What Should Be In A Mental Health Safety Plan?

Patient Presentation
In the early fall, several residents were discussing an increase in admissions for suicide attempts to the hospital. “Starting school sure is stressful for some kids. Lots of classroom stress, boyfriend/girlfriend stress, and all the other social stress. Luckily, one took pills and then called someone to tell them about it and she got to the hospital right away. The other one, the mother noticed that he had been cutting his forearms and she brought him to the emergency room before he did something else,” one resident recounted. “Since I’ve been working in the ER this month, we’ve been doing a lot more depression and suicide screening and I’ve gotten better at making safety plans with families,” another resident said. “What do you do when you make a safety plan? I haven’t done that. Usually the psychiatry resident or nurse does that on the inpatient floor,” an intern asked. “Usually there is a nurse in the ER who also does it, but I’ve done a couple. We have a form we fill out in the ER with the patient and family. I’ll show you,” said the ER resident.

IF YOU ARE IN A CRISIS SITUATION AND NEED HELP, call 1(800) 273-TALK(8255) there IS someone there who can help you, En Espanol 1-888-628-9454, or Text “HOME” to 741-741 .
Other resources are available at http://www.suicidepreventionlifeline.org

About 10-20% of children and adolescents have a mental health or substance abuse disorder. Suicide is the seconding leading cause of death in the US for ages 10-19 years old at ~2000/year. Unfortunately the numbers of trained mental health professionals in the US and most countries is inadequate to provide appropriate care.

Emergency department (ED) visits for psychiatric conditions increased from 4.4% to 7.2% in 2011 and most likely is higher currently, as the emergency room is used to access mental health services that often are weeks to months away for an outpatient appointment. Most of the ED visits are for adolescents and volume varies according to the school year and calendar; stressful times such as beginning and ending of terms, final examinations or national examinations may be reasons for increased visits. “According to the results of the 2013 National Youth Risk Behavior Survey, 17% …of high school students reported having “seriously considered attempting suicide” during the [past] 12 months…,” 14% reported making a suicide plan, and 8% reported a suicide attempt.

Asking about suicide or screening for suicide does not increase attempts, but in a study, screening allowed pediatric patients “”…to feel known, heard and understood,” by an unbiased listener.” Suicide risk assessment tools for pediatric patients can be reviewed here.

  • Reynolds Suicide Ideation Questionnaire – a standard self-administered questionnaire that takes about 10 minutes to complete, but it is recommended that providers have training using the instruments.
    Information can be found from several online publishers.

  • Columbia Suicide Severity Rating Scale – a semi-structured interview that takes variable amounts of time depending on the answers. Providers need training but online training is available.
    Information is available through the Columbia Lighthouse Project here.

  • Ask Suicide-Screening Questions – 4 item questionnaire that takes 2 minutes to administer. All answers are Yes or No. Forms and instructions are available through the National Institute of Mental Health here

      1. In the past few weeks, have you wished you were dead?
      2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
      3. In the past week, have you been having thoughts about killing yourself?
      4. Have you ever tried to kill yourself? If yes, how and when?

      If YES, to any of Questions 1-4 ask:
      5. Are you having thoughts of killing yourself right now?


        If answers to Questions 1-4 are all NO, then screening is complete and no intervention is needed.

        If any answer to Questions 1-4 is YES, then ask question 5.

        If NO to Question 5, this is considered a non-acute positive screening because a potential risk is identified. The patient requires a brief suicide safety assessment to determine if a full mental health evaluation is needed. The patient cannot leave the office/ED without being evaluated for safety. Appropriate personnel should be contacted immediately.

        If YES to Question 5, this is an acute positive screening with imminent risk identified. The patient requires an immediate (STAT) full mental health evaluation and safety evaluation. The patient cannot leave until evaluated for safety. The room the patient is in should be made safe by removing dangerous objects, and the patient should be kept in sight. Appropriate personnel should be contacted immediately.

To review a case about post traumatic stress disorder in children click here
To review a case about resiliency to the effects of war click here.

To review a case about the effects of bullying click here.

To review a case about gun violence click here.

Learning Point
Treatment for suicidal ideation and attempts is multi-modal with medication, psychotherapy and appropriate support from health professionals, family, and friends. The appropriate environment must be chosen at various points in treatment to protect the patient’s safety. In community/home settings items that could be used for deliberate self-harm should be removed including weapons, sharp instruments, and medications, and the patient should be monitored frequently. Locations within the community/home where patients could be more likely to deliberately hurt themselves should be identified and also monitored frequently such as a balcony, window, stairs, pools and other bodies of water, etc.

A mental health safety plan is a tool that helps the patient to identify resources they can use if the suicidal urge occurs again. Patients can list their coping strategies after each element.
Elements include:

    List: The one thing that is most important for the patient and worth living is:
    1. Recognizing warning signs: Warning signs that a crisis may be developing such as thoughts, images, mood, situation, behaviors
    2. Internal coping strategies: Things that the patient can do to take their mind off problems without contacting another person such as relaxation techniques, physical activity, etc.
    3. Socialization strategies for distraction and support: People and social settings that provide distraction or support – names or places, telephone
    4. Social contact for assistance in resolving crisis: People the patient can ask for help – names and telephone
    5. Professionals or agencies contacts to help resolve crisis: Professionals or agencies the patient can contact during a crisis – clinician name/location/phone/emergency contact number, local urgent care services with address/phone, Suicide Prevention Lifeline Phone
    1(800) 273-TALK(8255), En Espanol 1-888-628-9454, or Text “HOME” to 741-741
    6. Means restriction: Ways to make the environment safe

Questions for Further Discussion
1. What are risk factors for depression and/or suicide?
2. What are medical treatment options for acute and chronic treatment of depression and/or suicide?
3. What local resources do you have for patients who may be in crisis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Suicide, Teen Depression and Self Harm.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

US Department of Veterans Affairs. VA Suicide Prevention Resources. Safety Planning. Available from the Internet at:
https://starttheconversation.veteranscrisisline.net/pdf/what-is-a-safety-plan/ (cited 6/29/18).

Sher L, LaBode V. Teaching health care professionals about suicide safety planning. Psychiatr Danub. 2011 Dec;23(4):396-7.

Norris D, Clark MS. Evaluation and treatment of the suicidal patient. Am Fam Physician. 2012 Mar 15;85(6):602-5.

Carubia B, Becker A, Levine BH. Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges. Curr Psychiatry Rep. 2016 Apr;18(4):41.

ASQ Suicide Risk Screening Questionnaire. National Institute of Mental Health. Available from the Internet at: Page (rev 6/13/17, cited 6/29/18)

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa