What is the difference between “proactive” and “reactive” suicide risk assessment and management of individuals with Serious Mental Illness (SMI)?

For “proactive” risk management, the best approach to suicide prevention hinges on the assessment of risk in a proactive, structured, and ongoing manner. In “proactive” suicide risk management, there are initial and ongoing risk assessments that are an essential part of treatment. These risk assessments can be conducted using a rating scale such as the Columbia – Suicide Severity Rating Scale (C-SSRS). These assessments occur at regular intervals, e.g. every 6 months, even if there are no additional indications of increased risk, e.g., stressful life events or a worsening of depression.

Proactive risk management involves proactive interventions such as psychoeducation about suicide risk and Safety Planning Intervention (SPI). These interventions are implemented in anticipation that suicidal thinking and behavior might occur. For individuals with a positive assessment screen, the clinician immediately implements an SPI. In routine treatment, the individual completes the SPI document with a clinician to develop a suicide prevention plan. This approach can be used during a treatment session and refined over time. The aim is to integrate SPI as part of a standard care plan and re-visit regularly as part of treatment.

In “reactive” suicide risk management, appropriate clinical action is taken when there is an acute increase in suicide risk usually triggered by the occurrence of a stressful life event or an increase in depression. “Reactive” risk management involves an appropriate reaction to acute risk when it occurs as well as an increase in team alertness. Reactive suicide risk management is crisis management and includes suicide safety intervention planning and an increase in risk monitoring. The approach is aimed at keeping the person safe and out of the hospital. In fact, for most treatment programs, reducing the rate of hospitalization is a very important goal. Hospitalization can be traumatizing for individuals and families, and can be costly for the health care system as well as for the individual and his or her family. Clinicians often try to determine if an individual is safe in an outpatient setting versus requesting a hospitalization. However, there are situations in which hospitalization is necessary to keep the individual safe and might ultimately provide improvement in care.

For additional information about suicide risk assessment and management, view this webinar on Recognizing and Addressing Suicidal Ideation and Behavior in Individuals with First Episode of Psychosis.

For help with managing suicidal individuals see the Suicide Prevention Resource Center and ZeroSuicide.

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