NU674 Unit 4 SAFE-T Suicide Risk Assessment Example

The Tobacco Tin on the Bookshelf: A SAFE-T Suicide Risk Assessment for a 71-Year-Old Retired Cartographer Keeping Leftover Oxycodone

[Student Name]

Purdue University Global

NU674: PMHNP Diagnosis and Management Across the Lifespan Clinical I

Unit 4 Suicide Risk Assessment

[Instructor Name]

[Date]

The patient is composite; details, counts and times are bracketed.

Context

Outpatient follow-up, [Thursday], [14:00 to 14:50]. Mr. [W.], [71], a retired cartographer, was seen four weeks ago for depression after the death of his wife of [44] years, [eight] months ago, and started on sertraline. At today's visit he mentioned, when asked about pain, that he still has "a good supply" of oxycodone from his surgeries. The assessment follows the SAFE-T approach, which organizes suicide risk assessment into five steps: identifying risk factors, identifying protective factors, conducting a suicide inquiry, determining risk level and intervention, and documenting (Substance Abuse and Mental Health Services Administration, 2009).

Step 1: Risk Factors

1. Older man, widowed within the past year, living alone.

2. Major depressive episode, PHQ-9 today [17], little change from [19] four weeks ago.

3. Access to a lethal means: about [40] oxycodone [5] mg tablets from surgeries in [2021] and [2023], kept in a tin in the living room.

4. Chronic back pain.

5. Social withdrawal: stopped attending his map society meetings.

6. Recent loss of role: his wife managed their social life, and he says he has "no reason to go out now."

Older adults die by suicide at high rates relative to their attempts, in part because they use more lethal means and plan more carefully, and physical illness, social disconnection and access to means are among the factors reviews highlight (Conwell et al., 2011).

Step 2: Protective Factors

1. Close relationship with his daughter, who lives [15] minutes away and visits weekly.

2. A grandson he is teaching to read maps, whom he calls "the one bright spot."

3. Engaged in treatment; attended both visits and takes sertraline as prescribed.

4. Says he would not want his daughter "to find me like that."

Step 3: Suicide Inquiry With the Columbia Scale

The Columbia Suicide Severity Rating Scale was used for its structured questions on ideation and behavior; it has shown good validity and internal consistency in multisite studies (Posner et al., 2011).

1. Wish to be dead, past month: yes. "Most nights I think I wouldn't mind not waking up."

2. Nonspecific active suicidal thoughts: yes, "a few times," most recently [last week].

3. Active ideation with any method, without intent: yes. When asked what method he had thought about, he looked at the bookshelf and said, "The pills, obviously. That's why I didn't throw them out, if I'm honest."

4. Active ideation with some intent: denied.

5. Active ideation with a specific plan and intent: denied.

6. Suicidal behavior, lifetime: none; no preparatory acts, although he acknowledged counting the tablets [two] weeks ago.

He kept the tin for pain, he said at first, and then, asked about method, he said he kept it for this; the assessment turns on that second answer.

Step 4: Risk Level and Intervention

Risk formulation: moderate risk. He has active suicidal ideation with a method, access to that method, and has counted the tablets, which is close to preparatory behavior; he denies intent and has strong protective ties to his daughter and grandson and is engaged in care. His risk is raised by his age, sex, recent bereavement, living alone and pain.

Intervention:

1. Means restriction. Putting time and distance between a person and a lethal method has strong support as a prevention strategy, since many suicidal crises are brief and substitution of another method is incomplete (Barber & Miller, 2014). With his agreement, his daughter will come to his home this evening to collect the tin and take it to a pharmacy drug take-back, and she will text the clinic when done. He also has no firearms at home, confirmed with him and his daughter.

2. Safety plan. He and I wrote a Stanley and Brown safety plan together, in his handwriting: his own warning signs, what he can do alone, his daughter and a neighbor as contacts, the clinic and the 988 line, and the tin already on its way out (Stanley & Brown, 2012). His daughter received a copy with his permission.

3. Treatment. Sertraline increased to [100] mg. Grief-focused therapy referral. Follow-up in [one] week instead of four, with a phone check in [two] days.

4. Pain. Referral back to his primary care clinician for a pain plan that does not depend on stored opioids.

Step 5: Documentation

This note records the risk factors, protective factors, the inquiry and his words, the risk formulation, the means restriction step with confirmation to follow, the safety plan and the follow-up. The preceptor reviewed and agreed with the formulation and plan at [15:10]. At [19:40] his daughter texted that the tin had been taken to the pharmacy.

References

Barber, C. W., & Miller, M. J. (2014). Reducing a suicidal person's access to lethal means of suicide: A research agenda. American Journal of Preventive Medicine, 47(3, Suppl. 2), S264-S272. https://doi.org/10.1016/j.amepre.2014.05.028

Conwell, Y., Van Orden, K., & Caine, E. D. (2011). Suicide in older adults. Psychiatric Clinics of North America, 34(2), 451-468. https://doi.org/10.1016/j.psc.2011.02.002

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. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. https://doi.org/10.1016/j.cbpra.2011.01.001

Substance Abuse and Mental Health Services Administration. (2009). SAFE-T: Suicide assessment five-step evaluation and triage [Pocket card]. U.S. Department of Health and Human Services.