Clinicians have historically focused on treating mental health problems, such as depression and anxiety, with the assumption that a patient’s suicidal thoughts and behaviors will cease once the depression or anxiety disorder is resolved.
The research evidence strongly supports targeting and treating suicidal ideation and behaviors specifically and directly, independent of diagnosis, as well as any diagnosed mental health or substance abuse problem.
Newer models of care suggest that treatment and support of persons with suicide risk should also be carried out in the least restrictive setting.
In a Zero Suicide approach:
- All clients with suicide risk, regardless of setting, receive evidence-based treatment to address suicidal thoughts and behaviors directly, in addition to treatment for other mental health issues.
- Clients with suicide risk are treated in the least restrictive setting possible.
How will we provide research-based treatment in the least restrictive setting to address suicidal thoughts and behavior directly?
To Implement Zero Suicide
Provide Evidence-Based Care
- Provide evidence-based interventions specific to suicide in addition to treatments for other mental health issues.
- Train staff in one or more of suicide-specific interventions.
- Assess fidelity to the core treatment components.
- Assess patient outcomes.
- Create standard patient education materials about expectations for specific treatment modalities.
- Create a process for charting patient progress with suicide-specific treatment.
- Share progress on suicide-specific treatment with the patient.
More details about specific interventions are provided at the Interventions/Treatment tab, above.
Provide Care in the Least Restrictive Setting
- In addition to suicide-specific outpatient care, work with community agencies and other partners to provide options for treatment settings and modalities, including but not limited to:
- Crisis center hotline support and follow-up
- Brief intervention and follow-up
- Emergency respite care
- Partial hospitalization, with suicide-specific treatment
- Inpatient psychiatric hospitalization, with suicide-specific treatment
- Telemental health
More details about alternatives to inpatient hospitalization and a stepped-care model for suicide prevention are provided at the Least Restrictive Care tab.
Interventions for Suicide Risk
Care for suicide risk should directly target and treat suicidal thoughts and behaviors and behavioral health disorders using effective, evidence-based treatments.
Some interventions that might be more accurately designated as research-informed are also included in the standard of care for suicide prevention. Research-informed interventions are based on research and theory and perhaps even have components that are evidence-based, but they do not have a body of research showing effectiveness.
Evidence-based interventions include interventions and treatment that are designed to target suicide risk directly. These interventions have demonstrated effectiveness in reducing suicidal thoughts and behaviors.
At this time, only a few interventions are supported by research. In the video to the right, David Jobes, PhD, a clinician-researcher at Catholic University of America, provides a quick overview of these interventions:
- Non-demand “caring contacts”
- Structured, problem-solving therapies
- Collaborative assessment and treatment planning
Jobes, D. A. (2012), The collaborative assessment and management of suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42(6), 640–653. http://onlinelibrary.wiley.com/doi/10.1111/j.1943-278X.2012.00119.x/abst...
Whichever specific model is used, interactions with patients should always be person-centered, collaborative, and careful to acknowledge the ambivalence that patients contemplating suicide risk often feel. Understanding that ambivalence—the desire to find a solution to the intense pain they feel versus the innate human desire to live—is essential for any clinician working with a patient at risk of suicide.
The following sections provide more detail about the interventions Dr. Jobes describes. You’ll find links to resources about these interventions in the Readings and Tools section at the bottom of this page.
Non-Demand Caring Contacts
A growing body of evidence suggests that post-discharge follow-up contacts with high-risk individuals may be an effective suicide prevention strategy. While non-demand, caring contacts are not treatment per se, they can be used as adjuncts to treatment to:
- Keep patients engaged
- Follow up with patients who are difficult to engage
- Extend the connection between provider and patient after treatment has ended
Caring contact interventions include:
- Postcards and/or letters containing brief expressions of caring
- Telephone follow-up contacts with patients after discharge
- Telephone calls combined with in-person contact
Luxton, D. D., June, J. D., & Comtois, K. A. (2013). Can postdischarge follow-up contacts prevent suicide and suicidal behavior? Crisis, 34(1), 32–41. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22846445
Organizations can use automated systems to send postcards, letters, e-mails, or text messages.
Cognitive Behavioral Therapy for Suicide Prevention
This intervention, known as CBT-SP, is theoretically grounded in principles of cognitive behavior therapy (CBT); dialectical behavioral therapy (DBT); and targeted therapies for suicidal, depressed adolescents and adults.
Two studies tested the efficacy of this intervention: one study with adults, which found reductions in attempts and symptoms,, and a second study demonstrating the feasibility of using a similar intervention with adolescents.
CBT-SP can be used with adults and adolescents and includes:
- Cognitive restructuring strategies, such as identifying and evaluating automatic thoughts from cognitive therapy
- Emotion regulation strategies, such as action urges and choices, emotions thermometer, index cue cards, mindfulness, opposite action, and distress tolerance skills from DBT
- Other CBT strategies, such as behavioral activation and problem-solving strategies
Stanley B., Brown, G., Brent, D. A., Wells, K., Poling, K., Curry J., . . . Hughes, J. (2009). Cognitive behavioral therapy for suicide prevention (CBT-SP): Treatment model, feasibility and acceptability. Journal of the American Academy of Child & Adolescent Psychiatry, 48(10), 1005–1013.
Because adolescents’ suicidal crises occur within an environment that may include problematic relationships, abuse, family dysfunction, or poor school performance, CBT-SP includes family interventions if needed.
Dialectical Behavior Therapy (DBT)
The term dialectical means a synthesis or integration of opposites, and in DBT, it refers to the seemingly opposite strategies of acceptance and change.
DBT has four components, although these may be adjusted in practice to suit specific circumstances:
- A skills training group meeting once a week for 24 weeks
- Individual treatment once a week, running concurrently with the skills group
- Phone coaching, upon request by the client
- Consultation team meetings—a kind of “therapy for the therapists”
Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York, NY: Guilford Press. Retrieved http://behavioraltech.org/resources/whatisDBT.cfm
Numerous research studies, including several randomized control trials, have shown DBT to be effective in reducing suicidal behavior and other behavioral health issues. For example, Linehan et al. (2006) compared one year of DBT with women with borderline personality disorder and two or more suicide attempts and/or self-injuries in the past 5 years and at least one in the past 8 weeks to non-behavioral community treatment by experts. Those receiving DBT were significantly less likely to
- Drop out of treatment
- Attempt suicide
- Visit psychiatric emergency rooms
- Experience psychiatric hospitalization
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., . . . Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766. Retrieved from http://jamanetwork.com/journals/jamapsychiatry/fullarticle/209726
Collaborative Assessment and Management of Suicidality
Outpatient care is the explicit goal of the Collaborative Assessment and Management of Suicidality (CAMS), which is designed to strengthen the therapeutic alliance and increase patient motivation. CAMS is best understood as a therapeutic framework that emphasizes a collaborative assessment and treatment planning process between the patient at risk of suicide and the clinician.
CAMS is supported by six published correlational studies and one randomized feasibility study, described briefly as follows:
- Two studies of suicidal college students in a college counseling center showed reductions in suicidal ideation.
- Two studies in outpatient settings in Denmark demonstrated the cross-cultural feasibility of CAMS.
- One study in an inpatient psychiatric setting showed reductions in suicidal ideation, depression, hopelessness, and suicidal cognitions.
- One study in U.S. Air Force outpatient clinics found suicidal ideation was reduced more quickly than in a control group. The intervention was also correlated with reductions in primary care appointments and emergency department visits.
- One study to test the feasibility of a randomized control trial, in an outpatient community mental health center, found reductions in suicidal ideation, overall symptom distress, and optimism/ hope, with the most robust effects occurring at the most distal assessment point—12 months after the start of treatment.
Comtois, K. A., Jobes, D. A., O’Connor, S. S., Atkins, D. C., Janis, K., Chessen, C. E., . . . Yuodelis-Flores, C. (2011). Collaborative assessment and management of suicidality (CAMS): Feasibility trial for next-day appointment services. Depression and Anxiety, 28(11), 963–972. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/da.20895/abstract?deniedAcces...
The standard of care for patients with suicide risk includes some interventions that may be informed by research and clinical practice but do not have a body of research to support them.
Safety planning and lethal means reduction are two such interventions.
A safety plan is a prioritized written list of coping strategies and sources of support developed by a clinician in collaboration with patients who are at high risk for suicide.
According to Dr. Stanley's webinar presentation to the right, safety planning incorporates elements of four evidence-based suicide risk reduction strategies:
- Reducing access to lethal means
- Teaching brief problem-solving and coping skills
- Enhancing social support and identifying emergency contacts
- Using motivational enhancement to increase likelihood of engagement in further treatment
As Dr. Stanley emphasizes in the webinar, a safety plan is not a “no-suicide contract,” which is not recommended by experts in the field of suicide prevention. As they are generally used, no-suicide contracts ask patients to promise to stay alive without telling them how to stay alive.
Additional information about safety planning, including a webinar and training module, can be found in the Engage section of the Toolkit.
Reducing Access to Lethal Means
Limiting access to medications and chemicals and removing or locking up firearms and other weapons are important actions to keep patients safe.
Reducing access to lethal means is based on the following suppositions:
- Many suicide attempts occur with little planning during a short-term crisis
- Intent isn’t all that determines whether an attempter lives or dies; means also matter
- 90% of attempters who survive do NOT go on to die by suicide later
- Access to firearms is a risk factor for suicide
- Firearms used in youth suicide usually belong to a parent
- Reducing access to lethal means saves lives
Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M., ... & Purebl, G. (2016). Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry, 3(7), 646–659. Retrieved from http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(16)30030-X/abstract
Reducing access to possible methods of suicide may be one of the most challenging tasks a clinician faces with a patient. Organization policies should clearly state what clinicians should do regarding lethal means, including the protocol to follow in the event a patient brings a weapon or other lethal means to the clinical setting. More information about reducing access to lethal means, including a webinar and a link to an online training, can be found in the Engage section of the Toolkit.
Providing the Least Restrictive Care
Along with the emphasis on treating suicide risk directly with evidence-based interventions, newer models of care suggest that treatment and support of persons with suicide risk should be carried out in the least restrictive setting. Interventions should be designed—and clinicians should be sufficiently skilled—to work with the person in outpatient treatment, with an array of supports, and avoid hospitalization if at all possible.
A recent article in the American Journal of Preventive Medicine recommended a “stepped care treatment pathway” for suicide prevention. According to the authors, in a stepped care model for suicide prevention, patients are “offered numerous opportunities to access and engage in effective treatment, including standard in-person options as well as telephonic, interactive video, web-based, and smartphone interventions.”
Stepped care has been applied to a myriad of health and behavioral health issues, including substance abuse, depression, stroke, chronic illness, and insomnia, to name just a few. Stepped care involves delivering care such that less intensive, often less restrictive interventions are offered to patients first and then “stepped up” to more intensive services as clinically indicated.
Stepped Care Model
In the video featured on the right, David Jobes of the Catholic University of America emphasizes that less restrictive care is also potentially less expensive. Dr. Jobes offers six levels of care for a stepped care model for suicide risk:
- Crisis center hotline support and follow-up
- Brief intervention and follow-up
- Suicide-specific outpatient
- Emergency respite care
- Partial hospitalization, with suicide-specific treatment
- Inpatient psychiatric hospitalization, with suicide-specific treatment
The following sections provide more information about each of the levels of care Dr. Jobes describes.
Crisis Support & Follow-Up
In the field of suicide prevention, the term "crisis services" has often meant a hotline or helpline model of care—counselors staffing phones or, increasingly, text or chat lines to assist often anonymous callers with a suicidal or behavioral health crisis.
Crisis services, however, have a broader scope. They include mobile crisis teams, walk-in crisis clinics, hospital-based psychiatric emergency services, peer-based crisis services, and other programs designed to provide assessment, crisis stabilization, and referral to an appropriate level of ongoing care. These services can serve as a connection with patients between outpatient visits and are particularly helpful for patients with barriers to accessing outpatient mental health services. Crisis services also include care coordination services with the potential to lower readmission rates for high-utilizing patients.
Pairing a full range of crisis services with mental health follow-up care can reduce involuntary hospitalizations and suicides. Many communities offer two or three levels of crisis care, but few provide a full continuum designed to provide the right care at the right time and support an individual’s ability to cope with suicidal thoughts or feelings.
To incorporate the use of crisis services, health and behavioral health organizations should:
- Establish formal agreements or subcontract with crisis centers to provide follow-up services for their patients.
- Provide written information with the crisis center phone number to every patient with suicide risk, as part of a formal safety plan.
- Provide every patient with the crisis center information again upon discharge from treatment.
- Obtain patient consent prior to discharge from inpatient or ED care for a crisis center to provide follow-up support in the form of phone calls.
Crisis centers that are members of the National Suicide Prevention Lifeline follow best practices in assessing suicide risk and imminent risk and have access to a national network of crisis center peers and resources. Crisis lines for veterans, people who are deaf or hard of hearing, and Spanish speakers are also available. Some crisis lines provide translation for a number of different languages.
Brief Intervention & Follow-Up
Brief interventions have been found to be effective in the reduction of alcohol use and problems and therefore are widely used in substance abuse prevention. Specific interventions range from a single, in-person session to a computer-administered intervention in a primary care office to an online screening and feedback intervention that can be done on a personal electronic device.
Early results from use of brief interventions to reduce suicide risk are promising. For example, Fleischmann and colleagues (2008) tested an information, education, and coping advice intervention with ED patients paired with long-term follow-up contact. They found that the intervention reduced suicide deaths up to 18 months after discharge.
The Safety Planning intervention developed by Barbara Stanley and Greg Brown is another example of a brief intervention, one that is being widely used in health and behavioral health care settings.
Brief interventions can be an immediate intervention and also used in conjunction with any other level of care, for example with individuals in outpatient care. Safety planning is recommended for those individuals who refuse outpatient care.
The delivery of a brief intervention for suicide theoretically requires significantly less training than that required for more sophisticated treatments such as Dialectical Behavior Therapy or Cognitive Behavior Therapy for suicide prevention. Brief interventions also are relatively inexpensive to deliver, as they can be delivered almost anywhere.
Outpatient treatment interventions designed to address suicide risk directly are described in the Interventions/Treatments tab above.
Emergency Respite Care
Respite care is an alternative to inpatient or emergency department services for a person in a mental health or suicidal crisis when that person is not in immediate danger. Respite centers are usually located in residential facilities that are designed to feel more like homes than hospitals. They may also include peers with lived experience of suicide as staff. Individuals in crisis may prefer such settings.
Respite care has shown better functional outcomes than acute psychiatric hospitalization, which increasingly is being considered the intervention of last resort by experts.
Respite center practices may include the following:
- Assistance with providing continuity of care and establishing longer-term support resources
- Provision of phone, text, or online virtual supports for an individual before and/or after a stay
- Evaluation of the development, operation, and outcomes of services provided
Inpatient hospitalization is generally the most restrictive and most costly option for addressing suicide risk. While being in a hospital may reduce the risk for suicide while a patient is in care, most inpatients do not receive suicide-specific, empirically supported techniques aimed at preventing suicide and attempts once they are discharged.
Research has suggested that patients may be at higher risk immediately following discharge from inpatient care.
Therefore, the need to hospitalize a patient at risk for suicide should be carefully considered and weighed against other reasonable alternatives.
Facilitating Less Restrictive Care
Two additional care strategies—mobile crisis care and telemental health—can be helpful supplements at any stage of a stepped-care plan. These strategies may help to maintain a person at risk for suicide in outpatient treatment, thus potentially reducing the need for hospitalization. They also are useful in supporting transitions in care.
Mobile Crisis Teams
Mobile crisis teams provide care in the community at the location of the person who is suicidal. Ideally, these teams include peer specialists and members of relevant professional disciplines, including psychiatry, psychology, counseling, social work, and/or case management.
Research has shown that mobile outreach can help people address psychiatric symptoms and reduce:
- The number and cost of psychiatric hospitalizations
- The need for law enforcement intervention
- The number of ED visits
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2014). Crisis Services: Effectiveness, cost-effectiveness, and funding strategies (HHS Publication No. [SMA]-14-4848). Retrieved from http://store.samhsa.gov/product/Crisis-Services-Effectiveness-Cost-Effec...
Telemental health uses electronic communication, such as two-way video, to provide clinical mental health services from a distance. Health and behavioral health care organizations can use these services to provide emergency assessments and treatment—particularly for patients located in remote geographic regions.
Telemental health has been shown to improve outcomes in general medical settings for patients with behavioral health conditions. In addition to emergency assessments, telemental health services include medication management, clinical therapeutic treatments, and provider-to-provider consultation.
Telemental health may also be a good option for health care organizations with limited access to mental health resources.
Use Evidence-Informed Treatment
The basic next steps to treat patients at risk of suicide are:
- Determine the training needs of and provide training to clinical staff.
- Establish use of the EHR or paper record to document treatment and other services offered and the patient’s use of those services.
There are several additional items to help you plan these next actions:
Quick Guide to Getting Started with Zero Suicide. This one-page tool lists ten basic actions to take to implement a Zero Suicide initiative. Use this tool to get an overall vision of the path you will take to adopt this comprehensive suicide care approach.
Zero Suicide Organizational Self-Study. Every organization should complete the self-study as one of the first steps in adopting a Zero Suicide approach. While the self-study is available in the Lead section of the Zero Suicide online toolkit, it’s provided again here for your convenience.
Zero Suicide Work Plan Template. This form contains an expanded list of action steps to guide your implementation team in creating a full work plan to improve care and service delivery in each of the seven core Zero Suicide components.