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When attempting to identify an at-risk patient in the E.D., remember these techniques to encourage a patient to open up to you:

Establish a rapport and sense of partnership with the patient to gain trust: Show concern, be sincere, be supportive, speak privately if possible; try sitting or standing at the same level as the patient; and avoid judging, taking sides, or labeling.

Ask open-ended questions about the patient's presenting situation. Encourage the patient to provide context: ask WHAT happened, WHY the patient has this complaint, HOW and WHEN it came about, and WHO else is involved.

Listen reflectively to ensure communication and demonstrate empathy: Repeat or paraphrase what the patient said, and summarize your understanding of the situation.

If a patient warrants further screening, remember the SAD PERSONS toolkit, to help you remember ten of the most common risk factors for suicide:

S: SEX – Men are more at-risk than women.
A: AGE – Patients most at risk are under 25 or over 65.
D: DEPRESSION – Depression can be a good predictor of suicide risk.
P: PREVIOUS ATTEMPT – Previous suicide attempts are a risk factor.
E: ETHANOL ABUSE – Excessive use of alcohol or drugs increases suicide risk.
R: RATIONAL THINKING LOSS – This includes psychosis, delusions, and hallucinations.
S: SOCIAL SUPPORTS LACKING – Risk is lowered if the patient has social supports in place.
O: ORGANIZED PLAN – Ask the patient if he has a plan, and access to the means necessary to carry out the plan.
N: NO SPOUSE – Separated, divorced, or widowed patients are at a higher risk.
S: SICKNESS – Chronic disease or pain, or severe sickness, increases risk.

For each risk factor found, score the patient with one point. If the patient scores from 1-4, he or she is low risk. If the patient scores 5-10, the patient is high-risk for suicide, and you should strongly consider hospitalization.

If you've identified a patient as high-risk following a SAD PERSONS screening, according to SAFE-T, you'll need to determine the appropriate intervention.

If the patient has health insurance, contact the insurance company to get a referral for behavioral health services. In other cases, free or low-cost services may be available through crisis line numbers, psych-urgent care centers, community clinics, organizations, or places of worship.