meaning to
his/her life?
Three Groups
• It is useful to categorize depressed
patients who are potentially suicidal into
three groups:
– Patients with ideation, plan, and intent
– Patients with ideation and plan but without
intent, and
– Patients with ideation but no plan or intent.
Interventions / treatment issues
• With all patients, one should employ:
– Empathy / sympathy
– ‘I care. I would be upset if you ended your
life’
– Give 800 number:
• National 1-800-273-TALK (8255)
• Local (415) 752-3778
– Arrange for frequent visits
– Arrange for people at patient’s living place to
check the person more often
Interventions / treatment issues
• Depressed patients with suicidal ideation, plan,
and intent should be hospitalized, especially if
they have current psychosocial stressors and
access to lethal means.
• When a patient's life is in imminent danger, the
caregiver may breach confidentiality and contact
a family member.
• Depressed patients who refuse hospitalization
may be involuntarily hospitalized
Interventions / treatment issues
• Caregivers can contact their local crisis center, or
emergency department for assistance in arranging such
commitments.
• Depressed patients with suicidal ideation and a plan but
without intent may be treated on an outpatient basis,
especially when they have good social support and no
access to lethal means.
• However, some of these patients need hospitalization,
especially if their environment does not offer adequate
safety measures, such as responsible supervision.
• Outpatient treatment may consist of antidepressant
therapy (preferably with antidepressants that are safe in
overdose), referral to a drug and alcohol treatment
program, psychotherapy, or all of these.
Interventions / treatment issues
• Depressed patients who express suicidal
ideation but deny plan or intent should be
evaluated carefully for psychosocial stressors.
• Caregivers should encourage the patient or
family members to remove weapons and other
potentially lethal means from the patient's
environment.
• In general, patients in this category may be
safely treated with antidepressant medication on
an outpatient basis, but they should be seen by
their physician often as long as suicidal thoughts
persist.
Interventions / treatment issues
• No suicide contract or “handshake:”
– Although some caregivers use a written "no suicide"
contract / no suicide handshake with patients
– This is never a substitute for a thorough risk
assessment.
– Many patients who sign such a contract later commit
suicide.
– Therefore, the use of these contracts / handshake
may give caregivers a false sense of security and
provides no protection from legal liability
The case manager, therapist,
peer or caregiver
• How would you feel if a patient of yours
ended their life?
• Has it ever happened to you?
• What things would you do to help
yourself?
• Seldom is the caregiver / therapist
considered after a suicide