Least Restrictive Care

Providing the Least Restrictive Care

Along with the emphasis on treating suicide risk directly, newer models of care suggest that treatment and support of persons with suicide risk should be carried out in the least restrictive setting.1 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 whenever possible.2 3

Stepped-Care Model

A 2014 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, individuals at risk of suicide are “offered numerous opportunities to access and engage in effective treatment, including standard in-person options as well as telephone, video, web-based, and smartphone interventions.”1 Stepped care has been applied to many health and behavioral health challenges and delivers care by first offering less intensive, often less restrictive interventions and then “stepping up” to more intensive services when clinically indicated. In the video below, David Jobes sets out six levels of care for a stepped care model for suicide risk:

  1. Crisis center hotline support and follow-up
  2. Brief intervention and follow-up
  3. Suicide-specific outpatient
  4. Emergency respite care
  5. Partial hospitalization, with suicide-specific treatment
  6. Inpatient psychiatric hospitalization, with suicide-specific treatment
Least Restrictive Suicide Care
David Jobes
A “Stepped Care” model for suicide prevention.

Crisis Support and Follow-Up

In the field of suicide prevention, the term “crisis services” has a broad scope. Crisis services 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 are particularly helpful for individuals with barriers to accessing outpatient mental health services. They can also serve as a point of contact for individuals between outpatient visits.

Crisis services include care coordination services, which have the potential to lower readmission rates and some can provide follow-up services. Crisis centers that are members of the National Suicide Prevention Lifeline (988) follow best practices in assessing suicide risk. These centers have access to a national network of crisis center peers and resources. Crisis lines for Veterans, people who are deaf or hard of hearing, LGBTQIA+ individuals, and Spanish speakers are also available. Some crisis lines provide translation for several different languages. Follow-up can include caring contacts in the form of non-demand messages given to individuals through email, mail, phone calls, text messages, or other forms of electronic communication. See the Transition element for more information about incorporating Crisis Services into Zero Suicide.

Brief Interventions and Follow-Up

Brief 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 smartphone or tablet.6, 7

Brief interventions can be immediate, free-standing interventions or they can be used in conjunction with any other level of care. For example, while best practices emphasize that safety planning is most effective when done as part of a larger treatment plan to address suicide risk, ensuring individuals who decline outpatient care have a safety plan can be instrumental in saving lives. In theory, the delivery of a brief intervention for suicide theoretically requires less training than for more comprehensive treatments such as Dialectical Behavioral therapy or Cognitive Behavioral Therapy for suicide prevention. Brief interventions can be inexpensive, and they can be delivered almost anywhere. More information can be found on safety planning in the Interventions tab and within the Engage element.

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 individual 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 staff members who are peers with lived experience of mental health issues or suicide. Individuals in crisis may prefer such settings.4 Respite care has shown better functional outcomes than acute psychiatric hospitalization and 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

Partial and Inpatient Hospitalization

Inpatient hospitalization is generally the most restrictive and costly option for addressing suicide risk. While hospitalization may reduce the risk for suicide while an individual is in care, most inpatient services generally do not include empirically supported suicide-focused care.5 Research suggests that individuals may be at higher risk immediately following discharge from inpatient care.6 7   Potential reasons for this are complex and varied. Some experts who study suicide have questioned whether aspects of the experience of hospitalization itself may be harmful and increase post-discharge suicide risk.8

Hospitalizations can represent the loss of autonomy for some individuals which can sometimes exacerbate suicidal thoughts and behaviors. Unless the individual is in imminent danger, the decision to seek inpatient care should be collaborative.

Facilitating Less Restrictive Care

Two additional strategies – mobile crisis care and telehealth – can augment any stage of a stepped-care plan. These strategies may help to maintain a person at risk for suicide in outpatient treatment, thus reducing the need for hospitalization.

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 visits9


Telehealth uses electronic communication, such as telephone or video, to provide clinical mental health services. Health and behavioral health care organizations can use these services to provide emergency assessments and treatment—particularly for individuals located in remote geographic regions, or with transportation or mobility barriers. Telehealth has been shown to improve outcomes in medical settings for individuals with behavioral health concerns. In addition to emergency assessments, telehealth services can include medication management, clinical therapeutic treatments, and provider-to-provider consultation. Telehealth may also be a good option for healthcare organizations with limited access to mental health resources.10 11 12

  • 1. a b 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 https://theactionalliance.org/
  • 2.Ward-Ciesielski, E. F., & Rizvi, S. L. (2021). The potential iatrogenic effects of psychiatric hospitalization for suicidal behavior: A critical review and recommendations for research. Clinical Psychology: Science and Practice, 28(1), 60.
  • 3.Forte, Alberto MD; Buscajoni, Andrea MD; Fiorillo, Andrea MD, PhD; Pompili, Maurizio MD, PhD; Baldessarini, Ross J. MD. (2019). Suicidal Risk Following Hospital Discharge: A Review. Harvard Review of Psychiatry, 27:4, 209-216 doi: 10.1097/HRP.0000000000000222
  • 4.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 https://store.samhsa.gov/product/Crisis-Services-Effectiveness-Cost-Eff…
  • 5.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/abs
  • 6.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
  • 7.Chung, D., Hadzi-Pavlovic, D., Wang, M., Swaraj, S., Olfson, M., & Large, M. (2019). Meta-analysis of suicide rates in the first week and the first month after psychiatric hospitalisation. BMJ Open, 9(3), e023883. https://doi.org/10.1136/bmjopen-2018-023883
  • 8.Large, M. M., & Kapur, N. (2018). Psychiatric hospitalisation and the risk of suicide. British Journal of Psychiatry, 212(5), 269–273. https://doi.org/10.1192/bjp.2018.22
  • 9.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 https://store.samhsa.gov/product/Crisis-Services-Effectiveness-Cost-Eff…
  • 10.Sullivan SR, Myhre K, Mitchell EL, Monahan M, Khazanov G, Spears AP, Gromatsky M, Walsh S, Goodman A, Jager-Hyman S, Green KL, Brown GK, Stanley B, Goodman M. Suicide and Telehealth Treatments: A PRISMA Scoping Review. Arch Suicide Res. 2022 Feb 9:1-21. doi: 10.1080/13811118.2022.2028207. Epub ahead of print. PMID: 35137677.
  • 11.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
  • 12.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