As a provider of primary care services you are in a unique position to prevent suicides among your patients. Research tells us that people who die by suicide are more likely to have seen their primary care provider shortly before their death than any other health care professional.

At any given time, some of your patients are having thoughts of suicide. They may come to your exam rooms presenting with many different concerns, but the one they may not be telling you about could be the one that will kill them–unless you and your staff are prepared.

Quick Start Guide
Start your suicide prevention efforts by checking out the Quick Start Guide. It will walk you step-by-step through the process of seamlessly integrating suicide prevention into your practice.

Implementation Checklist

Ensure that your efforts are organized and thorough by using the Implementation Checklist provided in this section. Check off each element of the suicide prevention efforts outlined in the toolkit as you put it into place.

Office Protocol for Suicidal Patients Development Guide

Your practice can soon have systems in place that will allow you to intervene effectively without significantly disrupting the flow of patients. After you have familiarized yourself with the entire toolkit, use the Office Protocol for Suicidal Patients Development Guide to establish the roles and responsibilities, as well as the procedures you will follow when your find that a patient is suicidal. If everyone in the clinic knows what he or she is expected to do, the process will be smoother than you might expect.

Office Protocol for Suicidal Patients Office Template

Use this template and the Office Protocol for Suicidal Patients Development Guide above to proactively complete an individualized Office Protocol for Suicidal Patients for your practice.

Click here to download all of section one in a separate document.

The educational section of this toolkit contains a primer presented in five modules. The first two modules are background material that may be of interest to the entire staff. The third module provides an understanding of general prevention practices that should be implemented to maximally benefit the entire patient population and should be read and discussed by the entire primary care staff. Modules four and five are designed to educate clinicians for the specialized suicide prevention roles they will play. Module four provides the information necessary to evaluate patients who may be at heightened risk for suicide and to make a clinical assessment of that risk. Module five discusses interventions that may be necessary to protect patients from intentionally harming themselves, up to and including making arrangements for involuntary hospitalization. Additional educational resources can be found in the Patient Education Tools/Other Resources section of this toolkit.

Module 1 – Prevalence and Comorbidity
This two-page learning module summarizes the magnitude of the suicide problem in the U.S. and describes how the vast majority of those cases are associated with one or more mental health or substance abuse problems.

Module 2 – Epidemiology
This three-page learning module summarizes the epidemiology of suicide attempts and suicide deaths in various demographic groups.

Module 3 – Prevention Practices
This five-page learning module discusses general practices that can be incorporated into primary care settings to lower the risk of suicide across their entire patient population. 

Module 4 – Suicide Risk Assessment
This six-page learning module presents a methodology for gathering information about a patient’s suicidal thoughts and plans and an approach for assessing the level of suicidal intent. It concludes with pointers for clinical decision making regarding the assessment of risk.

Module 5 – Intervention
This eight-page learning module discusses a range of patient management approaches that can be implemented in the primary care setting according to the level of risk.

Click here to download all of section two in a separate document.

The strong association between behavioral health problems and suicide suggests that the majority, though not all, of the patients you evaluate for suicide risk may also be in need of mental health care. In many rural areas, accessibility to specialized mental health treatments is limited. Regardless of how far away the nearest mental health care may be, ongoing communication between the primary care provider and mental health clinicians is a key to achieving treatment success. When comprehensive treatment is delivered to patients, recovery becomes an achievable goal in most situations.

Additional resources related to developing these partnerships are available in the Patient Education Tools/Other Resources section of this toolkit.

Mental Health Outreach Letter
To help build strong, collaborative partnerships between primary care and mental health practices, this toolkit includes a draft outreach letter. This letter may be modified to fit your personal style and circumstances and then sent to providers of mental health services to whom you expect to refer patients.

Click here to download all of section three in a separate document.

Many concrete and easy-to-use tools are available to assist you and your staff in preventing suicide. This section includes pocket-sized tools to facilitate assessment and intervention with at-risk patients in the office, as well as templates for helping to ensure the patients’ safety outside of your office.        

Primary Care Pocket Guide
The Pocket Guide for Primary Care Professionals provides a summary of important risk and protective factors for suicide, questions you can use in a suicide assessment, and a decision tree for managing the patient at risk for a suicide attempt. The card is designed to be printed on both sides and folded in quarters to fit easily in the pocket. Hard copies are available for purchase through WICHE MHP at [email protected] or by calling 303-541-0311.

SAFE-T Pocket Card
This pocket card, designed by mental health experts for mental health professionals, provides a brief overview of conducting a suicide assessment using a five-step evaluation and triage plan. The SAFE-T Pocket Card link above will direct you to the SAMHSA Publications Ordering website where the card can be downloaded. SAMHSA’s suicide prevention app, Suicide Safe, was based on the SAFE-T card. More information about Suicide Safe is available here. 

Safety Planning Guide
The pocket-sized safety planning guide reminds clinicians of the most important points to cover in collaboratively developing a safety plan with a patient. The guide was adapted from content developed by the Department of Veterans Affairs.

Patient Safety Plan Template
The Patient Safety Plan Template is filled out collaboratively by the clinician and the patient and then used independently by the patient to help ensure their safety in their day-to-day lives. The Safety Planning Guide (listed above) can be used as a source of questions to ask to facilitate development of the Safety Plan.

Crisis Support Plan
The Crisis Support Plan is used by the patient and the clinician to enlist social support from a trusted friend or relative should a suicide crisis recur. It explains roles that supportive individuals can take to help protect the person at risk for suicide and serves as an informal contract that the designated support person will fulfill these roles. Active support of a friend or loved one is among the strongest protective factors against suicide.

Click here to download all of section four in a separate document.

Policies, billing procedures, and referral procedures related to suicide prevention in primary care vary significantly across states. Understanding how to bill for mental health services in primary care, how to obtain higher levels of care for individuals at risk for suicide, and where to find information relevant to your state is critical. Learning to successfully navigate these processes will reduce the barriers to mental health service provision within your setting and will enhance your ability to partner with mental health treatment centers when crisis services are needed.

Tips and Strategies for Reimbursement
This brief module provides strategies that billing personnel within primary care practices may use to increase their success in obtaining reimbursement for mental health services.

State-Specific Resources and Policy Information
This template may be used as a guide to direct providers and staff to state-specific behavioral health resources and policies. It includes suggestions for locating information regarding crisis services and inpatient mental health care.

Click here to download all of section five in a separate document.

Health care providers have higher rates of depression and suicide and are less likely to seek help compared to the general population. It is therefore important for health care providers to regularly engage in self-care and ensure that their mental health needs do not go untreated.

Physician Suicide

Provides an overview of suicide rates and related risk factors among health care providers and links to additional information on physician depression and suicide.

Tips and Resources for Health Care Provider Self-Care

This section provides tips for practicing self-care and resources for self-care.

Click here to download all of section six in a separate document.

This section contains a list of additional tools to educate providers and help increase awareness in patients, families, and communities about suicide. The public awareness materials include items that may be ordered for posting in your clinic as well as items that may be disseminated to patients and families. Increasing awareness is an important component of addressing the problem of stigma associated with suicidality.

Also included in this section is a list of suicide prevention resources. This list includes additional resources for providers as well as for patients, families, and community members. Samples of several of the tools included in this list are provided in the front pocket of the toolkit, along with samples of the pocket guides described in the Developing Mental Health Partnerships and Patient Management Tools sections of the toolkit.

Public Awareness Materials

This section lists materials you may find useful for posting in your office to promote suicide prevention awareness or for making available to patients in need of information about suicide.

Suicide Prevention Resource List

This is a guide to direct providers and staff to state-specific behavioral health resources and policies. It includes suggestions for locating information regarding crisis services and inpatient mental health care.

Click here to download all of section seven in a separate document.