ResouRces

n

n

n

n

Download this card and additional resources at

Resource for implementing The Joint Commission 2007 Patient 

sAFe-T drew upon the American Psychiatric Association 

Practice Guidelines for the Assessment and Treatment of 

Patients with Suicidal Behaviors http://www.psychiatryonline.com/

pracGuide/pracGuideTopic_14.aspx

 Practice Parameter for the Assessment and Treatment of Children and 

Adolescents with Suicidal Behavior. Journal of the American Academy 

of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s

AcKNoWLeDGMeNTs

n Originally conceived by Douglas Jacobs, MD, and developed as 

a collaboration between Screening for Mental Health, Inc. and 

the Suicide Prevention Resource Center.

n This material is based upon work supported by the Substance 

National Suicide Prevention Lifeline

1-800-273-TALK (8255)

http://www.sprc.org

HHS Publication No. (SMA) 09-4432 • CMHS-NSP-0193

Printed 2009

SAFE-T

SuicideAssessment Five-step

Evaluation and Triage

1

IDeNTIFY RIsK FAcToRs

Note those that can be 

modified to reduce risk

2

IDeNTIFY PRoTecTIVe FAcToRs

Note those that can be enhanced

3

coNDucT suIcIDe INQuIRY

Suicidal thoughts, plans,

behavior, and intent

4

DeTeRMINe RIsK LeVeL/INTeRVeNTIoN

Determine risk. Choose appropriate

intervention to address and reduce risk

5

DocuMeNT

Assessment of risk, rationale,

intervention, and follow-up

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

www.samhsa.gov
Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical 

change; for inpatients, prior to increasing privileges and at discharge.

1. RISK FACTORS 

3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior

3 current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality 

disorders, conduct disorders (antisocial behavior, aggression, impulsivity) 

Co-morbidity and recent onset of illness increase risk

3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations

3

3 Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real 

or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation

3 change in treatment: discharge from psychiatric hospital, provider or treatment change 

3 Access to firearms

Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk

Internal: ability to cope with stress, religious beliefs, frustration tolerance

external: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent 

Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever

Plan: timing, location, lethality, availability, preparatory acts

Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions

Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious. 

Explore ambivalence: reasons to die vs. reasons to live

3

3

3

3

3

3

* For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition

* Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above

3

3

4. RISK LEVEL/INTERVENTION

Assessment of risk level is based on clinical judgment, after completing steps 1–3

Reassess as patient or environmental circumstances change

RISK LEVEL RISK/PROTECTIVE FACTOR SUICIDALITY POSSIBLE INTERVENTIONS

High

Psychiatric diagnoses with severe 

symptoms or acute precipitating event; 

protective factors not relevant

Potentially lethal suicide attempt or 

persistent ideation with strong intent or 

suicide rehearsal

Admission generally indicated unless a significant 

change reduces risk. Suicide precautions

Moderate Multiple risk factors, few protective 

factors

Suicidal ideation with plan, but no intent 

or behavior

Admission may be necessary depending on risk 

factors. Develop crisis plan. Give emergency/crisis 

numbers

Low Modifiable risk factors, strong protective 

factors

Thoughts of death, no plan, intent, or 

behavior

Outpatient referral, symptom reduction. 

Give emergency/crisis numbers

(This chart is intended to represent a range of risk levels and interventions, not actual determinations.)

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant 

others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.