MIRECC / CoE
Risk Stratification Table | Therapeutic Risk Management
Therapeutic Risk Management with Patients at Risk for Suicide
ACUTE Therapeutic Risk Management - Risk Stratification Table
HIGH ACUTE RISK
Core Features
- Suicidal ideation with intent to die by suicide AND
- Inability to maintain safety independently without external help or support
These individuals will often have a plan for suicide and access to lethal means. They may be experiencing an exacerbation of mental health conditions (e.g., Major Depressive Disorder episode, acute psychosis, recent/current recurrence of drug use, increased borderline personality disorder symptomatology) and/or psychosocial stressors (e.g., job loss, relationship dissolution, recurrence of alcohol use). They may have also recently engaged in suicidal self-directed violence (e.g., suicide attempt and/or preparatory behaviors).
Action
Typically requires psychiatric hospitalization (either voluntary or involuntary) to maintain safety and aggressively target modifiable factors.
These individuals need to be directly observed until on a secure unit and kept in an environment with limited access to lethal means (e.g., keep away from sharps, cords/tubing, toxic substances).
During hospitalization co-occurring psychiatric symptoms should also be addressed.
INTERMEDIATE ACUTE RISK
Core Features
- Suicidal ideation AND
- Ability to maintain safety, independent of external support/help
These individuals may present similarly to those at high acute risk, sharing many of the same features.
The only difference may be lack of intent, based upon an identified reason for living (e.g., children), and ability to abide by a safety plan and maintain their own safety. Preparatory behaviors are likely to be absent.
Action
Consider psychiatric hospitalization, if related factors driving risk are responsive to inpatient treatment (e.g., acute psychosis).
Outpatient management should include:
- Frequent contact
- Re-assessment of risk
- Development or update of safety plan, and
- Lethal means safety counseling
Outpatient care should address the factors contributing to elevation in acute risk (e.g., exacerbation of symptoms, financial stress).
LOW ACUTE RISK
Core Features
- May have suicidal ideation, but no current suicidal intent AND
- No specific and current suicidal plan AND
- No recent preparatory behaviors AND
- Collective high confidence (e.g., patient, care provider, family member) in the ability of the patient to independently maintain safety
Individuals may have suicidal ideation, but it will be with little or no intent or specific current plan. If a plan is present, the plan is general and/or vague, and without any associated preparatory behaviors (e.g., “One of these days, I might just end it.”). These individuals are likely to be capable of engaging appropriate coping strategies, and willing and able to utilize a safety plan in a crisis situation.
Action
Care should be focused on mitigation of chronic risk through enhancing protective factors and reducing modifiable risk factors.
Consider upstream suicide prevention, health promotion interventions, and applicable resources (e.g., financial, housing).
Outpatient mental health treatment may be indicated, particularly if suicidal ideation and psychiatric symptoms are co-occurring. Risk should be re-assessed per clinical judgment.
Updated: May 2024
CHRONIC Therapeutic Risk Management - Risk Stratification Table
HIGH CHRONIC RISK
Core Features
These individuals are considered to be at chronic risk for becoming acutely suicidal, often in the context of psychosocial stressors (e.g., loss of relationship, job loss, recurrence of drug use). Common risk factors include:
- Chronic mental health conditions
- Chronic pain or medical condition
- Chronic suicidal ideation
- History of prior suicide attempt(s)
- History of substance use disorder
- Limited ability to identify reasons for living
- Limited coping skills
- Unstable psychosocial status (e.g., unstable housing, erratic relationships, marginal employment)
Action
These individuals typically require:
- Routine mental health follow-up
- A well-developed safety plan and lethal means safety counseling
- Routine suicide risk assessment
- Coping skills building
- Management of co-occurring psychiatric symptoms
INTERMEDIATE CHRONIC RISK
Core Features
These individuals may feature similar risk factors as those at high chronic risk, but these are balanced with protective factors, coping skills, reasons for living, and relative psychosocial stability, resulting in enhanced ability to endure future crisis without engaging in suicidal self-directed violence.
Action
These individuals typically require:
- Routine mental health care to optimize psychiatric condition and maintain/enhance coping skills and protective factors
- A well-developed safety plan and lethal means safety counseling
- Management of co-occurring psychiatric symptoms
LOW CHRONIC RISK
Core Features
These individuals may range from persons with no or little in the way of mental health or substance use problems, to persons with significant mental illness that is associated with relatively abundant strengths/resources.
Stressors have typically been endured without suicidal ideation emerging.
The following factors will generally be missing:
- History of self-directed violence
- Chronic suicidal ideation
- Tendency towards being highly impulsive
- Risky behaviors
- Limited psychosocial functioning
Action
Appropriate for mental health care on an as needed basis, some may be managed in primary care settings. Others may require mental health follow-up to continue successful treatments.
Updated: May 2024
