Basic Steps of a Suicide Risk Assessment for Providers Serving Military Populations

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By Jennifer Tucker, Ph.D.
September 11, 2017

The increasing focus on stemming the tide of the opioid epidemic in the U.S. has highlighted the risk for opioid overdose in individuals who are or become suicidal while taking opioids. In order to mitigate overdose risk, the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain advises prescribers and other clinicians working with opioids to assess their patients for suicide risk before initiating long-term opioid therapy as well as when continuing treatment.

For a comprehensive suicide risk assessment, you will need to ask service members numerous questions about their suicide-related thoughts and behaviors.  Information gathered should include:

  • Characteristics of suicidal thoughts (e.g., frequency, severity, passive/active, acute/chronic, etc.)

  • Intention to act on those thoughts (e.g., certain/uncertain, contingent on a particular life event, etc.)

  • Desire to engage in suicidal behavior

  • Evidence of planning or preparatory behavior for a suicide attempt (e.g., buying a gun, researching lethal doses of medications)

  • Warning signs of intention to act on suicidal urges (e.g., talking about suicide, writing a suicide note, social withdrawal)

  • Access to lethal means (e.g., firearms, ammunition, poisons, medications)

Next, you should evaluate common risk and protective factors that could influence whether the service member will engage in suicide-related behaviors. Common risk factors include a history of suicide attempt(s) and/or self-injury, relationship difficulties or breakups, exposure to suicide, and loss of status or rank. Common protective factors include a strong social support network and unit cohesion, child rearing responsibilities, an optimistic outlook on life, and ongoing participation in treatment.

Once you have gathered information about suicidal intent and risk and protective factors, consult the below chart to determine risk level.  The 2013 VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide defines the levels of risk as follows:

Level of Risk for Suicide

  • High Acute Risk

General
Characterization

  • Serious thoughts of suicide
  • Suicidal intent and/or plan
  • Warning signs
  • A recent suicide attempt
  • Symptoms of agitation, impulsivity, and/or psychosis
  • Acute precipitating events
  • Low levels of protective factors
  • Intermediate Acute Risk
  • Suicidal thoughts and/or a plan
  • No suicidal intent or preparatory behavior
  • Generally able to control suicidal urges
  • Limited protective factors
  • Low Acute Risk
  • Suicidal thoughts
  • No specific suicide plan or intent
  • No history of suicidal behavior
  • Some protective factors
  • Limited risk factors
  • Not at Elevated Risk
  • No current suicidal thoughts, intent, or plan

You will then determine appropriate interventions for your patient’s risk level.  The recommended interventions in the VA/DoD suicide CPG are as follows:


Level of Risk for Suicide

  • High Acute Risk

Recommended
Interventions

  • Immediate referral for a specialty evaluation
  • Direct observation by healthcare professional
  • Limit access to lethal means
  • Health care professional should remain with the individual until he/she is safely escorted to an urgent/emergent care setting for hospitalization
  • Intermediate Acute Risk
  • Referral to a behavioral health professional for a comprehensive evaluation
  • If necessary, consult a behavioral health professional to determine the urgency of the evaluation
  • Limit access to lethal means
  • Low Acute Risk
  • Consider for referral to a behavioral health professional
  • If necessary, consult a behavioral health professional to determine appropriateness of referral
  • Address safety issues
  • Follow up with suicide risk reassessments
  • Not at Elevated Risk
  • Routine care
  • Periodic suicide risk assessments

In following the above basic steps for suicide risk assessment, health care professionals can mitigate risk of overdose for service members starting or continuing opioid therapy. 

Note: All suicide-related information contained in this blog can be found in the VA/DoD suicide CPG.

Clinician Resources:

Crisis Resources:

Dr. Jennifer Tucker is a suicide prevention subject matter expert at Deployment Health Clinical Center. She has a master’s and doctorate in clinical psychology and has worked with service members hospitalized for suicidality as part of a large randomized controlled trial for cognitive behavioral therapy for suicide prevention.


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


Comments

  • I am quite concerned the PHCoE makes absolutely no mention of seeing their Primary Care Provider when any risk of suicide is present. Suicide will NOT be stemmed by Behavioral Health 'Professionals' folks, but by an integrated community offering what the client (and their trusted family-friends) feel are concerned about them. I strongly advise revising these guidelines to making Primary Care the first referral point, in conjunction with referral to a behavioral health colleague team member.

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