Should suicidal patients be referred to a psychiatrist or a behavioral health specialist for evaluation and treatment?

Suicidal Patient Referral and Management

All suicidal patients should be referred to a mental health professional for evaluation, with the urgency of referral determined by the assessed level of risk. 1, 2

Risk Assessment and Triage Algorithm

Immediate Psychiatric Evaluation Required (High Risk):

• Patients with:
  • Current suicidal ideation with specific plan and intent
  • Recent suicide attempt with high lethality
  • Persistent wish to die despite intervention
  • Severe agitation, hopelessness, or impulsivity
  • Psychosis, severe depression, or bipolar disorder
  • Substance intoxication or active withdrawal
  • Inadequate social support or inability to engage in safety planning
  • Inability to contract for safety

Same-Day Mental Health Evaluation (Moderate Risk):

• Patients with:
  • Suicidal ideation without specific plan or intent
  • Moderate depression with adequate impulse control
  • Willingness to engage in safety planning
  • Responsive and supportive family
  • No previous attempts with high lethality

Urgent Outpatient Referral (Lower Risk):

• Patients with:
  • Passive suicidal thoughts without plan or intent
  • Mild to moderate symptoms
  • Good impulse control
  • Strong social support
  • Willingness to seek help

Intervention Based on Risk Level

High Risk Management:

1. Arrange immediate psychiatric evaluation through:

   • Direct transfer to emergency department
   • Same-day psychiatric consultation
   • Inpatient psychiatric hospitalization 1

2. Never leave the patient alone during the referral process

3. Remove access to lethal means:

   • Recommend removal of firearms from home
   • Secure medications and other potential means 1

Moderate Risk Management:

1. Arrange same-day mental health professional evaluation
2. Develop a detailed safety plan including:
   • Warning signs identification
   • Coping strategies
   • Social support contacts
   • Emergency contact information 1
3. Involve family/support persons in monitoring and follow-up

Lower Risk Management:

1. Schedule mental health follow-up within 1-2 weeks
2. Provide crisis resources and emergency contact information
3. Create safety plan and means restriction counseling
4. Consider screening for underlying psychiatric disorders 1

Key Considerations for All Risk Levels

Documentation Requirements:

• Detailed risk assessment findings
• Rationale for level of care decision
• Safety planning discussion
• Follow-up arrangements
• Collateral information obtained 2

Common Pitfalls to Avoid:

• Relying solely on "no-suicide contracts" (ineffective) 2
• Underestimating risk in patients who appear calm
• Failing to obtain collateral information
• Inadequate follow-up arrangements
• Overlooking comorbid substance use disorders 2, 3

Special Populations:

• Adolescents: Always involve parents/guardians in safety planning 1
• Elderly: Higher completion rates require lower threshold for hospitalization
• Substance users: Consider dual-diagnosis treatment programs 2

Follow-up Recommendations

1. Maintain contact with referred patients to ensure continuity of care 1
2. Collaborative care between primary care and mental health professionals improves outcomes 1
3. Consider evidence-based psychotherapies like CBT, DBT, or problem-solving therapy 2, 4
4. For patients with mood disorders, consider appropriate pharmacotherapy:
   • Lithium has strongest evidence for reducing suicidal behavior 5
   • Monitor closely during initiation of antidepressants 6

Remember that suicide risk assessment is not a one-time event but requires ongoing monitoring and adjustment of the treatment plan as the patient's condition changes. The primary goal is to ensure patient safety while providing appropriate treatment for underlying mental health conditions that contribute to suicidal behavior.