Suicidal Ideation: Assessment and Intervention
Suicide is preventable. A comprehensive approach to suicide prevention is urgently needed in all states to continue to build on the progress that began in 2019. A comprehensive approach relies on the use of data to drive decision-making and robust implementation and evaluation of prevention strategies (3) that address the range of factors associated with suicide, especially among disproportionately affected populations.** Such strategies, as laid out in CDC’s Suicide Prevention Technical Package (3) are especially relevant during the COVID-19 pandemic and should include community partners, such as public health, education, health care, and employers, coming together to enhance resilience and improve well-being by strengthening economic supports (e.g., unemployment benefits), expanding access to and delivery of care (e.g., telehealth), promoting social connectedness, creating protective environments (e.g., safely securing medications and firearms), teaching coping and problem-solving skills, identifying and supporting persons at risk, and lessening harms and preventing future risk (e.g., safe media reporting on suicide) (3) Changes in Suicide Rates — United States, 2019 and 2020 | MMWR (cdc.gov)
Forty-five percent of individuals who die by suicide visit their primary care physician within a month before their death and 67% of those who attempt suicide receive medical attention because of their attempt (SAMHSA.gov). Suicidal ideation can present in any healthcare setting. Be aware of suicide risks and warning signs to help prevent suicide. For additional information about suicide prevention within the primary care setting, access the Suicide Prevention Resource Center’s Suicide Prevention Toolkit for Primary Care Practices. The U.S. Department of Veterans Affairs and the Department of Defense (VA/DoD) established a Clinical Practice Guideline for the assessment and management of patients at risk for suicide. The guideline identifies critical decision points in the management of suicide risk behavior and provides clear recommendations on incorporating current information into practice. The guideline is only a tool to assist providers and is not a substitute for clinical judgment.
Assessing for Suicidal Ideation
Ask the member if they feel suicidal or have thoughts of suicide then assess for the following:
Plan- Ask the member if they have a specific plan for how they would hurt themselves.
Access- Ask member if they have access to means they could hurt themselves with (weapons, pills, etc.).
Lethality- Assess if the plan is lethal. Is it possible that the member or another person will be harmed?
Warning Signs
- Threatening to kill oneself
- Talking of wanting to hurt oneself
- Looking for means to harm self (firearms, pills)
- Talking or writing about death and dying
- Increased risky behavior
- Increased substance use
- Stops taking medication (insulin, blood pressure medications)
- Family history of suicide
- PHQ-9 Score of 15 or higher
- Anxiety, agitation, too much/too little sleep
- Feeling trapped
- Hopelessness
- Withdrawal from friends or family
- Rage, uncontrolled anger
- Dramatic mood change
- Sudden elevation in mood
- Giving away belongings
- Rapid weight loss
- Previous suicide attempts
Interventions and Resources
- When active suicidal ideation presents, contact 911
- Identify your local Psychiatric Evaluation Team through local police or psychiatric hospitals for further assessment
- National Suicide Prevention Hotline (24/7): 988
- Crisis Text Line (24/7): Text CONNECT to 741741
- Refer to an in-network mental health provider
- After a crisis, refer the member to Molina Healthcare Case Management for care coordination and additional support
- PsychHub Resources for Providers: Through Molina’s partnership with PsychHub, providers may access a variety of learning hubs and online, digital education resources related to suicide prevention and treatment. This includes continuing education courses in Trauma Informed Care, CAMS, CALMS, Motivational Interviewing, Foundations in Safety Planning for Clinicians, and Suicidal Behavior Competency. To access these resources, go to https://resources.psychhub.com/molina and create an account at no cost to you. Suicide Prevention Resource Center Behavioral Health Care | Suicide Prevention Resource Center (sprc.org)
- Suicide Prevention Health Knowledge Platform (Suicide Prevention Resource Center) Home: All courses (healtheknowledge.org)
- The National Zero Suicide Model: Homepage | Zero Suicide (edc.org)
- Recent Studies found that higher fidelity to practices associated with the Zero Suicide Model was associated with lower instances of suicidal behavior among patients under care at 110 Outpatient Mental Health Clinics. Suicide specific quality improvement activities and lethal means reduction were two essential components of Zero Suicide fidelity along with five other highly effective practices. The Relationship Between Suicidal Behaviors and Zero Suicide Organizational Best Practices in Outpatient Mental Health Clinics | Psychiatric Services (psychiatryonline.org) and Psych News Alert: ‘Zero Suicide’ Practices at Mental Health Clinics Reduce Suicide Among Patients, Study Finds
- CAMS: Collaborative Assessment and Management of Suicidality. CAMS is a therapeutic framework for suicide specific assessment and treatment of a patient’s suicidal risk that is evidence based short term approach. Training and free CEUs are available using the above mentioned source, PsychHub https://resources.psychhub.com/molina
- Counseling on Access to Lethal Means (CALM) Zero Suicide (edc.org) Training and free CEUs are available using the above mentioned PsychHub: https://resources.psychhub.com/molina
- Lethal Means & Suicide Prevention : A Guide for Community & Industry Leaders Lethal Means & Suicide Prevention: A Guide for Community & Industry Leaders | National Action Alliance for Suicide Prevention (theactionalliance.org)
- Preventing Suicide in Emergency Departments Zero Suicide (edc.org)
- Choosing a Suicide Risk Screening Tool RS_suicide screening_91814 final.pdf (sprc.org)
- SAMHSA: Resources for Suicide Prevention Resources for Suicide Prevention | SAMHSA
- Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care | National Action Alliance for Suicide Prevention (theactionalliance.org)
- Recommended Standard Care for People with Suicide Risk Recommended Standard Care | National Action Alliance for Suicide Prevention (theactionalliance.org)
- Lifeline Online Postvention Manual: LifelineOnlinePostventionManual.pdf (sprc.org)
- The National Institute of Mental Health Ask Suicide-Screening Questions NIMH » Ask Suicide-Screening Questions (ASQ) Toolkit (nih.gov)
- National Institute of Mental Health : Suicide Prevention NIMH » Suicide Prevention (nih.gov)
- SPRC- Choosing a suicide prevention gatekeeper training program: https://sprc.org/wp-content/uploads/2022/12/GatekeeperMatrix6-21-18_0.pdf
4 Key Roles for Providers *Per the Suicide Prevention Resource Center
- Screen and treat or refer for major depressive disorders and substance use disorders.
- Assess and treat for common risk factors: insomnia, chronic pain, severe anxiety, PTSD.
- Educate patients and caregivers on warning signs and resources.
- Teach benefits of safe firearm, ammunition, and medication storage.
Additional Considerations
- In 2020 Suicide was the 2nd leading cause of death for people ages 10-14, and 25-34. Changes in Suicide Rates — United States, 2019 and 2020 | MMWR (cdc.gov) & Preventing Suicide (cdc.gov)
- Although many age groups experienced a decline in rates between 2019 and 2020, the suicide rates increased among persons aged 25–34 years (the 3rd highest group of suicides);
- Rates were highest among persons aged 85 years or older (the highest rates), followed by those aged 75-84 and then 25 to 34.
- Although, rates among non-Hispanic White females and males declined from 2019 to 2020, the suicide rate among Hispanic males and non-Hispanic multiracial females increased.
- The Suicide rate among males in 2020 was 4x higher than the rate among females.
- In 2020 the leading means of suicide was firearm, at a rate 2x that of suffocation, the second leading means. In 2020 the leading means for suicide for females was firearm, a change from previous years. For men, the use of firearms has continued to increase
- For children or adolescent members who have expressed suicidal ideation or suicide attempts, providers are encouraged to engage parents and recommend additional parenting support groups and resources (including, but not limited to, parenting support groups, individual and family counseling, faith- or community-based resources, resources available through school districts, etc.).
PsychHub Education and Learning Available to You
Through our partnership with PsychHub, an online platform for digital mental health education, Molina network providers are able to access PsychHub’s library of educational courses and material at no charge. To create an account at no cost, please visit the Molina PsychHub landing page at https://resources.psychhub.com/molina . Create an account to find these and other relevant courses: