One of the greatest failures of counselors and caregivers of persons with mental health problems is becoming complacent in attending to the urgency of our clients' situation. We get used to the depression waxing and waning and the periodic crises. We get desensitized to the constant crises of our patients with borderline traits. We get lax when our depressed patients start to come out of their depression, when in fact, this is when they are most likely to commit suicide. These are all common reasons that patients seemingly commit suicide with no warning. As a clinician and/or guardian of someone who is depressed or has bipolar disorder, there are several things you can do to prevent unnecessary tragedy.

It is simple to increase our effectiveness with the ABC(DEF)s.

• A is for assessment. A mental health assessment needs to be conducted and documented at each contact.
• B is for believe. It can be tempting to dismiss emotional upset as "just another passing crisis" but it is this attitude that prevents us from helping people stay alive.
• C is for consult. When you have a client in crisis, have a colleague you can consult with. They are less likely to miss subtle changes in the client's presentation and can provide unbiased advice. Additionally, it is good practice at the beginning of a relationship to get a release to speak with the patient's physician. In the event that he or she is medication noncompliant or using alcohol or other drugs with prescribed medications in a way that is dangerous (i.e. taking Risperdal and 1/5 of rum), it is important to consult with the patient's prescribing physician.
• D stands for document. Every single progress or contact note must include evidence that you completed at least a mini mental status exam.
• E is for educate. Equip your clients with tools to help them get through crises and deal with triggers. This includes emergency numbers, life pact/crisis action plan, cognitive behavioral interventions to get through an acute situation and information about the dangers of any medication noncompliance or other risky behaviors.
• F is for follow up. If a patient misses an appointment, it is best to follow up that same day, but at least within 24 hours and document that effort. When patients call or present in crisis, it is sometimes appropriate to follow up with them 24 hours after the contact to see how they are doing. In some extreme cases, a follow up may include a well being check by law enforcement.

Let's look at these a little more closely. First and foremost, regularly assess the person's mental status. Are they alert or confused? Can they make decisions? Is there any change in eating or sleeping patterns? Do they talk of suicide, hopelessness? Do they seem apathetic—not really enjoying anything? Additionally, there are several key warning signs for suicide. First, Do they have future plans? If they are talking about a vacation, an upcoming holiday or even plans for tomorrow, it is a good sign. Also, are they giving away and/or making arrangements for the care of their children/pets? People who see suicide as imminent will usually be making arrangements for those people and creatures that are dependent on them. Each time you meet with the person, you should assess these things. If you are a caregiver/guardian, just do a quick assessment in your head. If anything seems amiss, get the person in for a formal evaluation. If you are a clinician, this evaluation must be a part of every progress note. It is even a good practice to do a mini mental status exam (and document it) each time the person calls, especially if it is due to a crisis or to cancel an appointment.

There are also other factors that can help to mitigate/prevent suicide. For one, pay attention to the patient's triggers. For some people it is a holiday, for others it might be the anniversary of the death of a loved one or a pet and still for others it might be a situation that reminds them of a trauma in the past such as news coverage of a disaster, seeing a bad traffic crash etc. When these times are coming up, at least part of your sessions leading up to the trigger time should involve preparation for dealing with any feelings that arise. Devise a safety plan. For patients who might be triggered by a situation such as a traffic crash, these preparations should take place in the beginning of therapy. This way, whenever they run into a trigger they have some tools to deal with it. Another responsibility we as clinicians have, whether we take insurance or not, is to ensure the person has access to an emergency appointment (phone or face to face) within 24-hours of going into crisis. Since patients do not always call us when they go into crisis, it is a good practice to follow up with patients within 24 hours of a missed appointment.

Finally, many clinicians feel hamstrung about the issue of reporting patient medication noncompliance. For many patients, medication noncompliance (either monkeying with dosage or using alcohol or drugs with their medication) is life threatening. There is not currently case law that I know of, but a clinician that knowingly allows clients to potentially create a deadly cocktail by mixing alcohol or drugs with certain medication potentially could be held liable for failure to protect a person in imminent danger. For many patients, medication noncompliance is their way of indicating that their medications need to be adjusted. In the beginning of therapy, I have patients sign a release allowing me to talk with their physician. There are a multitude of reasons that the physician may need to be consulted, so this is helpful. I do however make a pact with my patients that I will tell them before I call their doctors. If during therapy I find out they are noncompliant, I have my patients sign an agreement that outlines the dangers of their medication noncompliance, states they will stop doing what they are doing, will notify their doctor and will bring back proof of that notification to me. I follow up with the patient each session on this issue until the issue is corrected. It is an art to handle this in a way that does not push the patient away, but lets them know you are genuinely concerned.

Since crises will come up despite your best efforts, it is advisable to do a life pact at the first session with patients who are severely depressed, have bipolar disorder or evidence a personality disorder. This life pact should contain emergency contacts, information about the availability of weapons, directions to the person's house, a contract to go to the emergency room or call 911 before they harm themselves, the number to the local crisis center and a notification statement to the person that if you feel they are in imminent danger you will be sending law enforcement to do a well-being check.

If you employ all of these techniques, you will be much less likely to have to experience the loss of a patient or loved one who is under your care.

About the author: Dr. Snipes received her Masters in Rehabilitation Counseling and her PhD in Counseling and Education from the University of Florida. She has worked for 10 years in community mental health. Currently she runs a small internet-based church and two online continuing education sites www.allceus.com and www.engineeringceus.com.

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