How do you make a safety plan with a patient who has suicidal thoughts?

Liam is a 28-yo-man with a history of one major depressive episode during which he was involuntarily hospitalized for 3 days for suicidal thoughts. After discharge, he saw a therapist for 6 months and a psychiatrist who titrated his sertraline to 150mg daily. His symptoms remitted after several months. A year later, Liam stopped the sertraline, and his depression remained in remission for several years.

2 months ago, Liam’s girlfriend broke up with him, and his heartbreak spiraled into another major depressive episode (PHQ9 21). He started to experience disturbing suicidal thoughts, specifically around hanging (just like he did during his previous episode) and spends an hour a day thinking about suicide. This rumination brought him a sense of calm at first – it was a way out if things didn’t improve – but now it is mainly frightening. Liam doesn’t have a place in mind or a specific means by which to hang himself. He doesn’t have a rope or firearms at home. He hasn’t been researching suicide methods online. He has no intent to die. He believes that these feelings will pass like they did the last time, and it would destroy his parents if he died by suicide. Liam has never tried to kill himself, doesn’t intentionally injure himself, and doesn’t know anyone who died by suicide. He is still working in a fully remote job which is both stressful and distracting. He used to live with his girlfriend but has lived alone since she moved out 2 months ago. He has recently started drinking a couple of beers at night, which calms him down.  

In this first visit, you recognize that Liam is in a severe major depressive episode with significant suicidal thoughts focused on hanging, with some increased alcohol use. He does not have a specific plan, he has not taken any preparatory action, he does not have access to a firearm, and he denies suicidal intent. He is future-oriented, believing that these thoughts will pass, is treatment seeking, and has family support. For these reasons, you don’t recommend inpatient hospitalization and instead focus on developing a plan for his depression and suicidal thoughts.  

You restart sertraline, with a plan to titrate it to the previously effective dose (150mg) over a couple of weeks. You also recommend that he avoid drinking by himself. He agrees with you about the drinking and thinks he’ll be able to do it. You refer him to psychiatry (both the intensive outpatient program and the regular outpatient program), but both are unavailable for at least 8 weeks. You schedule a follow-up appointment next week to check in with Liam and create a safety plan.

How do you make a safety plan with a patient who has suicidal thoughts or behaviors?

Interventions that reduce the risk of suicide fall into three groups: clinical assessment, a tailored safety plan, and follow-up contact (Zortea, 2020). While a mental health professional could implement all 3 of these interventions, PCPs often manage significant suicidality due to limited access to psychiatric care. I want you to feel empowered to help a patient like Liam create a safety plan.  

A safety plan – sometimes called a crisis response plan – is an evidence-based intervention to reduce future suicidal behavior. The relative risk of suicidal behavior among patients who receive a safety planning intervention compared with those who do not is 0.57 (95% CI 0.41-0.80, P = 0.001; NNT 16 to prevent one person from attempting suicide) (Nuij, 2021). Although many people think about suicide for years, interviews with people who have survived serious suicide attempts indicate that the acute suicide intent or impulse – the time when someone is actively ready to kill themselves – lasts minute-to-hours (Paashaus, 2021). During this period, a person’s mind is altered, and the cognitive tools of problem solving are less available. A safety plan helps patients, clinicians, and ideally a support person, think together about the symptoms of a future suicidal crisis and write down coping strategies with increasing levels of external support as a roadmap to survival. Then, in a moment of crisis, the patient needs to remember (or be reminded by a social support) that they have a safety plan and follow it. 

Please note that creating a safety plan is not “contracting for safety” (i.e. a no-harm contract that asks a patient to promise not to act on the urge to die by suicide before their next appointment). “Contracting for safety” has been shown to have no impact on the risk of future suicide attempts (Miller 2014).  

The safety plan below includes suggested questions to ask the patient and Liam’s responses in italics.


*Limit access to lethal means
Given the limited duration of the suicidal impulse, anything that increases the time between a suicidal impulse and access to lethal means has the potential to save lives.  We ask everyone about firearms because they are the deadliest means of suicide attempts. This is true at a population level and at an individual level. Suicidal means – for example a rope that is connected with thoughts of hanging, or a stockpile of old pills that is connected with thoughts of overdosing – should be disposed of. Ideally, someone other than the patient will remove lethal means from a home. If the patient has thoughts of overdosing on pills that they currently take, consider prescribing only a week of medications at a time or having a trusted person hold the bottles in a locked box. 

Everyone with suicidal thoughts (or who has a family member with suicidal thoughts) should be asked the question – do you have access to a firearm? If a patient has guns at home, disposing of them is preferred. In California, patients can call their local police station to arrange to dispose of firearms and ammunition. If that is not possible or desired, other firearm safety measures include removing ammunition from the home, locking the gun in a safe with a new combination that the patient does not know, or giving the gun to someone else to store safely until the patient is feeling better.

**List reasons for living
While this is not part of a formal safety plan intervention, reflecting on one’s reasons for living (future goals, focus on family, religion, etc.) can reduce suicide risk in adults (Steele, 2018). Some clinicians, myself included, end a safety plan discussion with a conversation about a patient’s reasons for living (e.g. what keeps you going?), and a plan to make physical reminders of those reasons visible wherever they are spending time.


It’s helpful to have 2 safety plan formats available:

1) A safety plan app on a smartphone that can be shared with a clinician or social supports electronically. The VA recently released a free app called SafetyPlan that includes all the prompts for a safety plan and offers brief lessons on >20 coping strategies, including slowed breathing, mindful walking, disconnecting from thoughts, and a list of options for distracting activities, among others. A motivated patient with or without suicidality could use SafetyPlan as an introduction to some core skills in cognitive behavioral therapy and dialectical behavioral therapy, with a focus on distress tolerance.  

2) A one-page handout for a safety plan can be printed, copied for the patient, and uploaded to the medical record. We’ve made one that you can download and edit on our Resources Page. If you are working with a patient who is using the handout but struggling to think of coping strategies or warning signs, consider opening the SafetyPlan app on your phone to offer some choices.

In filling out his Safety Plan, you learn that Liam is close with both his mother and father, who live 30 minutes away. Given his current depressive symptoms, you ask him whether he thinks it would be helpful to stay with his parents for a few weeks while he recovers. He starts to cry – he doesn’t want to be a burden on them. After a brief discussion, Liam agrees to reach out to his parents later today. You review the next step in the sertraline titration and schedule another visit in 2 weeks.  

This is the last PsychSnap in a 3-part series on suicidality. Rather than Key Points, I offer a list of interventions for suicidality that draws from all 3 PsychSnaps.


What can we offer our patients with suicidal thoughts and behaviors?

  • Pop the bubble of isolation by talking with patients about suicidality.
  • Treat underlying disorders, acute anxiety, and insomnia.
  • Link to mental health providers, including higher levels of care if necessary (Intensive Outpatient Programs (IOP), Partial Hospitalization Programs (PHP), Inpatient).
  • Create a safety plan with the national 988 suicide hotline and a plan to limit access to lethal means.
  • Engage supportive family or friends to stay with the patient, for social support, and to remove suicidal means.
  • Follow-up closely.
  • Take care of yourself. Managing a patient with an elevated risk of suicide can be stressful and anxiety provoking. It’s important to have the opportunity to discuss challenging situations and find support among colleagues.

Related PsychSnaps:
“Can suicide risk assessments prevent your patients from dying by suicide?” Emma Samelson-Jones, March, 2024.
“How do you talk with patients about suicidal thoughts and behaviors?” Emma Samelson-Jones, April 2024.

References:
Miller, M. C. (2014). Contracting for safety. In S. H. Koslow, P. Ruiz, & C. B. Nemeroff (Eds.), A concise guide to understanding suicide: Epidemiology, pathophysiology, and prevention (pp. 372–377). Cambridge University Press. https://doi.org/10.1017/CBO9781139519502.042

Nuij, Chani, et al. “Safety planning-type interventions for suicide prevention: meta-analysis.” The British Journal of Psychiatry 219.2 (2021): 419-426.

Paashaus, Laura, et al. “From decision to action: Suicidal history and time between decision to die and actual suicide attempt.” Clinical Psychology & Psychotherapy 28.6 (2021): 1427-1434.

Steele, Ian H., et al. “Understanding suicide across the lifespan: a United States perspective of suicide risk factors, assessment & management.” Journal of forensic sciences 63.1 (2018): 162-171.

Zortea, Tiago C., et al. “Understanding and managing suicide risk.” British Medical Bulletin 134.1 (2020): 73-84.


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