Suicide Prevention Guidance from DHCS

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Dear Health Care Providers:

Thank you for serving on the frontlines of health care, helping Californians with their physical and behavioral health. We at the Department of Health Care Services and Public Health and the Office of the California Surgeon General are reaching out because of our concern about the COVID-19 epidemic’s immediate and long-term impacts on the mental health of our residents.

Social isolation, financial insecurity, and unemployment all drive increases in deaths from suicide, overdose, and illness, disproportionately impacting communities of color. Individuals who have a history of Adverse Childhood Experiences (ACEs) are particularly at risk.

You have the opportunity to screen, intervene and prevent these events.

There is no way to know if someone is in trouble unless you ask. When you ask, there are tools and resources you can offer that can save a life.

The National Institute on Mental Health (NIMH) developed the Ask Suicide-Screening Questions (ASQ): https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml), four questions in 20 seconds to identify people at risk of suicide. In a NIMH study: https://pubmed.ncbi.nlm.nih.gov/23027429/, a “yes” response to one or more questions identified 97% of youth aged 10 to 21 at risk of suicide:

  1. In the past few weeks, have you wished you were dead?
  2. In the past few weeks, have you felt that you or your family would be better off ifyou were dead?
  3. In the past week, have you been having thoughts about killing yourself?
  4. Have you ever tried to kill yourself?

What’s next?

If an individual responds “yes” to one or more of the four Ask Suicide-Screening Questions, they are at “imminent risk” or “potential risk” of suicide.

To better understand risk-level, ask “are you having thoughts of killing yourself right now?” and if the individual says “yes,” then they are at imminent risk of suicide and need an urgent mental health evaluation to ensure immediate safety. If the individual answers “no,” then a potential risk is identified and they require a brief suicide safety assessment to determine next steps.

The Zero Suicide Model: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829088/ is an evidence-based practice outlining how to apply this model in a clinical setting. Practices include:

  • Make a safety plan the patient can follow to take action if thoughts of suicide appear, including calling help lines such as the National Suicide Prevention Lifeline (1-800-273-8255).
  • Discuss restricting access to things they might use to hurt themselves – especially firearms (firearms in the house are a major risk factor for completed suicide https://www.hsph.harvard.edu/means-matter/means- matter/risk/ ).
  • Create a follow-up monitoring plan to ensure the patient receives ongoing help and support

Overdose and Suicide: An overdose or self-harm event in the emergency department indicates an extreme high risk. An opioid overdose indicated an 18-fold greater risk of suicide https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2757488 and over 100-fold greater risk of overdose in the next year, compared to the general population. A visit for suicidal ideation led to a 30-fold increase in the risk of suicide in the next year.

ACEs and Suicide: Individuals with four or more ACEs are 37.5 times as likely to attempt suicide, when compared to individuals with no ACEs12. For more information on addressing ACES in your clinical practice, visit www.ACEsAware.org.

Screening individuals for risk of suicide saves lives! Health care professionals can help people get needed care, support and resources.

Other Tools and Resources

Call the county behavioral health access line https://www.dhcs.ca.gov/individuals/Pages/MHPContactList.aspx for urgent crisis help or the phone number on the back of the patient’s health plan card. The COVID-19 emotional support website https://covid19.ca.gov/resources-for-emotional-support-and-well-being/ has resources for people at risk of suicide – you can find suicide hotlines, crisis lines, peer support lines, and other resources for people experiencing stress from the emergency – including how to find substance use disorder treatment.

Don’t Forget Yourself

You may be feeling stressed, anxious, overwhelmed or burned out by practicing on the front lines. Health workers are also at higher risk of suicide, and you are not alone. Reach out for free counseling from volunteers at the COVID-19 counseling website: https://www.covid19counselingca.org/ . There is support for you. If you want to talk to someone, there are professionals ready to support you to keep supporting others.

The Office of the California Surgeon General also has a simple guide: https://files.covid19.ca.gov/pdf/wp/california-surgeon-general_stress-busting-playbook_draft-v2clean_ada- 04072020.pdf with things you can do every day, at home, to help support your mental and physical health, utilizing six key strategies: 1) Supportive relationships, 2) Exercise, 3) Sleep, 4) Nutrition, 5) Mental Health Support, and 6) Mindfulness. Learn more in the California Surgeon General’s Playbook: Stress Relief during COVID-19 (PDF): https://files.covid19.ca.gov/pdf/wp/california-surgeon-general_stress-busting-playbook_draft- v2clean_ada-04072020.pdf. The guide is also available in Arabic https://files.covid19.ca.gov/pdf/wp/osg- general-stress-relief-playbook_arabic.pdf, Chinese (Simplified https://files.covid19.ca.gov/pdf/wp/osg-general- stress-relief-playbook_chinese_simplified.pdf and Traditionalhttps://files.covid19.ca.gov/pdf/wp/osg-general- stress-relief-playbook_zh.pdf) Korean https://files.covid19.ca.gov/pdf/wp/osg-general-stress-relief- playbook_ko.pdf, Spanish https://files.covid19.ca.gov/pdf/wp/2020-0334-osg-general-stress-relief-playbook- spanish-lsu-final.pdf, Tagalog: https://files.covid19.ca.gov/pdf/wp/osg-general-stress-relief- playbook_tl.pdf.ca.gov/img/wp/osg-general-stress-relief-playbook_tl.pdf, and Vietnamese: https://files.covid19.ca.gov/pdf/wp/osg-general-stress-relief-playbook_vi.pdf . We hope you join other health care professionals and take 20 seconds to ask the four questions and save a life. Thank you for all you do to protect the health of our communities!

With appreciation,
Original signed by Original signed by Original signed by
Will Lightbourne, Director Nadine Burke Harris, MD, MPH Sonia Angell, MD, MPH
Department of Surgeon General Office of State Public Health
Health Care Services Surgeon General Officer & Director


Department of Public Health

  1. Suicide-Screening Questions: https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit- materials/index.shtml
  2. NIMH Study: https://pubmed.ncbi.nlm.nih.gov/23027429/
  3. Zero Suicide Model: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829088/
  4. Major risk factors for completed suicide: https://www.hsph.harvard.edu/means-matter/means-matter/risk/
  5. Data on suicide risk after ED visit: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2757488
  6. County behavioral health access line: https://www.dhcs.ca.gov/individuals/Pages/MHPContactList.aspx
  7. COVID-19 emotional support website: https://covid19.ca.gov/resources-for- emotional-support-and-well-being/
  8. COVID-19 counseling website: https://www.covid19counselingca.org/
  9. Suicide Prevention Safety Plan Template: https://suicidepreventionlifeline.org/wp- content/uploads/2016/08/Brown_StanleySafetyPlanTemplate.pdf
  10. Safety Planning Quick Guide for Clinicianshttps://sprc.org/resources-programs/safety-planning-guide- quick-guide-clinicians
  11. California Surgeon General’s Playbook: Stress Relief During COVID-19 https://covid19.ca.gov/img/wp/california-surgeon-general_stress-busting-playbook_draft-v2clean_ada- pdf
  12. Research on ACES: Hughes K, Bellis MA, Hardcastle KA, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health2017; 2: e356-66