NUR 676 Module 7 Milestone Two Example

Milestone Two: Assessing Suicide Risk and Building a Safety Plan for a 19-Year-Old in Primary Care

[Student Name]

Southern New Hampshire University

NUR 676: Primary Care for Mental Health

Module Seven Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Assessing Suicide Risk and Building a Safety Plan for a 19-Year-Old in Primary Care

Primary care clinicians often worry that asking about suicide will upset patients or open a conversation they cannot manage in a short visit. The evidence suggests the opposite risk is greater: missing people at risk who are already in the clinic. Jordan is a 19-year-old college student seen at a composite community clinic for a sports physical, who scored 15 on the PHQ-9 and marked the self-harm item as present on several days. This milestone documents how the clinician assessed suicide risk, formulated it and responded in the same visit. It argues that a structured assessment, a clear formulation of risk and a collaborative safety plan with follow-up contacts are feasible in primary care and supported by evidence.

Why Primary Care Matters for Suicide Prevention

Ahmedani et al. (2014) traced the medical visits of people across eight large health systems in the twelve months before they died by suicide. Most had at least one health care visit in that year, and about half had a visit in the four weeks before death. Many of these visits were in primary care or other medical settings rather than mental health clinics, and a substantial share of patients had no recorded mental health diagnosis. The findings mean that primary care is a critical point of contact, and that asking about suicidal thoughts and responding well can reach people who might not otherwise be identified.

Structured Assessment

When Jordan's PHQ-9 showed the positive item, the clinician returned to it in private, explaining that the clinic asks everyone about these thoughts because they are common and treatable. Posner et al. (2011) developed and tested the Columbia Suicide Severity Rating Scale in three multisite studies with adolescents and adults, finding that it distinguished levels of suicidal ideation and behavior and that its ideation severity measure was associated with later suicide attempts. The screening version asks, in plain language, about wishing to be dead, active thoughts of killing oneself, thinking about how, intent to act, a specific plan and any suicidal behavior, with recent behavior asked about separately.

Jordan described days when he hoped to fall asleep and stay that way, over the past two weeks, but denied thoughts of killing himself, any method, intent or plan. He had never attempted suicide or harmed himself. He described three months of low mood, poor sleep and falling grades after a breakup and the loss of his starting position on the team. He drinks heavily at weekend parties, up to eight drinks, and uses cannabis occasionally. His father keeps a handgun at home, where Jordan returns on weekends. Protective factors include close relationships with his sister and coach, plans to stay in school and religious beliefs that suicide is wrong.

Risk Formulation

Jordan's suicidal ideation is passive, without active thoughts, method, intent, plan or past behavior, which places him at a lower acute risk level on the screening scale. However, several factors raise concern: moderately severe depression, recent losses, heavy episodic drinking, which increases impulsivity, male sex and access to a firearm during weekend visits. His protective factors are meaningful. The formulation is that he is at low to moderate acute risk that could rise quickly with intoxication or a new loss, and that the priority is to treat his depression, reduce drinking, limit access to lethal means and ensure close follow-up. He does not require emergency evaluation today, but he does require a same-day safety plan.

Safety Planning With Follow-Up

Stanley et al. (2018) compared a safety planning intervention with structured follow-up telephone calls against usual care for suicidal patients discharged from emergency departments. The intervention, in which clinician and patient write a personal step-by-step plan, from recognizing early warning signs and self-soothing to reaching friends, family, professionals and crisis lines and making the home safer, followed by at least two phone calls, was followed by less suicidal behavior during the next half year and greater engagement in outpatient mental health care.

Jordan and the clinician wrote a safety plan together. His warning signs are lying in bed awake after midnight and drinking alone. His coping strategies are going for a run and playing guitar. His people for distraction are his roommate and teammates. His people for help are his sister and his coach, whom he agreed to tell. His professionals are the clinic and the campus counseling center, and the 988 Suicide and Crisis Lifeline is saved in his phone. For a safer environment, he agreed to ask his sister to talk with their father about locking the handgun and storing ammunition separately or keeping it elsewhere while Jordan is home, and to avoid drinking alone. The care manager will call him in two days and again in one week.

Treatment and Follow-Up

Jordan was diagnosed with major depressive disorder, moderate, after confirming criteria and a negative bipolar screen. He preferred counseling first, and a warm handoff was made to the campus counseling center with an appointment within a week. His drinking was discussed using a brief intervention, and he agreed to a limit of three drinks at parties and none when alone. Because he is under 25, if an antidepressant is started later, he will be told about the increased risk of suicidal thoughts in young adults early in treatment and monitored closely. He will return in two weeks, with the PHQ-9 and the Columbia screen repeated at every visit. His sports clearance was deferred until follow-up, with his agreement, so the team physician can support his return.

Conclusion

Jordan came in for a sports physical and left with a safety plan, a counseling appointment and a follow-up call scheduled. The evidence that most people who die by suicide see a clinician in the preceding year makes asking essential. A validated scale separated passive thoughts from active risk, a formulation identified what could change and a collaborative safety plan with follow-up contacts, supported by trial evidence, turned a positive screen into a plan to keep him safe.

References

Ahmedani, B. K., Simon, G. E., Stewart, C., Beck, A., Waitzfelder, B. E., Rossom, R., Lynch, F., Owen-Smith, A., Hunkeler, E. M., Whiteside, U., Operskalski, B. H., Coffey, M. J., & Solberg, L. I. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870-877. https://doi.org/10.1007/s11606-014-2767-3

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-1277. https://doi.org/10.1176/appi.ajp.2011.10111704

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900. https://doi.org/10.1001/jamapsychiatry.2018.1776