Suicide Risk Assessment and Care Planning Clinical Pathway — Outpatient Specialty Care
Suicide Risk Assessment and Care Planning Clinical Pathway — Outpatient Specialty Care
Case Example (Low Acuity)
Sarah and Charlotte are 12-year-old females with symptoms of anxiety. Each reveals that she has had had a history of suicidal thoughts in the past, placing them at low acuity based on their suicide risk assessment using the C-SSRS.
Sarah has a history of wish for death and non-specific suicidal ideation (without method or intent). The last time she had these thoughts was more than one month ago. She does not have a history of self-injury. She has struggled with symptoms of anxiety in the past but has not needed mental health services. There are no other red flags.
Charlotte has a history of wish for death and suicidal ideation, and has occasionally considered methods including overdosing on pills or slitting her wrists. The last time she had these thoughts was more than one month ago. Red flags include a history of engaging in non-suicidal self-injurious behaviors (cutting) within the last 3 months. Charlotte has previously been diagnosed with an anxiety disorder in the past. She used to receive supportive therapy, but she is not currently engaged in routine outpatient mental health services.
Sarah’s clinician weighs this additional information when formulating Sarah’s overall risk.
Charlotte’s clinician weighs this additional information when formulating Charlotte’s overall risk.
Sarah would benefit from active monitoring, with a focus on anticipatory guidance, healthy lifestyle choices and continued screening for reoccurrence of suicidal thoughts or behavior. The family may benefit from psychoeducational tools related to monitoring and supporting youth with suicidal thoughts. The clinician might consider a referral for outpatient mental health to help Sarah better manage her anxious distress if symptoms persist.
Charlotte and her family would benefit from psychoeducation and suicide safety planning, including discussion about making the home safer. Charlotte would also benefit from re-engaging in outpatient mental health treatment to address the anxiety and additional coping.
Case Example (Intermediate Acuity)
Tommy and Brandon are 16-year-old males who receive outpatient mental health treatment for depression. During today’s individual appointments, Tommy and Brandon both reveal suicidal ideation with method within the last month, placing them both at intermediate acuity based on their suicide risk assessment using the C-SSRS.
Brandon has a history of suicidal ideation but no history of suicidal behavior. He has been engaged in treatment and has shown good response to medications and individual therapy so far, but is struggling recently in the context of academic stressors and peer conflict. Brandon’s family is felt to be a strong source of support. There are no other red flags.
Tommy also has a diagnosis of ADHD, can be impulsive, and is intermittently compliant with treatment recommendations. He has a history of red flags, including punching walls and burning his skin when he is upset. His mother also reports that Tommy recently came home after curfew from a party and appeared to be intoxicated.
Brandon’s clinician weighs this additional information when formulating Brandon’s overall risk.
Tommy’s clinician weighs this additional information when formulating Tommy’s overall risk.
Brandon would benefit from standard treatment recommendations including Suicide Safety Planning with Brandon and his family, increasing the frequency of individual outpatient therapy, and continuing medication management services.
Tommy would benefit from enhanced treatment recommendations including suicide safety planning with Tommy and his family, incorporating suicide-specific skills and strategies into the individual therapy, continuing medication, and referral to intensive outpatient programming.
Case Example (High Acuity)
Juan and April are 17-year-old teens who each reveal that they have had recent suicidal ideation with method and some intention to act on these thoughts within the past month, placing them both at High Acuity based on their suicide risk assessment using the C-SSRS.
Juan has a diagnosis of major depressive disorder and has been compliant with treatment recommendations including outpatient therapy and medication management. However, his depressive symptoms continue to persist, and Juan has had had several absences from school recently due to his distress. Juan has no previous history of suicide attempt, self-injury, or substance use.
April’s clinician additionally uncovers the following red flags: April has a history of witnessing domestic violence between her parents, and more recently she has been a victim of sexual assault. Caregivers report that April has been drinking alcohol several nights a week, and she has been running away from home. April has a diagnosis of major depressive disorder but has refused to see her therapist or take her medications. Caregivers report that April has become increasingly unpredictable and impulsive and has been having mood swings. They do not believe they can keep her safe at home.
Juan’s clinician weighs this additional information when formulating Juan’s overall risk.
April’s clinician weighs this additional information when formulating April’s overall risk.
Juan would benefit from suicide safety planning and increasing his level of outpatient care to partial hospitalization Program for additional structure and support. Afterwards, Juan might additionally benefit from expanding his therapy to include suicide-focused strategies and coping, and connection to a BH provider to reassess the current medication regimen.
April and her family would benefit from an evaluation at an emergency department or local psychiatric crisis center to determine whether psychiatric hospitalization is warranted to maintain safety.