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.”1
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.2
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.3
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.4
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.5
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.6
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.7 For more information on safety planning, go to the Patient Engagement section of this toolkit.
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.2
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.8
Research has suggested that patients may be at higher risk immediately following discharge from inpatient care.9 Although the reasons why this might be the case are not known, experts who study suicide have questioned whether there is something about the experience of hospitalization itself that may be harmful. At the same time, there have been no studies that demonstrate that lifetime probability of suicide is reduced.
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 visits2
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.
- 1. Ahmedani, B. K., & Vannoy, S. (2014). National pathways for suicide prevention and health services research. American Journal of Preventive Medicine, 47(3 Suppl 2), S222–S228. Retrieved from http://actionallianceforsuicideprevention.org/sites/actionallianceforsui... citation
- 2. a. b. c. 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...
- 3. National Action Alliance for Suicide Prevention, Crisis Services Task Force. (2016). Crisis now: Transforming services is within our reach. Washington, DC: Education Development Center, Inc. Retrieved from http://actionallianceforsuicideprevention.org/sites/actionallianceforsui...
- 4. National Suicide Prevention Lifeline. (2007). NSPL suicide risk assessment standards. Rockland, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Retrieved from https://suicidepreventionlifeline.org/best-practices/
- 5. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2011). Screening, brief intervention and referral to treatment (SBIRT) in behavioral healthcare. Retrieved from https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf
- 6. Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Bolhari, J., Botega, N. J., ... & Schlebusch, L. (2008). Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bulletin of the World Health Organization, 86(9), 703–709. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18797646
- 7. Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. http://www.sciencedirect.com/science/article/pii/S1077722911000630
- 8. 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...
- 9. Bickley, H., Hunt, I. M., Windfuhr, K., Shaw, J., Appleby, L., & Kapur, N. (2013). Suicide within two weeks of discharge from psychiatric inpatient care: A case-control study. Psychiatric Services, 64(7), 653–659. Retrieved from http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201200026
- 10. Godleski, L., Darkins, A., & John Peters, J. (2012). Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006–2010. Psychiatric Services, 63(4), 383–385. Retrieved from http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201100206
- 11. Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: A 2013 review. Telemedicine Journal and E-Health, 19(6), 444–454. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23697504