Systems of Care
At CAMS-care we are passionate about creating systems of care that result in the treatment of people with serious suicidal thoughts.
Public awareness of suicide as a leading cause of death is growing. It is often the case that people suffering from serious suicidal thoughts will not reach out for help because they are worried that acknowledging their suicidality will lead to being invalidated or even being hospitalized (which can be a significant life disruption). While hospitalization may be necessary in extreme cases, our goal should be to keep the patient out of the hospital for the benefit of the patient and the system of care as a whole. The goal of any system of care should be to provide resources to a large percentage of the population as effectively as possible. Growing numbers of celebrities have come forward with their mental health struggles and suicidal thoughts which may encourage more people who struggle to ask for help. We need to ensure that the right resources are available to effectively treat those who seek help.
There are a number of training tools for communities and systems of care that educate everyone involved how to talk to people with serious suicidal thoughts. “Gatekeepers” include medical staff, school counselors, teachers, first responders, mental health workers and volunteers.
A person with serious suicidal thoughts will often express his or her pain in ways that invite others to reach out and help. Gatekeeper training helps someone to recognize these signs and provide help to the person who is suffering, ideally so that such people receive evidence-based care.
Anyone, regardless of background or experience, can learn skills to help keep someone safe and alive. Well known tools in this domain include:
- Question Persuade Refer (QPR)
- LivingWorks Start
- Umatter is a training program developed by the Center for Health and Learning in Vermont
- Counseling on Access to Lethal Means CALM training is primarily designed for mental health professionals. Others who work with people at risk for suicide, like social service professionals and health care providers, may also benefit from this training
- Sources of Strength is a school-based program that helps students and faculty better support those at risk
A suicide risk screening is a short assessment that can help find out how likely it is that someone may be considering suicide. Most screenings include a shortlist of brief questions about certain thoughts, feelings, and behaviors.
One very popular, evidence-based screening is the Ask Suicide-Screening Questions (ASQ) tool. The Joint Commission approves the use of the ASQ for all ages. Additional materials to help with suicide risk screening implementation are available in The Ask Suicide-Screening Questions (ASQ) Toolkit, a free resource for use in medical settings (emergency department, inpatient medical/surgical units, outpatient clinics/primary care) that can help providers successfully identify individuals at risk for suicide. The ASQ is a set of four screening questions that takes 20 seconds to administer. In an NIMH study, a “yes” response to one or more of the four questions identified 97% of youth (aged 10 to 21 years) at risk for suicide. Led by the NIMH, a multisite research study has now demonstrated that the ASQ is also a valid screening tool for adult medical patients. By enabling early identification and assessment of medical patients at high risk for suicide, the ASQ toolkit can play a key role in suicide prevention.
Another screening tool that has been used for many years in the mental health field is the PHQ-9. The PHQ-9 is a depression screener that in recent years has been used to help identify suicide risk.
The goal of screening should be to identify someone who is suicidal and refer them to a mental health clinician who is equipped to care for them.
Doctors, nurses, and healthcare workers are being asked to assess patients for suicidal thoughts and behaviors putting even more time pressure on them in Emergency Department and clinical settings. They typically do not have the 45 to 60 minutes required to conduct an assessment and safety plan and most likely have never been trained how to do so. Screening, and particularly the ASQ screener, can be administered in minutes. A person deemed to be at risk can then be referred to a clinician that has the time and training to conduct an assessment, ideally using an evidence-based treatment that starts with a therapeutic assessment and safeguarding plan. When building your system of care, time constraints of the caregivers is an important consideration. You should also consider the number of touchpoints for the patient. In many systems of care, patients are asked to repeat themselves multiple times as they are screened, assessed, and, hopefully, treated. A rapid screener followed by a single clinician capable of assessing, safeguarding, and treating the patient results in a significantly better patient experience.
Suicide Risk Assessment
Suicide risk assessment is a process of estimating the relative risk of someone for attempting or dying by suicide. Assessments are more thorough and take longer than simple screeners. The goal of a thorough suicide risk assessment is to learn about the circumstances of an individual person with regard to suicide, including warning signs, risk factors, and protective factors. Risk for suicide is often re-evaluated throughout the course of care to assess the patient’s response to personal situational changes and clinical interventions. Valid and reliable risk assessment requires a clinician to integrate their clinical judgment with the latest evidence-based assessment tools (although accurate prediction of low base rate events, such as suicide, is inherently difficult and prone to false positives). In emergency department settings, doctors and nurses often do not have the 45 minutes to an hour to administer an assessment and a safety plan before discharging the patient. In these cases, screening followed by a warm handoff to a clinician may be a better system of care.
There are numerous suicide risk assessment tools available. Popular assessment tools include the C-SSRS (Columbia-Suicide Severity Rating Scale), the Scale for Suicide Ideation (SSI), the Suicide Intent Scale (SIS), the Suicide Behaviors Questionnaire (SBQ), and the Suicide Status Form (used within the Collaborative Assessment and Management of Suicidality—CAMS). We recommend that clinicians routinely incorporate results from suicide assessment tools into clinical documentation for patients who are suicidal. There are dozens more suicide risk assessment tools in the literature, we have noted just a few of the more prominent.
Studies show that clinicians who use “Treatment as Usual” are generally providing a lower standard of care for their patients than clinicians who use evidence-based, suicide-focused, clinical treatments. There are four major evidence-based treatments referenced by the Joint Commission, Zero Suicide, the CDC, the Surgeon General, and others. These include DBT, CT-SP, BCBT, and CAMS. The vast majority of clinicians are not taught about suicide-focused treatment in professional training programs. CAMS-care hopes to change this reality with our free “CAMS on Campus” offerings. We thus encourage all clinicians to train in one or more of these evidence-based treatments for suicidal risk.
Non-Demand Caring Contacts
The goal of these interventions is to reduce the risk of suicide by sending various forms of caring communication (e.g., using letters, postcards, texts, emails, and phone calls). These one-directional communications of caring require no response and have been shown to decrease suicide attempts and completions in various large-scale intervention trials.
Technology Platforms for Care
There are exciting technology advances in the mental health care field with platforms like NeuroFlow, bhworks and WellTrack which deliver evidence-based, personalized self-care programs with over 70% engagement rate. Continued activity informs a severity score, allowing ongoing monitoring of patient progress, compliance and outcomes.
Jaspr Health has developed a tablet and app for emergency department and post discharge use that empowers evidence-based suicide care at scale, optimizing provider workflow and improving patient outcomes and experience.
Finally, depending upon the resources available in an area, certain systems of care or social services work with the discharged patient to help them with factors that might have caused them to want to end their life such as housing or healthcare. We know from suicide prevention research that case management can play a key role in supporting people who are struggling. Indeed, mental health workers who provide case management can help support people who are dealing with suicidal thoughts to find jobs, housing, and transportation which can make a life saving difference.
Around the Clock Support
People with suicidal thoughts will frequently have feelings of despair outside regular office hours. Services like Protocall provide and ecosystem of support available around the clock to help people find the support they need in their time of crisis including warm handoffs to suicide treatment trained clinicians.