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Many experts predict a sharp rise in psychiatric emergencies as the nation emerges from sheltering-in-place, especially since individuals are dealing with unprecedented stressors and have been unable to access traditional treatment settings. Mental health crises may be one area in which therapeutic professionals might be a logical substitute for traditional police interventions. But what services comprise the crisis spectrum of care? And, if you treat patients in a private office or clinic, how might you best access these services when you encounter a psychiatric emergency?

Crisis services for behavioral health emergencies may include a wide variety of approaches, and they tend to vary depending on your state, county, or community. Yet, there are general overall concepts applicable to most crisis programs and their target patient populations.

A mental health crisis is a situation in which a person’s thoughts, emotions, and behaviors can put them in jeopardy of harming themselves or others and/or put them at risk of being unable to care for themselves or access food, clothing, and shelter. Crises also include acute conditions that could quickly deteriorate into dangerousness or inability to care for self, even if those issues do not currently pose a problem.

A mental health crisis can surface anywhere—in public, in the home or work environment, or in any number of clinical settings. This discussion will focus on the considerations when an apparent crisis arises in patients under a clinician's direct care.

The following questions will help determine if a mental health crisis exists and if crisis services should be accessed 

1. Due to their behavioral health conditions, is this individual acutely dangerous to self or others, or unable to care for self?

2. If the answer to question 1 is not clear, are there concerns that, without prompt intervention, the behavioral health situation could evolve into dangerousness or inability to care for self?

If the answer to question (1) or (2 ) is “yes,” then answer (A) and (B) below.

A. Is this condition unlikely to be resolved by interventions without the need for a higher level of care?

B. Even if our interventions can temporarily stabilize the situation, is there a high degree of concern that dangerousness or inability to care for self will return shortly after our contact has ended?

If the answer to (A) or (B) is “yes,” then there is a crisis situation requiring acute external interventions.

Determining dangerousness and/or inability to care for self

The clinician should consider several factors when assessing a patient for dangerousness and ability to care for self.

. Is this the first time you have met with this individual, or are they well known to you?

. How certain are you about the veracity of their statements? Do you believe them when they say they will follow through with a plan?

. What is your understanding of how they have acted when experiencing similar behavioral issues in the past?

. Has this person made suicide attempts or become aggressive in the past?

. What do family, significant others, co-workers, and caregivers say about the patient’s current behavior and their concerns about these behaviors?

These considerations and questions help to determine the acuity and level of intervention needed. For example, an initial meeting with reported symptoms requires a different level of evaluation than if the patient and their symptom history are well-known to you. Similarly, a patient that is well-known who reports a sudden change or demonstrates a marked difference from their usual behavior should raise the level of acuity. Based on familiarity, you must evaluate your level of trust with the patient. If trust is nebulous, then it is paramount to delve into collateral opinions of family and significant others. Concerns may first arise from a patient’s report, their significant others’ report, or your personal assessment. Regardless of the source of the initial warning, the response should be comparable.

Although an individual’s mention of the word 

 in discussing previous thoughts or incidents may not be considered a reason for accessing crisis services, any concern that patients may be at risk to harm themselves should be considered a reason for action. It is most important to learn about an individual’s thoughts around suicide, especially if there is any suicidal plan or intent. To determine if a patient needs a higher level of care, clinicians should consider the following issues. 

 Is the person thinking/talking about suicide, or saying that death seems to be an option, or expressing that the world would not miss them/would be a better without them?

 Does the person have a specific idea about how they would kill themselves? How lethal is this method?

 How much does the person want to use a particular method to kill themselves? How serious are they about it?

 Does this individual have access to the means they have described to kill themselves?

 Does the person have strong religious or cultural beliefs that forbid suicide? Do they have others who rely on them that they feel they cannot leave?

Chronic symptoms of psychosis may be a well-controlled part of an individual’s life and not necessitate an emergency referral. Acute psychosis, however, may lead the patient to harm themselves or others or may cause an inability for them to care for themselves. For example, if the patient is currently stable and the hallucinations are tolerable and not placing the patient at risk, then long-standing auditory hallucinations (eg, a running commentary of what the patient sees) may be fine. On the other hand, a new delusion may necessitate intervention, especially if the hallucinations have negative consequences for the patient (eg, hallucinations dictating all food is poisonous and must be avoided, which results in the patient starving themselves). Similarly, command auditory hallucinations to attack family members or delusions that one has the ability to fly and should jump off a tall buildingare clearly psychiatric emergencies. Thus, there are many issues that must be considered.

 Is the person newly experiencing auditory hallucinations or experiencing a substantial increase in chronic hallucinations? Are the hallucinations commanding them to do things, especially to harm themselves, others, or objects? Are the hallucinations derogatory or highly critical of the patient? Does the patient feel they are unable to resist doing what the hallucinations are telling them?

 Does the person feel others wish to harm them and they might have to defend themselves or preemptively attack others? Does the person believe other people want to kill them? Is the person obsessively fixated on another person who may not share their feelings? Is the patient paranoid or delusional about anything that would prevent them from accessing food, clothing, or shelter (eg, if they go inside they will die, all foods are poisonous, they are impervious to cold and do not require a coat in subzero weather)?

. Has the individual become so confused or withdrawn that they are unable to appropriately interact with others and their environment and, thus, unable to access food, clothing and/or shelter?

When symptoms of mania are uncontrolled, there is risk for harm to self or others as a result of rash judgements, impulsivity, inability to rest, grandiosity, and impaired decision-making. Evaluating the severity of a manic or hypomanic episode may be determined with the following considerations.

 Is the person displaying poor judgment, unable to differentiate between right and wrong, spending money they do not have, placing themselves into dangerous situations unwittingly?

 Is the patient going without sleep or doing specific activities nonstop for long hours?

 Is the person easily angered, lashing out, or easily moved to anguish and sobbing?

, unlike uncontrolled mania, is often more objectively apparent in terms of current intoxication or effects of drug misuse. The severity of substance abuse may be apparent in terms of mood, judgement, or disorganization.

 Is the person despondent about their substance abuse or inability to quit? Have they mentioned suicide?

 Is their current intoxication or level of withdrawal clouding their judgment and putting them at risk?

 Can the person safely leave the facility and get home on their own?

Fortunately, there are a variety of crisis programs that can assist the clinician in providing help for their patient. Programs vary in their level of care and support as well as cost. By becoming familiar with the options in your area, you will be better able to offer information to patients before a crisis occurs as well as when the need arises.

 number is available in most areas; it can be reached via 800-273-TALK. The FCC has approved a 3-digit hotline number—988—to make it easier for people to access mental health resources, which should be available by summer 2022. If you are in direct contact with a patient, you likely will not need to refer them to a hotline; however, you will want to ensure patients are informed about such resources and should add the information to your voicemail message.

. Although technically not crisis programs, many county and municipal programs have a 24-hour mental health line, sometimes called an ACCESS line, to arrange for prompt mental health appointments, referrals, and links to services. These programs can also direct individuals to appropriate 

 These are crisis professionals, typically therapists or social workers, who will go to an individual in crisis for an onsite assessment. When possible, they will attempt to de-escalate and stabilize the patient at the site, so the patient does not need to be moved offsite to access a higher level of care. Based on the assessment, mobile crisis teams will often transport patients to an appropriate destination, which could be a community crisis center, a psychiatry emergency department (ED), a psychiatric inpatient unit, or a general hospital ED. Mobile crisis models can operate independently or may partner with the police; frequently the mobile crisis team can be accessed via police dispatch.

Community crisis programs/centers/mental health urgent care

. In recent years, many locations around the country have created drop-in crisis facilities. These can range from a simple set-up, like a section of the community mental health clinic staffed with crisis therapists, to a comprehensive crisis center with crisis intervention, 23-hour crisis stabilization units (intensive outpatient stabilization services which typically have a limit of 23 hours 59 minutes—anyone requiring a longer stay is moved to an inpatient unit), and substance abuse and/or detox programs. Patients typically need to arrive voluntarily, but mobile crisis teams, case managers, and police officers can also bring them to these centers. Although they may be able to accommodate involuntary detention patients, including initiation of involuntary holds, these patients are typically transferred to a medical ED or hospital rather than remaining onsite involuntarily.

. Although not available in every region,, a substantial number of locations have Psychiatric Emergency Programs that are designated as the main receiving site for involuntary and high-acuity psychiatric detentions. These programs typically accept voluntary patients and self-presenting individuals, but most patients tend to be involuntary cases that arrive via police or ambulance. These programs offer immediate assessment and treatment (including medication) with 23-hour crisis stabilization capacity. These units are invariably locked, so anyone entering will have to be discharged by a clinician before they can leave. For this reason, it may be the preferred option for individuals who refuse emergency care or who are flight risks.

. Most inpatient psychiatric hospitals accept the majority of their patients via direct referrals from psychiatrists with hospital admitting privileges or via referrals from regional medical and psychiatric EDs. However, many programs have intake hours in which an individual can self-present on recommendation from their outpatient therapist. In such situations, a member of the psychiatric hospital staff will assess for a possible admission to the inpatient unit.

. In the United States, the default location to send a crisis patient is the nearest general hospital medical ED, which is open 24 hours a day and obliged to evaluate any individual who requests services. The numbers of behavioral emergency patients presenting at medical EDs around the country has climbed in recent years, and it is currently estimated that 1 in every 8 patients in EDs 

with a behavioral emergency as the chief complaint.

 Most EDs, however, have little more to offer than a medical clearance, (perhaps) sedating medications, or a referral to an inpatient hospital bed.

A promising trend has been to offer higher levels of psychiatric care in medical EDs, including psychiatric assessment and treatment recommendations via on-demand telepsychiatry. Another new and useful trend is the availability of EmPATH (Emergency Psychiatry Assessment Treatment and Healing) units, which are specialized psychiatric emergency programs affiliated with the ED, analogous to an ICU dedicated for emergency behavioral health patients.

. When there are no other alternatives, calling 911 remains a legitimate best option for activating emergency services. It allows for a patient assessment and transport to a crisis facility or ED. Depending on your community or state as well as the acuity of the emergency, response may be from a crisis team, emergency medical services, and/or police.

 is Vice President for Acute Psychiatry with the physician partnership 

 and Assistant Clinical Professor of Psychiatry, 

is a registered nurse working as Operations Consultant for 

 Psychiatry/Neurology practice line. Dr Zeller and Ms Kircher have no disclosures to report regarding the subject of this article.

1. Kalter L. Treating mental illness in the ED. AAMC. September 3, 2019. Accessed July 27, 2020. 

https://www.aamc.org/news-insights/treating-mental-illness-ed

Inevitably, some of your patients will need of emergency psychiatric services. These tips will help prepare you and your patients when a crisis unfolds.

Understanding Crisis Services: What They Are and When to Access Them

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Suicide is a global public health crisis and is the 

 In 2018, more than 45,000 adults in the US died by suicide, surpassing the number of homicides by more than 2-fold. Moreover, suicide risk is even higher among individuals with comorbid medical illnesses. Illness such as cancer, diabetes, and asthma have all been shown to increase risk for suicide.

 Given that medical illness is a concerning suicide risk factor, medical settings provide an optimal venue for suicide risk detection and intervention.

Medical settings are well positioned to detect suicide risk. The majority of people who died by suicide visited a health care professional months before their death, placing medical providers on the frontlines of suicide risk detection and suicide prevention.

 However, many patients with suicidal thoughts who present to the health care system with somatic complaints do not disclose suicidal thinking unless asked directly, and most medical settings do not screen for suicide risk.

Notably, suicides in the hospital are one of the top 5 most frequently 

sentinel events to The Joint Commission (TJC).

 Many are surprised to learn that although in-hospital suicides are relatively rare for patients undergoing general medical care, a sizeable portion of them occur on non-behavioral health units, such as intensive care units or emergency departments (EDs). Given these striking statistics and the goal of leveraging hospitals as partners in suicide prevention, TJC revised National Patient Safety Goal 15.01.01 (NPSG 15) in 2019.

 NPSG 15 outlines several elements to optimize patient safety and the reduction of suicide risk in medical settings. In particular, NPSG 

performing environmental safety assessments, removing ligature risks, screening patients with behavioral health issues for suicide risk, and providing further assessment of at-risk individuals who screen positive.

 Although NPSG 15 refers to suicide risk screening of all patients who are being treated or evaluated for a behavioral health condition as their primary reason for care, the TJC issued Sentinel Event Alert 56 in 2016, recommending suicide risk screening for all patients, using brief, evidence-based screening tools.

Following these recommendations, a growing number of health care systems have implemented suicide risk screening programs for all patients, including those presenting with medical complaints. Such a program at 

 (PHHS) is an example of how to successfully implement hospital-wide universal suicide risk screening. Using one of the screening tools recommended by TJC, PHHS screened more than 325,000 patients in the first 6 months of implementing their screening program and detected a positive screen rate of below 4% among patients undergoing medical care.

 It will be important for hospitals to work with frontline clinicians to develop safe and feasible procedures for implementing the safety guidelines outlined in NPSG 15 across diverse rural and urban settings and to be able to articulate their procedures to TJC surveyors when they assess hospitals for safe care delivery.

Several suicide risk screening tools are commonly used, with varying levels of evidence to support their use among these patients. Thom and colleagues

 reviewed several brief suicide risk screening tools and discussed the benefits and limitations of each for use in a hospital setting.

 Their review discusses 6 screening tools, including the Ask Suicide-Screening Questions (ASQ), the Patient Safety Screener (PSS-3), and the Columbia-Suicide Severity Rating Scale (C-SSRS), most of which are also TJC-recommended screening tools.

 The authors highlighted that only 2 of the tools discussed, the ASQ and the PSS-3, were developed and validated specifically for patients undergoing medical care.

Notably, the C-SSRS, a tool used by many hospitals due to its application to both youth and adults, has not been validated specifically for use in medical settings. Although Thom and colleagues highlighted that no suicide risk screening tools have been validated for use among both pediatric and adult patients undergoing medical care, recent data show that the ASQ, originally validated for use among youth, also has excellent psychometric properties among adult medical patients, potentially allowing for the use of 1 screening tool across hospitals.

Some medical settings utilize depression screeners to identify patients at risk for suicide. For example, the Patient Health Questionnaire (PHQ-9), which is an excellent depression screen, is sometimes utilized as a suicide-risk screening tool.

 Although there is a well-documented association between suicide and depression, extant research shows that the 2 are not synonymous. In 1 study, 90% of suicide decedents met criteria for diagnosis of a mental illness; however, only 28% of suicide decedents met the criteria for major depressive disorder.

 Moreover, screening solely for depression in patients undergoing medical care may not adequately detect suicidal ideation.

Question 9 on the PHQ-9, which asks about the frequency of a patient being bothered by “thoughts that you would be better off dead, or of hurting yourself in some way,” contains both an “or” and the word hurting instead of killing. Some studies have used this item to identify large numbers of at-risk patients.

However, specific concerns exist regarding the sensitivity and specificity of item 9

; the awkward wording of the question leading to inaccurate responses

; and that relying solely on item 9 may miss a large portion of patients at risk for suicide.

Using depression screeners such as the PHQ-9 as a proxy for suicide risk screening may be insufficient to detect suicide risk. Additionally, other mental health disorders, such as substance use disorders, schizophrenia, and anxiety disorders are associated with risk of suicide, which would go undetected by screening only for depression.

 Asking directly about suicide risk and using validated tools specific to hospital settings is necessary to accurately screen for suicide risk.

risk screening tools that was created and tested specifically for use among patients undergoing medical care, the ASQ is also part of a 3-tiered suicide risk screening clinical pathway.

 Although this pathway was designed for use among youth, the 3-tiered system can be applied to all such patients, including adults. The proposed pathway starts with the use of a brief screening instrument to rapidly screen all medical patients for suicide risk. For this step, Brahmbhatt and colleagues

 recommended the use of the ASQ due to its brevity and focus on patients undergoing medical care. The PSS-3 is the other screening tool that has been tested on adult patients in the ED and makes an excellent first-line brief screener.

After a patient screens positive for suicide risk, the second and essential step is to have a trained clinician (eg, a mental health clinician, nurse practitioner, physician assistant, primary care physicians) conduct a 10- to 15-minute brief suicide safety assessment (BSSA) to determine how to effectively manage the patient’s suicide risk. The secondary safety assessment step was created to avoid a one-size-fits-all planfor anyone who screens positive on a primary screener. All positive screens should not be treated as an 

; in fact, the majority of positive screens will be non-acute positives that do not require full safety precautions, but rather need further assessment.

This second step helps to ensure that mental health resources are used effectively and patients who reveal suicidal thoughts are not treated in a way that may seem punishing. For the BSSA, the clinical pathway published by Brahmbhatt and colleagues suggested the C-SSRS or the ASQ BSSA. Anecdotal evidence from frontline screeners suggests that the C-SSRS, which is a good in-depth suicide risk severity rating scale, is lengthy as a first-line screener and is more appropriate as a secondary suicide safety assessment tool for use among patients who screen positive for suicide risk. The ASQ and the ASQ BSSA are available as part of the ASQ Toolkit.

 The aim of the BSSA is to help a clinician further assess suicide risk in order to determine next steps in the pathway—whether a full mental health evaluation is needed at that particular medical visit, or if it can wait for an outpatient mental health referral.

Following a positive suicide risk screen, an essential component of ensuring patient safety is safety planning and lethal means counseling. Stanley and Brown

 published a safety plan worksheet that can help clinicians assist patients in planning how they will handle a future suicidal crisis. This worksheet consists of 6 steps that includes identifying personal warning signs, internal coping strategies, people and settings that can provide distraction, trusted people who can provide help, contact information for mental health resources, and ways to make the environment safe. The last step refers to the process of lethal means safety counseling, which is a detailed discussion on how to limit access, remove, or safely store dangerous items (eg, pills, firearms, knives, and ropes).

Implementation of suicide risk screening has been a specific challenge for many hospital systems due to difficulty selecting an evidence-based tool across the lifespan and across medical/surgical specialty settings that work in both inpatient and outpatient settings. In addition, guidance around how positive screens should be interpreted have led to systems developing untenable rules, such as “all positive screens require 1-to-1 sitters” and “strict safety precautions.”

Somewhat surprisingly, the rate of positives screen results due to reporting a past suicide attempts is significant. Past suicidal behavior is one of the most predictive risk factors of future behavior, but many reported attempts were in the distant past (eg, more than 10 years earlier). How should these truthful responses be interpreted? Such past behavior may be important clinical history when delivering a poor medical prognosis to a patient. Clearly more implementation research is needed on how to handle past attempt history and how frequently patients should be screened.

Suicide risk screening is especially challenging in the time of a pandemic. Data are not yet available to ascertain how COVID-19 will affect the suicide rate. However, the 3-tiered clinical pathway needed to be revised to accommodate mostly telehealth screening. Due to the urgent need, we revised the suicide risk screening clinical pathways published by Brahmbhatt and colleagues to reflect the need for phone 

Typically, anyone who is in imminent danger requires an urgent psychiatric evaluation in an ED. The pathway needed to be revised to help patients with acute suicide risk avoid exposure to COVID-19 in the ED and to spare the ED from over-crowding during the pandemic crisis. Separate adult and youth versions of this 

were created and are available as part of the ASQ Toolkit (

 However, they have not yet been empirically tested. A critical part of this pathway is for the health care practitioner to provide 

 to the patient and family members or friends to ensure safe storage or removal of potentially dangerous items (eg, pills, firearms, belts, knives).

Detection and management of suicide risk screening in the medical setting is no longer theoretical. There are many hospitals successfully implementing suicide-risk screening programs with validated instruments. Universal suicide risk screening can be successfully implemented without incurring a need for additional resources. Use of the intermediate step of a brief suicide safety assessment provides critical guidance for determining appropriate follow up in a safe and efficient manner. Given the increasing suicide rates in the general population, medical venues offer important opportunities for early detection, assessment, and referral. With evidence-based tools and pathways to guide them, every health care provider can be a partner in suicide prevention.

is the Clinical Director of the National Institute of Mental Health (NIMH) Intramural Research Program at the National Institutes of Health, she is also the Deputy Scientific Director, NIMH; 

is an Intramural Research Training Award Fellow at the NIMH; 

 is a Staff Scientist and Clinical Psychologist at the National Institute of Mental Health Intramural Research Program at the National Institutes of Health, she also serves as a senior attending with a specialty in pediatric psychology on the Psychiatry Consultation Liaison Service in the Hatfield Clinical Research Center at NIH.

Acknowledgement—This research was supported in part by the Intramural Research Program of the NIMH (Annual Report Number ZIAMH002922).

1. CDC National Center for Injury Prevention and Control: Web-based Injury Statistics Query and Reporting System (WISQARS). 

2. Karmakar C, Luo W, Tran T, et al. Predicting risk of suicide attempt using history of physical illnesses from electronic medical records. 

3. Ahmedani BK, Stewart C, Simon GE, et al. Racial/ethnic differences in health care visits made before suicide attempt across the United States. 

4. Pan YJ, Lee MB, Chiang HC, Liao, SC. The recognition of diagnosable psychiatric disorders in suicide cases’ last medical contacts. 

5. Frankenfield DL, Keyl PM, Gielen A, et al. Adolescent patients”: healthy or hurting? Missed opportunities to screen for suicide risk in the primary care setting. 

6. The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. 

https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

7. The Joint Commission. Hospital National Patient Safety Goals. NPSG.15.01.01. 

https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf

8. The Joint Commission. Detecting and treating suicide ideation in all settings. 

9. Roaten K, Johnson C, Genzel R, et al. Development and implementation of a universal suicide risk screening program in a safety-net hospital system. 

10. Thom R, Hogan C, Hazen E. Suicide-risk screening in the hospital setting: A review of brief validated tools. 

11. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. 

12. Boudreaux ED, Jaques ML, Brady KM, et al. The patient safety screener: validation of a brief suicide-risk screener for emergency department settings. 

13. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. 

14. The Joint Commission. Validated/ Evidence-Based Screening Tools. Suicide Prevention Resources to support Joint Commission Accredited organizations implementation of NPSG 15.01.01. 

https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/suicide-prevention/suicide_prevention_resources_ep2_npsg150101.pdf

15. Horowitz LM, Snyder DJ, Boudreaux ED, et al. Validation of the Ask Suicide-Screening Questions (ASQ) for adult medical inpatients: a brief tool for all ages. 

16. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. 

17. Conwell Y, Duberstein PR, Cox C, et al. Relationships of age and axis I diagnosis in victims of completed suicide: a psychological autopsy study. 

18. Recklitis CJ, Lockwood RA, Rothwell MA, Diller LR. Suicidal ideation and attempts in adult survivors of childhood cancer. 

19. Simon GE, Coleman KJ, Rossom RC, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. 

20. Simon GE, Rutter CM, Peterson D, et al. Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? 

21. Uebelacker LA, German NM, Gaudiano BA, Miller IW. Patient health questionnaire depression scale as a suicide screening instrument in depressed primary care patients: a cross-sectional study. 

22. Suarez L, Beach SR, Moore SV, et al. Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease. 

23. Razykov I, Hudson M, Baron M, Thombs BD. Utility of the Patient Health Questionnaire?9 to assess suicide risk in patients with systemic sclerosis. 

24. Louzon SA, Bossarte R, McCarthy JF, Katz IR. Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? 

25. Dueweke AR, Marin MS, Sparkman DJ, Bridges AJ. Inadequacy of the PHQ-2 depression screener for identifying suicidal primary care patients. 

26. Brahmbhatt K, Kurtz BP, Afzal KI, et al. Suicide-risk screening in pediatric hospitals: Clinical pathways to address a global health crisis. 

27. National Institute of Mental Health. Ask Suicide-Screening Questions (ASQ) Toolkit, 2017. 

28. Stanley B, Brown GK. Safety Planning Intervention: a brief intervention to mitigate suicide risk. 

The authors share evidence-based guidance for patient safety that minimizes suicide risk in medical settings.

Implementation Challenges of Universal Suicide Risk Screening in Adult Patients in General Medical and Surgical Settings

On any given day, there are more than 400,000 children in foster care in the US (

). Children in foster care are at a higher risk for health and mental health problems.

 They are also connected to multiple systems, which require and challenge coordinated care.

 Further complicated by histories of maltreatment (Sidebar) and issues in assessment, diagnosis and treatment can be challenging-for children, their families and guardians, and their clinicians. In honor of 

, this article sheds light on these issues and provides information for psychiatrists caring for this vulnerable population.

“Joseph” is a 3-year-old in foster care. After 2 out-of-home placements, he was returned to his parents. Each removal was connected to allegations of physical abuse. His permanency goal is changing to adoption, but he still has visits with his parents. He is physically healthy but hyperactive and impulsive and has problems sleeping.

When Joseph first arrived at his current foster home, he had temper outbursts at least once a day that included screaming, hitting, kicking, and breaking things. Over the course of a few months, the outbursts decreased to weekly; the outbursts seemed connected to visits with his parents.

Joseph has a diagnosis of attention-deficit/hyperactivity disorder and oppositional defiant disorder. He was prescribed 18 mg methylphenidate ER in the morning, 0.1 mg clonidine at bedtime, and 0.5 mg risperidone twice daily, all by his primary care provider. How and when these medications were started is not clear from the records.

Upon entering treatment with a community mental health provider, Joseph’s foster mom reported “we can’t handle him without these medications.” Discussions continue about the risks and benefits of risperidone and the circumstances under which it would be possible to start tapering.

Providing psychiatric services to children and adolescents in foster care require collaboration not only with the clinical team, but also the child welfare team. Team members include parents, foster parents, and the social worker, at minimum. The team may also include representatives from courts and others engaged by the child welfare system to conduct assessments (eg, psychological, neuropsychological). Child welfare services’ organizational structure varies from state to state. State and/or local policy defines practice related to permanency and broader case planning, defining the consenting parties for health and mental health treatment, practices for obtaining informed consent for psychotropic medication, and tracking and oversight of psychotropic medication use for children in foster care.

Foster care workers typically serve 10 to 15 families. They are responsible for all aspects of case planning including monitoring placements, ensuring safety, arranging parental visitation, preparing for court, and planning for permanency. Case workers are often very knowledgeable about the youths and families they serve and can be a true partner in care. Psychiatrists and their office staff should reach out to local child welfare leadership to build collaborative relationships. In doing so, it is helpful to share office hours, emergency service policies, duration of initial assessment and follow up appointments, information needed prior to an initial assessment, and preferred pathways for communication between the office and the child welfare team. These outreach efforts are useful during usual care as well as when challenges or crises arise.

Children in foster care often experience placement changes. Maintaining continuity of care during treatment within a single organization as well as ensuring that comprehensive clinical information transfer occurs when children transition to new treatment providers presents a challenge. Psychiatrists should provide leadership in policy and practice development to accomplish this goal.

Child welfare systems present unique challenges for comprehensive psychiatric assessments. Psychiatrists must receive complete prior mental health records, including those prior to foster care placement; as such, they should establish mechanisms to obtain collateral history from parents, foster parents, and other caregivers (eg, staff in residential placement), and obtain health and school records. Psychiatrists should communicate these needs to the team, assist in developing protocols for consent for release of information documents, and maximize information transfer within systems.

Although most, if not all children, in foster care have suffered maltreatment exposure, the type, duration, and impact of such before foster care varies. Children may also experience traumatic exposures during foster care, including stress related to parental circumstances, separation from siblings, placement change, termination of parental rights, as well as illness and death of family members.

Although it may not be necessary or appropriate to ask children to recount specific experiences and/or exposures, psychiatrists should make the child and their family aware that they know that stressful events have occurred and provide psychoeducation on the impact of ongoing stressors in the context of maltreatment. Exposures need to be considered when conducting assessments. Doing so may include asking the child and caregivers to complete screening tools or diagnostic assessments specific to traumatic exposures as well as those related to other psychiatric diagnoses.

When a child in foster care is scheduled for a psychiatric assessment, clinical staff should inquire about the legal status of the child, the names and contact information for the person legally empowered to consent for treatment, and who will be bringing the child to the appointment. Unless the child and parent are prohibited from contact, arranging for parents to be present is optimal so that they can provide history, sign consents for release of information, and engage in consent for treatment. If a parent cannot be present, they can be contacted before the appointment for needed information.

The long-term priorities of the welfare systems are reunifying children and parents when possible and supporting family functioning. Engaging parents throughout their children’s time in foster care supports these goals; engaged parents are better equipped to address their children’s physical and mental health needs.

Unfortunately, involving parents is complicated by many factors. Maternal characteristics such as poverty, substance use, co-occurring disorders, and domestic violence as well as perception of the effects of sharing information may discourage involvement.

 Addressing parental needs (eg, substance use disorder treatment) is important for successful reunification, but may present a barrier to simultaneous engagement in a child’s health care.

 Given that reunification is the most common goal, educating all team members about the importance of parental engagement is important throughout foster care placement.

“James” is a 16-year-old admitted to a residential treatment facility after running away from 2 foster homes. His entrance into the foster care system was predicated by ongoing but undisclosed sexual abuse perpetrated by his stepfather that occurred for at least 5 years before discovery. At that time, he was diagnosed with bipolar disorder and anxiety. He was treated with ari- piprazole, titrated to 15 mg daily and 0.5-mg alprazolam up to 3 times daily for acute anxiety. During residential assessment, James reported periodic temper outbursts and moodiness without clear episodes of depression or mania. Also during this time, he reported significant anxiety and occasional panic attacks.

During residential treatment, he participated in individual and group therapy. The aripiprazole was gradually tapered and discontinued, alprazolam was also tapered. He made plans to transition from the residential facility to an independent living program.

There are a wide variety of psychiatric diagnoses among children in foster care (

 looked at Medicaid claims data (2002 to 2007) from a national sample of youths aged 3 to 18 years who were enrolled in foster care. The findings indicated that rates of mental health diagnoses generally increased over this time with 2 exceptions: depression was stable from 2002 to 2005 but decreased from 2006-2007, and schizophrenia remained stable throughout. Generally, the rates of diagnoses in this sample of children are higher compared with cumulative diagnosis by age 7 from a single state 2007 birth cohort sample.

Because of maltreatment, children in foster care often have trauma-related diagnoses, with posttraumatic stress disorder as the most specific trauma-related diagnosis. DSM-5 includes guidance about how PTSD may manifest in childhood. More general responses to trauma exposure may be captured by “trauma and stressor related disorder unspecified” if PTSD cannot be diagnosed with confidence.

To diagnose disorders common in childhood (eg, ADHD, anxiety disorders, and depressive disorders), psychiatrists should determine whether symptoms are present, the timing and duration of symptoms in relation to trauma exposures, and persistence after substantial reduction in trauma-related symptoms. Emotional dysregulation is a common response to traumatic exposures; if considering 

 or disruptive mood dysregulation disorder, clinicians must determine if full symptom, duration, and pattern criteria are met or if symptoms may be better explained by trauma.

Perception and thought disturbances are also relatively common in children with maltreatment exposure. Explanations may include intrusion of traumatic experiences (eg, nightmares, flashbacks, involuntary memories) and negative thoughts and feelings (eg, distorted beliefs about the self or others) rather than emerging psychosis.

Finally, the potential for other co-existing factors that affect diagnosis-such as exposure to substances and maternal stress in utero, perinatal stress related to neonatal abstinence syndrome, and the effect of any abuse-related physical or neurological injury-must be included in differential diagnosis, treatment planning, and assessment of longer-term services, supports, and prognosis. (See Keeshin et al

 for an in-depth discussion of manifestations of maltreatment and impact on psychiatric diagnosis.)

Psychotherapy is generally considered first line when addressing trauma- and stressor-related emotional and behavioral conditions in children. Strategies with empirical support include trauma-focused cognitive behavioral therapy (TF-CBT); parent-child interaction therapy (PCIT), which is suggested for children aged 2 to 7 years to improve parenting skills and reduce children’s disruptive behavior; and attachment and bio-behavioral catchup (ABC), which has been tested in toddlers in foster care.

 The National Child Traumatic Stress Network (

) provides information on a variety of evidence-based and promising psychotherapeutic approaches for children exposed to maltreatment.

Studies have shown an increase in the use of psychotropic medication, including antipsychotics, in children and adolescents through mid-2000.

 Use of psychotropics is even higher in foster care (

 Although this trend has raised over-medication concerns, other factors must be considered, eg, a higher risk of emotional and behavioral concerns related to family/genetic history and maltreatment exposure. Since its peak in the mid-2000s, psychotropic medication use has plateaued, possibly a consequence of oversight efforts.

Treatment with psychotropic medications should not be considered first line when targeting emotional and behavioral difficulties related to trauma. However, evidence-based use for co-existing disorders, and judicious use to target symptoms that cannot be managed by psychosocial treatments alone, may be considered.

Psychopharmacological treatment for psychiatric diagnosis such as ADHD, major depressive disorder, and bipolar disorder in the context of maltreatment should follow existing recommendations and guidelines. However, closer monitoring and re-evaluation should occur if the child’s response is not as expected, as children exposed to maltreatment may be more likely to experience side effects such as suicidal ideation on antidepressants.

 As generally recognized, clinicians should start with lower doses, advance slowly, maintain monotherapy versus multiple medications in combination and monitor for adverse reactions per clinical guidelines.14

When the child has symptoms that do not clearly meet diagnostic criteria for a specific disorder, the clinician should proceed more cautiously. Children, families, the psychiatrist, and other team members should discuss the full range of psychosocial interventions. If evidence-based interventions have not yet been implemented, the team should develop a plan to do so. The team should consider whether additional supports are needed, including the implementation of a parenting curriculum for children exposed to trauma or other support (eg, respite services).

Sleep disturbances are common in children but more frequent in the setting of trauma; the evidence for medications is limited. Melatonin is one option; other options such as benzodiazepines or second-generation antipsychotics should be avoided.

When children’s aggressive behaviors put them or others at significant risk, medications can be considered as one part of a comprehensive treatment plan. Medications should be used at the lowest possible dose and monitored carefully. The team should develop a plan to monitor response to medication (ie, improvement in target symptoms) and a target timeline for tapering and/or discontinuing medication. A plan to switch medications should also be in place; such a plan should include tapering of the first medication before starting the second. Additional support for the child and/or family may be needed during medication transitions.

Children in foster care who demonstrate symptoms such as severe aggression are also more likely to experience placement transitions in community and residential settings. Under these circumstances, there is risk of polypharmacy, and it is more difficult to assess individual medications. After any transition that involves a new treatment team, both written and verbal communication is critically important-some medications may need to be discontinued (

Young adults transitioning out of foster care may be less inclined to accept recommendations from treatment providers, if only because they perceive lack of control over their lives. They may also have fewer natural supports to help them navigate adult responsibilities. It is, therefore, important to inquire about support systems as well as to acknowledge their lived experience and engage them in shared treatment decision-making.

Children in foster care present with extra challenges and unique situations, but with thoughtful assessments and coordination, they can have positive outcomes. Psychiatrists are in the unique position to provide comprehensive clinical care and policy leadership supporting all children’s health and well-being.

is Associate Professor, Department of Psychiatry, Michigan State University, East Lansing, MI and Medical Consultant to the Michigan Department of Health and Human Services, Children’s Services Agency.

1. Szilagyi MA, Rosen DS, Rubin D, et al. Health care issues for children and adolescents in foster care and kinship care. 

2. Lee T, Fouras G, Brown R, AACAP Committee on Quality Issues. Practice parameter for the assessment and management of youth involved with the child welfare system. 

3. Keeshin B, Forkey HC, Fouras G, et al. Children exposed to maltreatment: assessment and the role of psychotropic medication. 

4. Marcenko MO, Lyons SJ, Courtney M. Mothers’ experiences, resources and needs: the context for reunification: 

5. Cao Y, Bunger AC, Hoffman J. Caregiver engagement in the behavioral health screening and assessment for child welfare-involved children: child welfare and behavioral health workers’ perspectives. 

6. Doab A, Fowler C, Dawson A. Factors that influence mother-child reunification for mothers with a history of substance use: a systematic review of the evidence to inform policy and practice in Australia. 

7. Rubin D, Matone M, Huang Y-S, et al. Interstate variation in trends of psychotropic medication use among Medicaid-enrolled children in foster care. 

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