The biggest concern facing a provider is whether a patient is at risk for suicide. Although this is a question on most screening tools, delicately asking a patient at every visit, and documenting the answer, is of vital importance. When patients are severely depressed, they may not even have the energy to contemplate suicide, and thus there is a small spike in the risk of attempts and completions several weeks after starting a medication.15

Table 4. Integrated care

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A simple statement to begin the discussion could be: “People who feel as down as you do sometimes think about what it would be like if they were not here. Has this ever crossed your mind?” Following up with questions regarding specific plans is important as well, to help create the safest environment possible by limiting access to the very means they have envisioned. This may mean involving family, neighbors, or even clergy to secure weapons, check in by phone or in person, and dispense medications — which leads to the idea of a “no-harm contract.”

Despite the security we as providers may get from having a patient sign a document that states they will call for help before killing themselves, the very nature of asking someone to provide consent when you doubt their ability to make sound decisions may not be realistic. Instead, consider crisis plans, which are a bit more time consuming but more helpful for the patient and you.

This involves brainstorming with the patients to outline all the things that have been troubling them and then coming up with short-term solutions. For example, if they tend to ruminate when they cannot fall asleep, have them list things they can do (e.g., take a hot bath, read a book, pray/meditate) or people they can call (with their phone numbers listed) who are willing to be woken up at any time of night. Always provide the local crisis hotline, as well as a national one (e.g., 800-273-TALK).

Include upcoming appointments with providers and other community support (e.g., meetings related to hobbies, addiction support groups), and be sure to review for successes and failures at the next appointment. This also provides a nice bridge to their therapist or psychiatry appointment. Suicide assessment can be remembered by IS PATH WARM; the SAD PERSONS Scale works for risk factors (Table 5). The Suicide Assessment Checklist is also helpful (