Emerging Best Practices for Addressing Suicidality in Primary Care

Suicide is a leading cause of death in the United States.¹ In 2023 alone, more than 49,000 people died by suicide.¹ While rates briefly declined during the COVID-19 pandemic years (2020–2021), they have since rebounded.¹

Individuals at risk for suicide are regularly seen in primary care and other general medical settings.^2–5 Forty percent of individuals who died by suicide had contact with a primary care provider in the month prior to their death, and up to 80% had contact within the past year.^2–5 These patterns underscore primary care providers’ role as a critical point of contact and a key opportunity to intervene and support patients at risk. Despite the high rates of contact, suicide often goes unidentified and unaddressed in primary care by providers. There are a few common reasons:

• Lack of training or confidence in suicide risk assessment and response.^6,7
• Limited or no relationships with behavioral health providers.⁸
• Uncertainty about what to do next once the risk of suicide is disclosed.⁹
• Time constraints and competing demands.⁹ 

As a result, providers may avoid the topic altogether or refer patients to emergency departments or inpatient settings. While well-intentioned, these approaches are not always equipped to provide sustained, suicide-specific care.¹⁶ Emergency departments may involve long waits¹⁷ and fragmented follow-up.¹⁸ Experiences in emergency departments and during psychiatric hospitalizations, where care may prioritize stabilization and risk containment over direct, suicide-focused interventions^19,20, can feel disempowering, and patients may feel stripped of agency, exacerbating feelings of helplessness or shame.¹⁸ These experiences may undermine trust, limit patient autonomy, and, ultimately, discourage future help-seeking.²¹

Beyond discouraging disclosure, these typical care approaches may sometimes have unintended consequences for patient well-being, particularly in the case of involuntary psychiatric commitment. Hospitalization may sometimes be necessary to ensure immediate safety during an acute crisis and can offer short-term stabilization.^22,23 However, it is not always sufficient to support longer-term recovery. Some individuals experience involuntary hospitalization as disempowering or isolating and may face challenges after discharge, including disruptions to employment and housing.²³ Notably, involuntary hospitalization has been associated with increased suicide risk after discharge.^23,24

Taken together, these findings point to an urgent need to reframe suicidality as a health issue that can be addressed in primary care. When equipped with the right tools, training, and support, primary care teams are well-positioned to detect suicide risk early, initiate brief interventions, and collaborate with behavioral health specialists to ensure patients receive the care they need in settings that are accessible, person-centered, and empowering. The remainder of this brief describes practical strategies and actionable advice for implementation to help primary care teams recognize and respond to suicide risk with confidence and compassion.

This section synthesizes strategies that can help primary care teams identify and support patients at risk for suicide. The approaches are organized along a continuum: some can be applied in any primary care setting, including those without on-site behavioral health staff or with limited resources. Others build on this foundation and benefit from integrated behavioral staff or additional infrastructure and resources. The goal of this brief is not to prescribe a single model, but to share a variety of interventions and frameworks so practices of all sizes and capacities can choose steps that fit their context. Once you have read through these strategies, the next section of this brief provides practical tools, training links, and resources to help you translate them into day-to-day workflows.

Practical Strategies for Any Primary Care Team

Primary care teams can take meaningful steps to reduce suicide risk—even in clinics without integrated behavioral health or care coordination support. The strategies below reflect core principles and practical interventions, grounded in the importance of connection, structure, and trust, that can be implemented across a wide range of care settings.

Structuring Primary Care to Include Suicide Prevention

Just like other high-risk clinical presentations—such as chest pain or arrhythmia—suicidality can be addressed through structured protocols and routine workflows. Integrating suicide prevention into routine care, rather than treating it as a behavioral health add-on, helps normalize and prioritize its management while supporting consistent, coordinated responses across the care team. Key clinical strategies include collaborative inquiry into suicidal feelings, proactive planning to equip people to handle future suicidal episodes and using motivational interviewing to give people better tools for managing their treatment.²⁵

Emphasizing Human-Centered Care

Validating distress, avoiding power struggles, preserving patient dignity and autonomy, and avoiding over-pathologizing suicidal thoughts are essential for effective and compassionate care. When clinicians acknowledge and validate patients’ experiences of suicidality or self-harm, patients may feel more hopeful and are more likely to seek help in the future.²⁶ Conversely, undermining or contesting their accounts may increase distress, diminish hope, and discourage future help-seeking.²⁶ Sensitive, clear, and supportive language during suicide inquiries further supports patient autonomy and dignity, while minimizing the risk of inadvertently silencing or pathologizing normal expressions of distress.²⁷ These principles of person-centered care—validating distress, preserving autonomy, and communicating with sensitivity—are foundational to how clinicians build trust and promote engagement. Motivational interviewing offers a structured, evidence-based approach that brings these values into practice, guiding how providers can engage patients in collaborative, nonjudgmental conversations about change.

Building on these core principles, motivational interviewing relies on a specific set of conversational techniques that help bring the approach to life in clinical encounters. Key techniques used in motivational interviewing include open-ended questions, affirmations, reflective listening, and summarizing. These techniques help clients clarify their goals, examine discrepancies between current behaviors and broader values, and strengthen their commitment to change.^29,30 These tools are designed to deepen understanding, elicit motivation, and support the client’s journey toward change in a respectful, non-confrontational manner.

Motivational interviewing interventions may increase self-efficacy and coping, and improve engagement with follow-up care.^33–35 Motivational interviewing can also enhance motivation for safety planning and adherence to care— critical foundations for longer-term suicide prevention.³⁵ Its emphasis on empathy, collaboration, and eliciting intrinsic motivation aligns well with the needs of individuals experiencing suicidal thoughts or ambivalence about living. Further, the brief, flexible structure of motivational interviewing makes it especially well-suited to primary care and can help providers surface suicidal thoughts in a nonjudgmental way, support patients in identifying reasons to stay safe, and build momentum for follow-up. When used, motivational interviewing offers a practical and respectful tool for early intervention.

Discouraging Harmful and Reactive Practices

Involuntary psychiatric hospitalization—particularly when perceived as coercive—can erode patient trust, discourage future help-seeking, and is not reliably associated with reduced suicide risk. While state laws do allow for involuntary commitment in cases of acute suicidality with a diagnosable mental illness,³⁶ standards vary and may not always reflect current clinical best practices. These laws were developed primarily as a legal mechanism to balance individual rights with personal safety, rather than as a treatment model focused on long-term recovery.³⁷

Reflexive or liability-driven admissions in response to suicidality may potentially cause harm to patients. Patients who perceive their psychiatric hospitalization as coercive may experience psychological distress, including fear, loss of autonomy, and trauma.³⁶ They may also feel neglected or dehumanized.³⁸ These experiences can erode trust and lead patients to avoid future behavioral health care, especially when suicidal intent prompted admission but direct treatment for suicidality was not provided. While treatments for suicidality that can be delivered during inpatient stays have been developed and tested, they are not yet commonplace, and their evidence is mixed.¹⁹ Instead, hospitalization often prioritizes risk containment (through environmental safety measures, patient observation, and medication initiation) over direct suicide-focused care.^19,20

Fear and trauma experienced during involuntary admission can lead patients to avoid future engagement with behavioral health services, even when support is needed.³⁸ Contrary to common assumptions, involuntary psychiatric hospitalization is not reliably associated with reduced suicide risk (in the short-term or the long-term), aside from the brief period of containment it provides.^39,40 In fact, the period following discharge is marked by elevated suicide risk,³⁹ particularly among patients who perceived their hospitalization as coercive.²⁴

Despite more than a century of relying on involuntary hospitalization to keep people safe, national suicide rates have continued to rise.¹ This raises important questions about how best to balance immediate safety with long-term recovery—and whether current practices are achieving that goal. These findings underscore the need for care models that minimize coercion, strengthen therapeutic alliance, and provide meaningful support after discharge. Primary care has a critical role to play in this shift—offering a trusted, non-crisis setting where suicide risk can be identified early, addressed collaboratively, and managed in ways that preserve dignity and promote ongoing engagement. In some cases, this will mean providing collaborative outpatient care, while in others it may require referral for acute hospitalization. Making these determinations can be complex; this risk stratification table from the Department of Veterans Affairs can support clinical decision-making by outlining key features of acute and chronic risk levels and appropriate actions for each, including outpatient efforts like those outlined in this brief.

Using 988 as a Support Tool

On July 16, 2022, the federally mandated crisis hotline 988 became available nationwide at no cost to all landline and cell phone users. This three-digit number connects individuals in crisis—via phone, text, or chat—to a network of over 200 locally and state-funded crisis centers, offering 24/7, confidential access to the 988 Suicide & Crisis Lifeline for counseling, resources, and referrals. Since its launch, 988 has shown early promise as a low-barrier, real-time support for individuals in crisis, with over 10 million answered contacts via phone, text, and chat.⁴¹ Despite rising demand, answer rates have improved and wait times have shortened, making it a more accessible and responsive resource.⁴¹ For individuals with suicidality, calls, texts, or chats to 988 should replace calling 911, and 988 should be provided as a resource to individuals experiencing suicidality or significant life stressors.

Importantly, early evaluations suggest 988 may play a meaningful role in suicide prevention. Over 97% of suicidal callers felt their call helped them, and almost 90% said the intervention stopped them from killing themselves.⁴²

While not a substitute for long-term support, 988 can offer real-time connection and de-escalation. Because the impulse to act on suicidality is often transient, support in the moment is very useful.⁴³ The Lifeline is also tailored to meet the needs of a wide array of callers, with prompt options and trained responders for specific groups, including veterans, Spanish speakers, and Deaf and Hard-of-Hearing individuals. As an easily accessible resource, 988 is particularly relevant for primary care practices, holding potential to reinforce patient safety, dignity, and autonomy, especially for individuals at elevated suicide risk.

Supporting Patients Using Caring Contacts

Caring Contacts are a low-cost, non-demanding intervention designed to reduce suicide risk by sending brief messages of care and support to individuals in crisis during periods of elevated suicide risk or following psychiatric hospitalization or emergency department visits. Messages can be delivered via a variety of modalities, including postcard, email, or text and concerns are expressed without requiring a response.⁴⁴

These sample messages reflect the key elements of Caring Contacts: brief, non-demanding, and emotionally supportive. Messages like these can be sent via text, email, or postcard. The goal is not to initiate clinical intervention, but to express genuine care and connection—reinforcing that the individual in crisis is not alone and that support is available.

"Hi John, just a quick note to say we’re thinking of you and hoping your week is going okay. You matter—and if you ever feel like checking in, we’re here for you." - Jane

"Jenny- I’m glad you’re persevering, and I hope things keep getting better for you. I’m sending good thoughts your way."  - Jim (Dr. Smith’s office)

Caring Contacts are one of the few suicide prevention strategies to demonstrate reductions in suicide deaths in randomized trials.⁴⁵ A 2022 systematic review and meta-analysis found that Caring Contacts were associated with a protective effect on suicide attempts at one year post-randomization.⁴⁴ For some recipients, Caring Contacts messages may help them feel connected and encourage help-seeking.⁴⁶ The use of Caring Contacts is generally well accepted and aligns with core principles of dignity, connection, and non-coercive support.^46,47 Importantly, since Caring Contacts can be sent via a variety of mediums (for example, texts and postcards), efforts can be adapted to rely on non-verbal formats without requiring involvement from busy professionals.

Training All Staff to Provide Quality Care for Patients in Distress

Suicide prevention training is important to equip clinic staff in all roles and across all levels with the confidence and competence to support patients in distress. Even brief interventions can produce meaningful gains: the Suicide Prevention Resource Center (SPRC) emphasizes that “after even minimal training, staff can observe and respond to warning signs of suicide,” enabling earlier detection and response.

Key targets for training are improving confidence in and providing basic knowledge to staff. Very few clinical training programs—even for mental health professionals—address suicide care.^47,48 Structured training may improve providers’ self-efficacy and reduce anxiety in working with suicidal patients.^48–50 Other staff, including nurses and social workers, may also benefit from participating in gatekeeper training and short-form programs to increase their knowledge and self-perceived competence.^51,52 Providers who feel sufficiently trained may be less likely to avoid or feel discomfort with suicidal patients, and more likely to follow best practices in care.^48,53 Booster sessions may be needed to sustain long-term gains, especially in attitudes, but the cumulative effect of multiple trainings can foster enduring improvements in both confidence and clinical behavior.^51,54

Strategies for Primary Care Teams with Behavioral Health Capacity and/or Greater Resources

The following approaches build on the foundational practices outlined above and are best suited to clinics with integrated behavioral health staff, access to care coordination infrastructure, or the ability to implement structured protocols. While these strategies may require more resources or specialized roles, they offer added potential to strengthen suicide prevention efforts and support sustained patient engagement through comprehensive, team-based care.

Introducing Brief, Evidence-Supported Interventions That Fit Primary Care Workflows

Brief suicide-specific interventions, such as the ones outlined below, can reduce suicidal ideation and behavior, particularly when delivered soon after risk is identified. These interventions can be implemented by behavioral health providers in integrated care settings or adapted for delivery by trained professional and paraprofessional staff in clinics without embedded behavioral support, offering flexible, scalable options that align with routine care delivery.

Primary Care Interventions for Safety Planning, Crisis Response Planning, and Collaborative Assessment and Management of Suicidality

Treatment approaches focused specifically on suicide and emphasizing collaboration between patients and clinicians during suicide risk assessment and intervention can reduce suicidal ideation.⁵⁵ These models aim to foster trust and promote patient autonomy and self-management skills while encouraging active engagement in care. By co-developing treatment goals and grounding treatment in the patient’s values and lived experiences, providers can better support individuals through suicidal crises. Approaches such as the Safety Planning Intervention, Crisis Response Planning, and the Collaborative Assessment and Management of Suicidality, all embody this collaborative ethos while offering structured frameworks to guide intervention.

Safety Planning Intervention

The Safety Planning Intervention is a structured, brief therapeutic approach designed to help individuals at acute risk of suicide. It is a single-session behavioral intervention leading to a collaboratively developed, personalized action plan—typically organized into six core steps:

1. Identify Warning Signs
   • Patients are guided to recognize early signs that a suicidal crisis may be developing. This self-awareness is foundational for timely intervention.
2. Develop Internal Coping Strategies
   • Patients brainstorm and document strategies they can use to distract themselves or relieve distress without needing to contact another person.
3. Utilize Social Contacts for Distraction and Support
   • Patients identify people or social settings that can provide distraction or support, such as friends, family members, or community places.
4. Contact Family Members or Friends for Help
   • Patients identify trusted people they can reach out to when coping strategies alone are insufficient.
5. Contact Mental Health Professionals or Agencies
   • Patients identify professionals or agencies they should contact during escalating crises, including emergency resources.
6. Reduce Access to Lethal Means
   • Patients collaboratively identify and limit access to potentially dangerous means, such as medications or firearms (a critical safety step).

A growing body of research supports the effectiveness of Safety Planning Interventions in reducing suicidal behavior, increasing treatment engagement, and lowering hospitalization rates. A systematic review of 26 studies found that Safety Planning Interventions were associated with improvements across multiple domains, including suicidal ideation and behavior, depression, and treatment follow-through, and noted their feasibility and flexibility across diverse clinical settings.⁵⁶ Similarly, a meta-analysis of studies including over 3,500 participants found that Safety Planning Interventions significantly reduced suicidal behavior.⁵⁷ Together, these findings suggest that safety planning is a low-burden, adaptable intervention that can reduce harm and improve outcomes for individuals at risk.

Crisis Response Planning

Similar to the Safety Planning Intervention, crisis response planning is a brief, personalized intervention designed to help patients manage acute suicidal crises. Crisis response planning serves as a problem-solving tool, often written on a simple index card, that patients can use when experiencing suicidal distress.⁵⁸ This intervention can also be conducted in a single visit. It builds on the principles of safety planning but incorporates a structured narrative approach to assessment, encouraging patients to “tell the story” of their most recent suicidal crisis. This process not only aids in emotional regulation but also helps clinicians and patients collaboratively identify early warning signs and strengths.⁵⁹

Crisis response planning includes several structured components:

• Narrative Assessment: Patients recount the chronology of a suicidal crisis, identifying associated thoughts, feelings, physiological reactions, and behaviors. This retrospective reflection is typically done for the first, worst, and most recent crises.
• Warning Signs: Patients identify the indicators that signal a crisis is emerging. These may include thoughts, emotions, physical sensations, or behaviors.
• Self-Management Strategies: Patients identify the coping techniques they can apply independently across a range of situations.
• Reasons for Living: Patients identify personally meaningful motivations for staying alive and reinforcing purpose and hope.
• Social Support: Patients identify other individuals they can contact for connection or stress relief—without needing to disclose suicidal thoughts.
• Professional Resources: Patients identify the names and contact information for treating providers and other professional sources of help.
• Crisis Services: Patients identify the national hotlines, mobile crisis teams, or emergency departments they can contact in high-risk scenarios.

As a standalone intervention, crisis response planning may reduce suicidal behavior and ideation, and increase optimism when compared to treatment as usual.^58,60 When implemented with fidelity, crisis response plans can be effective tools for addressing the needs of individuals experiencing suicidal crises, offering structure, support, and a pathway to safety.⁶¹

The Collaborative Assessment and Management of Suicidality (CAMS)

The Collaborative Assessment and Management of Suicidality, also known as CAMS, is an evidence-based therapeutic framework designed to assess, manage, and treat suicidal ideation and behaviors.⁶² CAMS is typically conducted over a few sessions by behavioral health professionals and requires brief, specialized training. Its effectiveness is derived from its specific and collaborative focus on suicidality.

CAMS is not a fixed protocol, but a flexible clinical framework that centers on the collaborative assessment and treatment planning between the clinician and the suicidal patient. Central to the CAMS approach is the use of the Suicide Status Form (SSF), a multipurpose tool for assessment, treatment planning, tracking, and outcome evaluation. The SSF enables both quantitative and qualitative understanding of a patient's suicidal risk, facilitating a problem-focused intervention that aims to identify and treat the specific "drivers" of suicidality for each patient.⁶² To operationalize this framework, CAMS emphasizes several core components supporting patient safety and engagement throughout treatment.

The Collaborative Process

• Therapeutic Alliance: CAMS is designed to enhance the therapeutic relationship by fostering collaboration and shared responsibility in treatment planning. This approach increases patient motivation and engagement.^62,63
• Stabilization Plan: CAMS includes the development of a CAMS Stabilization Plan (CSP), which ensures safety and stability between sessions by helping patients develop alternative coping strategies. The CSP is collaboratively constructed and revisited as needed.⁶³
• Targeting Drivers of Suicidality: Treatment focuses on identifying and addressing the underlying psychological drivers that contribute to suicidal thoughts and behaviors, rather than merely treating symptoms.^62,63

A growing body of randomized controlled trials and meta-analyses supports the effectiveness of CAMS. Randomized control trials consistently show that CAMS leads to greater improvements in suicidal ideation compared to treatment as usual (which typically involves counseling, case management, and medication support without a structured suicide-focused approach) , with effects that are sustained for up to 12 months post-treatment.^64–66 Meta-analytic findings further suggest that CAMS enhances treatment acceptability and instills greater hope while reducing hopelessness.^65,67 Patients engaged in CAMS also report stronger therapeutic alliances and greater satisfaction with treatment than those receiving standard care.^65,68 CAMS provides clinicians with a structured yet adaptable approach for engaging suicidal patients, empowering patients to identify life goals and develop hope for recovery.

Important Caveat: The Limitations and Risks of No-Suicide Contracts 
No-suicide contracts—also referred to as “no-harm contracts” or “contracting for safety”—were once a standard component of suicide care practice.⁶⁹ These agreements involve clinicians asking patients to promise verbally or in writing not to harm themselves. These contracts were originally viewed as a way to reduce suicide risk and protect clinicians from liability.⁷⁰ However, these contracts are largely ineffective. They do not reliably prevent suicide and may, in some cases, cause harm.^70–73 Despite their continued use in some settings, there is no credible evidence supporting their effectiveness. While these contracts require minimal training to implement, they may fail to deliver the protective benefits they were once assumed to provide.

Leveraging Integrated and Remote Care Models

Integrated behavioral health models in primary care may serve as effective frameworks for delivering suicide care. Two prominent models—the Primary Care Behavioral Health (PCBH) model and the Collaborative Care Model (CoCM)—offer distinct approaches that can both lead to improved outcomes for patients at risk.

The Primary Care Behavioral Health (PCBH) model emphasizes real-time consultation, high accessibility, and close collaboration between behavioral health consultants and primary care providers.⁷⁴ Behavioral health consultants serve dual roles as consultants to medical providers and as direct providers of brief (typically 30 minutes or less) behavioral health interventions focused on improving functioning across the lifespan.⁷⁵ Unlike in co-located care, behavioral health consultants are fully integrated into the care team and available for same-day consults, allowing them to see a higher volume of patients.⁷⁶ Behavioral health consultants and primary care providers often see patients in the same exam rooms, reinforcing the sense of coordinated, team-based care.⁷⁴

Intervention by behavioral health consultants may be associated with improvements in well-being, symptom management, and functioning, and decreases in suicidal ideation.^77–79 While more research is warranted, the PCBH model holds promise as a practical, effective approach to managing suicide risk in primary care.

Originally developed at the University of Washington, the Collaborative Care Model (CoCM) is a structured, team-based approach to integrating behavioral health into primary care settings. It is designed to improve the management of common mental health disorders (particularly depression and anxiety) by embedding behavioral health support directly into medical care.

CoCM relies on a dedicated care team: a structured partnership between a primary care provider, a behavioral health care manager, and a (often off-site) psychiatric consultant. The primary care provider and behavioral health care manager work together to deliver evidence-based treatments (medication-based or psychosocial) tailored to the patient’s needs. A key component of the model is the Systematic Caseload Review, during which the psychiatric consultant meets regularly with the behavioral health care manager to review patients who are not improving as expected, provide treatment recommendations, and ensure timely adjustments to the care plan.⁸¹

This coordinated, team-based approach has shown strong evidence for suicide prevention. Systematic reviews of randomized controlled trials indicate CoCM significantly reduces suicidal behavior, particularly with high-intensity interventions.⁸² Large-scale implementations show meaningful outcomes: one randomized trial reported a 25% reduction in suicide attempts following CoCM rollout.⁸⁴ CoCM may also decrease suicide risk in at-risk patients.^85,86

Importantly, CoCM is also adaptable for remote delivery. Providers like Concert Health expand access to behavioral health services by delivering CoCM virtually—via phone or video—while maintaining care coordination with the patient’s primary care team. This hybrid model shows early promise in expanding access to high-quality suicide prevention care.⁸⁶

Together, the PCBH and CoCM models demonstrate that primary care is a viable and effective setting for delivering suicide care. While their structures and intensities differ, both models offer practical pathways for integrating behavioral health support and improving outcomes for at-risk individuals.

This brief has outlined a range of approaches—such as safety planning, crisis response planning, motivational interviewing, and collaborative care—that can help address suicide risk in primary care. However, the question remains: How can these strategies be put into practice, especially in busy or resource-constrained settings?

The implementation strategies below offer concrete steps that providers and clinics can take, whether or not they have embedded behavioral health staff. These options are designed to be modular and adaptable. Not every practice will be able to do everything at once but doing something relevant and practical is better than doing nothing at all. Even small, low-lift actions, like introducing 988 or sending a caring follow-up message, can make a real difference in patient outcomes.

Establish Foundational Practices in All Primary Care Settings

Regardless of whether practices have integrated behavioral health staff, there are foundational steps that any primary care practice can take to support patients at risk of suicide, just as patients with heart disease, diabetes, or hypertension are supported. These strategies center on building trust, inquiring about thoughts of suicide using clear and supportive communication, and creating a clinical culture where conversations about suicidality are welcomed rather than avoided. Even small shifts in language or follow-up can make a meaningful difference—and every member of the care team can play a role.

How to Make Suicide Conversations Routine—and Respond with Empathy and Respect

How you ask about suicide, and how you respond, shapes whether patients feel safe sharing their experiences and whether they are willing to engage in care. Some practices have successfully implemented universal suicide screening among adults but this practice is not yet recommended by the USPSTF. Recognizing this, asking about suicidal thoughts in the context of a trusted healthcare relationship can be a valuable way to identify risk that might otherwise go unrecognized.⁸⁷ Since suicide and self-harm are stigmatized^88,89 and since patients may not realize that help is available for the emotional pain they are feeling⁹⁰, they may be unlikely to disclose without being asked.⁹¹ If your practice chooses to address this problem with screening, start with a standardized, validated tool (such as the Patient Health Questionnaire 9, or PHQ-9) that asks specifically about suicide, and distribute it in a supportive, consistent manner. Follow up with a conversation to determine next steps in partnership with the patient. Below are three ways to support open, respectful communications, complete with sample statements to have on hand if a patient discloses suicidal thoughts.

1. Ask Clearly and Routinely.
Normalize discussions about suicide by making it a standard part of the care team’s workflow. Framing the conversation as a routine part of whole-person care can help reduce stigma and increase comfort for patients. For example, “We ask about a range of health issues because we are concerned about all aspects of your health.” Use direct, compassionate language—not vague or leading questions. Avoid phrasing that implies you are hoping for a "no."²⁷

Try:

• “Have things gotten to the point where you’ve had thoughts about ending your life or hurting yourself?”
• “Sometimes when people feel overwhelmed, they think about not wanting to be here. Have you felt that way?”

Don’t ask:

• “You’re not feeling suicidal, right?”
• “You haven’t had any thoughts of hurting yourself?”

Framing the question within the context of broader emotional concerns makes it feel more natural and less stigmatizing. In contrast, “no-problem” questions (in which the provider assumes or favors a best-case scenario) may discourage honest disclosure.²⁷

2. Validate and Respond with Empathy.
When a patient shares something difficult—whether it is a disclosure or a denial—how a provider responds matters. Lean “in” to the conversation, not “out.” Avoid minimizing, contradicting, or debating their account. Statements that suggest doubt or imply they are not “really suicidal” can feel invalidating or coercive. ²⁶Even brief responses like “good” or “right” may inadvertently signal that denial is the expected answer.²⁷

Instead, say:

• “Thank you for telling me. I’m really glad you shared that.”
• “That sounds incredibly hard. I want to make sure you feel supported.”
• “If anything changes, I hope you’ll feel safe letting me know.”

These responses reinforce that you are open to continued conversation and trust the patient’s experience.^26,27

3. Use Nonverbal Cues to Communicate Respect.
Patients take in more than just your words. Nodding, maintaining eye contact, and using an open posture can help validate patients' accounts and foster a sense of safety. For example, a standard practice in CAMS is for the clinician to sit side-by-side with the patient, not behind a desk. These small gestures can go a long way in affirming that you are engaged and listening.²⁶

In addition to how conversations are initiated and responded to, the physical and digital environment of a practice can also help patients feel supported. A simple way to strengthen connection and show patients they are not alone is to make visible your practice’s commitment to suicide prevention. SAMHSA’s Suicide Prevention Month Toolkit includes posters, printables, and messages that can be displayed in waiting rooms, exam rooms, or online portals. While developed for Suicide Prevention Month, many of these materials are applicable year-round and can help signal to patients that your team is open to talking about suicide and ready to support them. Additionally, SAMHSA offers the 988 Partner Toolkit, which provides templates for social media, print materials, and other outreach resources to help reinforce awareness of the 988 Lifeline. These tools can be used to foster a practice culture of openness, compassion, and accessibility—complementing the verbal and nonverbal strategies described above.

How to Make Suicide Prevention Training the Norm for Everyone on a Care Team

Supporting patients in distress isn’t limited to those with clinical titles. Anyone who interacts with patients, regardless of role, can make a meaningful difference in recognizing risk and offering support. Front desk and administrative staff, for example, often serve as the first point of contact and may be uniquely positioned to notice signs of distress or receive disclosures.⁹² While this should not imply that these staff members should assume clinical roles, providing them with information and support about what to do if risks are disclosed is essential. Building suicide prevention into routine training can help ensure that every member of the team is ready to respond with compassion, confidence, and a clear path for connecting patients to appropriate care.

With so many training options available, it can feel overwhelming to know where to start. One helpful step is to get a sense of the team’s current comfort and preparedness around suicide care. For practices interested in strengthening their approach, tools like the Zero Suicide Workforce Survey can offer a starting point, helping to highlight areas of confidence as well as opportunities for growth. Even informal conversations or short team check-ins can surface valuable insights to guide next steps.

Once the team has a sense of its training needs, it can be helpful to think through which types of training are most relevant for different roles—clinical, non-clinical, or in between. No specific tools are needed, but for support, resources like the Thinking Through Appropriate Staffing Trainings online activity from Zero Suicide can guide the team’s thinking about the different roles staff may play and what types of training considerations might apply.

Regardless of the approach, be sure to carefully review the websites of any training programs considered and consult available literature to ensure the fit is right for the team’s goals and setting. While not comprehensive, reference tools from organizations like the National Action Alliance for Suicide Prevention, Zero Suicide, and the Suicide Prevention Resource Center offer helpful starting points for exploring available training programs. As options are explored, consider how each training fits within the practice’s broader approach to suicide care—reinforcing its values, workflows, and team culture.

How to Introduce Use of 988 as an Immediate Support Tool

988 is a no-cost, nationwide crisis lifeline available 24/7 by phone, text, or chat. Introducing it proactively can give patients an accessible, judgment-free source of real-time help.

If interested in how to introduce and use 988 in ways that support patient autonomy and shared decision-making, see the callout box for sample language and scripting suggestions.

How to Provide Support and Build a Culture of Follow-through with Caring Contacts

Caring Contacts protocols are simple, low-cost, and powerful tools for reducing suicide risk over time.

These brief, non-demanding messages—sent via text, email, postcard, or letter—reinforce connection and remind patients that support is available. Creating messages does not require clinical expertise, meaning any member of the care team can participate, making this an ideal strategy for team-based care.

Caring Contacts (whether calls, texts, or letters) can be effective even when the sender is unfamiliar to the recipient—an important consideration for busy or high-volume clinics.⁹³ The key lies in the consistency and sincerity of the outreach.

The AIMS Center offers a free online training on how to effectively implement Caring Contacts. The training draws from the Military Continuity Project (the Department of Defense and Veterans Affairs have pioneered approaches to suicide care), but the guidance applies broadly to any patient at risk of suicide. For sample language and example formats, Now Matters Now provides free templates that can be easily adapted to fit a practice.

How to Choose the Right Level of Care

Suicidality can be effectively addressed in primary care. While patient safety must always remain the top priority, not all individuals who express suicidal thoughts require emergency services or hospitalization. Unnecessary referrals to the emergency department can be distressing and disempowering and may erode trust—especially when the patient is not at imminent risk. Whenever possible, the goal should be to “de-escalate in place,” using the collaborative, evidence-informed strategies outlined above. Many patients can be supported safely through same-day behavioral health visits, safety planning, increased outreach, and warm follow-up.

A referral to the emergency department or call to 911 may be necessary when a patient expresses intent to die, has a feasible plan, and is unwilling or unable to engage in safety-focused treatment.⁹⁴ However, hospitalization is not the only option for 24/7 support. When risk is high but not immediately life-threatening, alternatives such as community crisis stabilization units, crisis residential centers, or 24/7 peer support models may offer safer, less disruptive options. The benefit of hospitalization lies primarily in temporarily removing the opportunity to attempt suicide, rather than in exerting a direct therapeutic effect on suicidal thoughts or feelings. This underscores the importance of considering less restrictive, supportive options whenever possible, particularly when strong social or community-based supports are available.⁹⁵

This risk stratification table from the Department of Veterans Affairs can help primary care teams triage appropriately—determining when emergency services are warranted and when alternative responses, including in-office treatment, may be more appropriate.

Leverage Opportunities in Integrated Care Settings

Integrated primary care settings offer a strong foundation for suicide prevention. With behavioral health professionals embedded in the care team, clinics can address suicidality as a core component of whole person care rather than a siloed specialty concern. Key elements of integrated care—such as real-time consultation, warm handoffs, team huddles, and cross-training—can help ensure patients receive timely, coordinated support. Many of these strategies align with principles such as accessibility, team-based care, and routine integration, which are core elements of the Primary Care Behavioral Health (PCBH) integrated care model.⁷⁴ However, these principles can be applied flexibly across a range of integrated settings to support sustainable suicide prevention.

Behavioral health clinicians can model suicide-specific care and build skills across the team. When all staff—primary care providers, nurses, medical assistants, and others—are equipped to recognize and respond to suicide risk, patients are more likely to receive effective, coordinated support. Embedding these practices into existing workflows strengthens sustainability, avoids creating parallel systems, and reinforces shared responsibility for suicide prevention across the entire care team.

Provide Warm Handoffs (When Possible)

Access to freestanding behavioral health treatment is often very difficult (one of the reasons why integrated care is so important and such a key enabler of improved suicide care). Warm handoffs support accessible, team-based care by enabling real-time coordination between primary care and behavioral health staff, enabling faster, more personalized support for patients experiencing suicidality.

A warm handoff occurs when a primary care provider introduces the patient directly to a behavioral health provider during the same visit, which can improve follow-up rates for behavioral health appointments.⁹⁶ This approach can also reduce drop-off and help patients feel supported through transitions in care. Additionally, warm handoffs serve as the foundation for real-time behavioral health consultation—a key strategy in integrated care.⁹⁷ Consider calling in behavioral health consultants to augment the care you provided to suicidal patients. Keep in mind that warm handoffs do not need to occur in person; telehealth can be an effective way to introduce patients to behavioral health providers when on-site support is unavailable.⁹⁸ These consultations allow you to remain in the lead while ensuring that patients receive targeted support in the moment.

If a practice is looking to implement or refine warm handoffs, several resources can help:

• The Agency for Healthcare Research and Quality’s (AHRQ) Design Guide for Implementing Warm Handoffs offers a structured, adaptable framework for making warm handoffs a standard part of care. The guide walks through step-by-step strategies, recognizing that practices differ in size, staffing, and workflow. Teams are encouraged to adjust the process to meet their unique needs.
• The Montana Primary Care Association and the American Medical Association both provide sample scripts to guide how providers can introduce behavioral health care in a supportive, collaborative way.

Even when warm handoffs are not possible, there are other ways to improve care transitions between providers. The National Council for Mental Wellbeing offers a concise tip sheet with practical strategies to improve care transitions between providers. In addition to providing guidance on conducting warm handoffs, the sheet outlines other approaches you can use when real-time introductions aren’t feasible.

Use Team-Based Approaches, Such as Huddles

Brief, structured meetings—often referred to as huddles—can strengthen coordination and improve outcomes for patients experiencing suicidality. These short, stand-up meetings reinforce team-based and routine care by creating dedicated time for team members to share observations, flag urgent concerns, and clarify roles in care delivery. They help ensure that suicide risk does not go unnoticed or unaddressed in the day-to-day demands of a busy practice.

Regular huddles can reduce hierarchy, promote shared situational awareness, and enhance communication across the full care team—including physicians, behavioral health clinicians, nurses, medical assistants, and administrative staff. By normalizing collaborative decision-making, huddles can help reinforce a culture of shared responsibility and sustained quality improvement.^99,100 The following resources can help providers begin or refine huddle practices in their clinic:

• Healthy Huddles (UCSF Center for Excellence in Primary Care): Includes an exercise for teams to co-design a huddle process that fits their needs.
• Daily Team Huddles (AMA Steps Forward™): A step-by-step guide for launching and evolving daily huddles.
• Huddles: Getting on Your Best Game (AHRQ EvidenceNOW): A brief video highlighting huddle benefits and implementation tips.
• Huddles (Institute for Healthcare Improvement): Offers tools and guidance for implementing daily team huddles.

Leverage Behavioral Health Providers to Train Staff on Brief Interventions

Behavioral health providers can play a key role in strengthening clinic-wide capacity for suicide prevention. In integrated settings, they can be leveraged to educate⁹⁷ other team members—such as primary care providers, nurses, and medical assistants—in addressing suicidality, including training on the interventions described in this brief.

By supporting cross-training efforts, behavioral health providers can help ensure that patients receive consistent, supportive messaging regardless of who they interact with. This approach reinforces shared responsibility for suicide prevention and helps embed best practices across the care team.

Behavioral health providers can also serve as an internal resource when selecting, tailoring, and implementing trainings that align with a clinic’s needs. Providers can find additional resources related to training and implementing the strategies described in this brief below.

How to Introduce the Use of Safety Planning Intervention
The Safety Planning Intervention is a brief, collaborative approach designed to support individuals at risk of suicide by helping them identify coping strategies, sources of support, and ways to reduce access to lethal means. To support training and implementation, the following resources offer practical guidance and tools:

• New York State Office of Mental Health and Columbia University Online Course – Offers instruction on when and how to use safety planning interventions, with step-by-step guidance on implementation.
• SPRC Quick Guide for Clinicians – Offers a concise reference to reinforce best practices during safety planning. Designed to be used with safety plan templates.
• Safety Plan Template (Brown & Stanley) – Offers a downloadable, fillable worksheet for developing plans collaboratively with patients.
• Counseling on Access to Lethal Means (CALM) – Offers a free self-paced online course that helps providers feel more confident and competent in discussing means of safety with patients and their families. A train-the-trainer version is also available.

How to Introduce the Use of Crisis Response Planning

Resources are presented below to support training and implementation of Crisis Response Planning, a brief, structured intervention designed to help providers recognize and respond to emerging suicidal crises.

• How to Use the Crisis Response Plan – In this video training, co-developer of the Crisis Response Plan, Dr. Craig Bryan, walks through the five key components of the plan, and details questions providers can use to help their patients.
• Crisis Response Plan Template (VA) – A fillable PDF version of the Crisis Response Plan that providers can use directly with patients.

How to Introduce Collaborative Assessment and Management of Suicidality (CAMS Framework®)

CAMS is a flexible, evidence-based framework for collaboratively assessing and treating suicidality. It is most easily learned and used by behavioral health professionals. CAMS-specific training is offered through CAMS-care, which provides structured support for implementing the CAMS Framework® in clinical settings.

CAMS-care offers a variety of training and certification opportunities, including video courses, reading materials, and interactive role-playing sessions to help providers implement the CAMS Framework® effectively. Options are available for individual and group learning, with associated costs. CAMS-care also offers a free resource library with access to articles, case studies, webinars, and other tools to support suicide prevention in clinical practice.

How to Introduce the Use of Motivational Interviewing (MI)

Motivational interviewing is a collaborative, person-centered counseling style designed to strengthen a person’s own motivation for change. Motivational interviewing can be used to address a range of physical and behavioral health conditions—including suicidality—by helping individuals in crisis explore ambivalence, identify reasons for living, and commit to safety-oriented behaviors.

Several resources are available to support MI training and integration into practice:

• Applying Motivational Interviewing in Suicide Risk Assessment: This webinar explores how clinicians can use motivational interviewing as a valuable tool during suicide risk assessment. It introduces core MI principles and demonstrates how they can be integrated with suicide prevention strategies. The session also includes suggested next steps for pursuing skills-based training.
• Motivational Interviewing Network of Trainers (MINT): This website includes information about motivational interviewing, links to training opportunities, and a directory of expert trainers.
• Pocket Guide to Motivational Interviewing: This guide covers the core principles and techniques of motivational interviewing, including examples of open-ended questions, affirmations, and reflective listening.
• Center for Evidence-Based Practices – MI Resource Hub: This curated selection of resources from Case Western Reserve University offers tools and tips to support motivational interviewing implementation across various service settings.

• Primary care is a key opportunity for suicide prevention. Up to 80% of people who die by suicide see a primary care provider in the year before their death. Suicidality can often be safely addressed in these settings through brief, collaborative, evidence-based approaches, avoiding unnecessary emergency department referrals that may disrupt care and erode trust.
• It is important to avoid overlooking suicide risk or responding reflexively to patient disclosures by referring to 911, emergency departments, or inpatient care when they may not be warranted.
• Foundational strategies can be implemented anywhere. Even in clinics without behavioral health staff, relatively low-lift actions—like introducing 988, sending Caring Contacts, and making suicide conversations routine—can meaningfully reduce risk and build connection.
• Integrated behavioral health expands capacity. When available, strategies like warm handoffs, team huddles, and shared training help embed suicide prevention across the care team, while interventions and frameworks like Safety Planning, Crisis Response Planning, and the Collaborative Assessment and Management of Suicidality, reinforce collaboration and patient autonomy.

Authors

• Annaka Paradis, ScM – Lead Research Associate, Westat
• Kent Corso, PsyD, BCBA-D – Founder, PROSPER Together
• Mike Hogan, PhD – Consultant & Advisor, Hogan Health Solutions, LLC

Contributors

• Danielle Durant, PhD, MS, MS, MBA – Principal Research Associate, Westat
• Garrett Moran, PhD – Principal, Moran Consulting
• Anne Roubal, PhD – Principal Research Associate, Westat