LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 302.13 Suicide Risk Screening, Assessment, and Mitigation
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Responsible Party:  Clinical Risk Management
 
Approved by Curley L. Bonds, MD, Chief Medical Officer, on May 19, 2022
 
I.  PURPOSE
 
To set standards within the Los Angeles County Department of Mental Health (DMH/Department) for screening, assessing, and mitigating suicide risk.
 
II.  DEFINITIONS
 
Columbia-Suicide Severity Rating Scales (C-SSRS): The standardized suicide risk screen tools utilized by DMH to assess the full range of ideation and behavior items with recommendations for next steps.

Suicide: The death of an individual by a deliberate self-inflicted injury.
 
Suicide Assessment: An evaluation of a client’s:
  • Past and current suicide ideation, attempts, intent and/or plan
  • Current mental status exam
  • Active psychiatric symptoms
  • Acute, chronic, and protective risk factors
Suicide Attempt: An act committed by an individual in an effort to cause their own death.

Suicidal Ideation: Thoughts, wishes, and preoccupations with death and suicide.

Suicide Intent: The seriousness or intensity of a client's wish to terminate their own life.
 
Suicide Risk Factors: Situation(s) that increase the possibility of suicide and could lead someone to consider suicide, including:
  • Recurring suicidal ideation
  • Previous suicide attempt(s)
  • Mental illness
  • Substance use disorder
  • Serious illness
  • Social isolation
  • Societal stressors (legal, financial, employment)
  • Impulsive or aggressive tendencies
  • Abuse, neglect, assault
  • Family/friend history of suicide
  • Relationship stressors
  • Grief and loss
  • Hopelessness and helplessness
Workforce Members: Employees, business associates, contracted employees, consultants, volunteers, other County departments and/or individuals whose conduct in the performance of work for DMH, its offices, programs, or facilities is under the direct control of the Department, office, program, or facility regardless of whether the person is paid or unpaid.
 
III.  POLICY
 
Workforce members shall:
  • Utilize clinical judgment to screen clients for suicide risk using the appropriate standardized risk assessment tools (C-SSRS versions) or non-standardized screening methods and document in a progress note.
    • Suicide risk screening information may be gathered from a client and/or support person(s).
    • Suicide screening shall be based on history, emergent risk factors, and clinical assessment.
  • Immediately report suicide risk to their clinical supervisor or manager.
  • Follow strategies to mitigate suicide risk. 
  • Monitor and reassess client suicide risk as appropriate.
IV.  PROCEDURES
 
Procedure Suicide Risk Screening, Assessment, and Mitigation
 
V.  AUTHORITY
 
California Welfare and Institutions Code Sections 5150 and 5585
 
VI.  ATTACHMENTS
 
C-SSRS (Lifetime/Recent Full Version)
Safety Planning:  Introduction, Sample, and DMH Template and Considerations
CLRM-01 Suicide Prevention Toolkit