SAFE-T Protocol with C-SSRS

SAFE-T Protocol with C-SSRS
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Staff Name*

First NameLast Name
Clinician Name/Credential

First NameLast Name
Today's Date*

MonthDayYear
Date
Step 1: Identify Risk Factors

C-SSRS Suicidal Ideation Severity

INSTRUCTIONS: Answer YES or NO within the last month
Step 1: 1. Wish to be dead (in the last month) Have you wished you were dead or wished you could go to sleep and not wake up?

NoYes (low)
1. Explain:
If the answer to Question 1) is "Yes", an explanation must be provided.
Step 1: 2. Current suicidal thoughts (in the last month) Have you actually had any thoughts of killing yourself?

NoYes (low)
2. Explain:
If the answer to Question 2) is "Yes", an explanation must be provided.
If YES to Question #2, ask questions #3, 4, 5, and 6. If NO to Question #2, go directly to question #6
Step 1: 3. Suicidal thoughts w/ Method (w/no specific Plan or Intent or Act) (in the last month) Have you been thinking about how you might do this?

NoYes (moderate)
3. Explain:
Step 1: 4. Suicidal Intent without Specific Plan (in the last month) Have you had these thoughts and had some intention of acting on them?

NoYes (high)
4. Explain:
Step 1: 5. Intent with Plan (in the last month) Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

NoYes (high)
5. Explain:
Step 1: 6. C-SSRS Suicidal Behaviors: (in the last 3 months and/or month) "Have you ever done anything, started to do anything, or prepared to do anything to end your life?” Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

No - Past 3 monthsYes - Past 3 months (moderate)No - Past monthYes - Past 3 months (high)
6. Explain:
Step 2 (check all that apply): Identify Internal Protective Factors (Protective factors may not counteract significant acute suicide risk factors)*

Ability to cope with stressFrustration toleranceReligious beliefsFear of death or the actual act of killing selfIdentifies reasons for livingOther
Step 2 (check all that apply): Identify External Protective Factors (Protective factors may not counteract significant acute suicide risk factors)*

Cultural, spiritual and/or moral attitudes against suicideResponsibility to childrenBeloved petsSupportive social network of family or friendsPositive therapeutic relationshipsEngaged in work or schoolOther
CLINICIAN: Access to lethal methods:*
Ask specifically about presence or absence of a firearm in the home or ease of accessing.
Step 3 includes specific questioning about Thoughts, Plans, and Suicidal Intent – (see Step 1 for Ideation Severity and Behavior). C-SSRS Suicidal Ideation Intensity (with respect to the most severe ideation 1-5 identified above)

Skip Step 3 If no suicidal thoughts, plans, or intent history present or stated.
Step 3 - In the last month: FREQUENCY - How many times have you had these thoughts?

(1) Less than once a week(2) Once a week(3) 2-5 times in week(4) Daily or almost daily(5) Many times each day
Step 3 - In the last month: DURATION - When you have the thoughts how long do they last?

(1) Fleeting - few seconds or minutes(2) Less than 1 hour/some of the time(3) 1-4 hours/a lot of time(4) 4-8 hours/most of day(5) More than 8 hours/persistent or continuous
Step 3 - In the last month: CONTROLLABILITY - Could/can you stop thinking about killing yourself or wanting to die if you want to?

(1) Easily able to control thoughts(2) Can control thoughts with little difficulty(3) Can control thoughts with some difficulty(4) Can control thoughts with a lot of difficulty(5) Unable to control thoughts
Step 3 - In the last month: DETERRENTS - Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of suicide?

(1) Deterrents definitely stopped you from attempting suicide(2) Deterrents probably stopped you(3) Uncertain that deterrents stopped you(4) Deterrents most likely did not stop you(5) Deterrents definitely did not stop you
Step 3: REASONS FOR IDEATION - What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn’t go on living with this pain or how you were feeling) or was it to get attention, revenge or a reaction from others? Or both?

(1) Completely to get attention, revenge or a reaction from others(2) Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling)(3) Equally to get attention, revenge or a reaction from others(4) Mostly to end or stop the pain (you couldn’t go on(5) Completely to end or stop the pain (you couldn’t go on and to end/stop the pain living with the pain or how you were feeling)
Total Score
Step 4: Determine Level of Risk and Develop Interventions to LOWER Risk Level

“The estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment, since no study has identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior.”

From The American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors, page 24.
STAFF COMPLETES THIS SECTION BELOW FOR RISK:

RISK STRATIFICATION
Step 4: High Suicide Risk

Suicidal ideation with intent or intent with plan in past month (C-SSRS #4 or #5) OrSuicidal behavior within past 3 months (C-SSRS Suicidal Behavior)N/A
Step 4: Moderate Suicide Risk

Suicidal ideation with method, WITHOUT plan, intent or behavior in past month (C-SSRS #3)N/A
Step 4: Low Suicide Risk

Wish to die or Suicidal Ideation WITHOUT method, intent, plan or behavior (C-SSRS #1 or #2) OrNo reported history of Suicidal Ideation or BehaviorN/A
Was the C-SSRS risk stratification level (STEP #4) MODERATE or HIGH? (If Yes, answer questions #1 and/or #2 below)*

YesNo
1. For MODERATE: If Yes, was a crisis plan developed? (If No, include clinical rationale in the space below)

YesNo
2. For HIGH: If Yes, were crisis services contacted? (If No, include clinical rationale in the space below)

YesNo
Clinical rationale if "No" to #1 or #2 above:
Should be Empty: