The SAFE-T Suicide Assessment Protocol: Integration Into the EMR and Assignment of Suicide Risk

Available with English captions and subtitles in Spanish.

Douglas G. Jacobs, MD, McLean Hospital, and Carsen Sulzer, MD, Massachusetts General Hospital, present as part of the 2023 Suicide-Focused Assessment and Treatment: An Update for Professionals course.

The Importance of Assessment

In their talk, Jacobs and Sulzer explain the components of a suicide assessment and how to use clinical judgment to identify features and symptoms that extend beyond traditional risk factors. They also demonstrate the integration of the SAFE-T protocol within the electronic health record software Epic.

Watch now to learn more about:

  • How to use the SAFE-T protocol to assess suicide risk
  • How to look beyond traditional risk factors when assessing suicide
  • Why it is important to integrate suicide risk assessment into the electronic medical record (EMR) systems

Over 12 million adults in the U.S. experience serious suicidal thoughts. Over three million adults have made a suicide plan, and 1.7 million have made a non-fatal suicide attempt. The underlying factors of suicide include psychiatric illness, relationship problems, recent psychosocial issues, and intolerable mental pain.

In 2006, Jacobs developed the SAFE-T: Suicide Assessment Five-Step Evaluation and Triage protocol with a grant from SAMHSA. The protocol has five components:

  • Identify risk factors
  • Identify protective factors
  • Conduct a specific suicide inquiry
  • Determine level of risk and choose appropriate intervention
  • Document level of risk, rationale, intervention, and follow-up

While identifying risk factors is the first step in the SAFE-T protocol, Jacobs discusses the difficulty in predicting whether someone will attempt suicide based on frequently considered risk factors. He states that it is important for clinicians to think beyond traditional risk factors.

View the Slides

In encouraging clinicians to take a broader view of this topic, Jacobs cites Joiner’s Interpersonal Theory of Suicidality, which explores why someone would have the desire and capability to die by suicide. Jacobs states it is important for clinicians to consider how a person’s sense of thwarted belongingness, as well as fearlessness, can increase risk of suicide.

Among other suggestions, Jacobs encourages providers to assess patients for “mental practice” of suicide, such as being able to see one’s death by suicide in their mind’s eye, as this can also be a predictor.

In her portion of the presentation, Sulzer shares how she and Jacobs have collaborated with Epic’s suicide prevention workgroup to integrate SAFE-T protocols as a risk-assessment tool within the EMR.

She explains how the group has conducted an extensive review of the most recent literature to include suicide-specific symptoms as well as risk and protective factors. The group hopes the integration will go live in 2024.


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About Douglas Jacobs

Dr. Douglas G. Jacobs is a recognized expert in suicide assessment and intervention. In the early 1990s, he initiated the concept of large-scale screening for mental health disorders, with the founding of National Depression Screening Day.

Dr. Jacobs was chairman of the workgroup that published the American Psychiatric Association’s Practice Guidelines for the Assessment and Treatment of Patients With Suicidal Behaviors.

About Carsen Sulzer

Dr. Carsen Sulzer is a graduate of the University of Connecticut School of Medicine and Harvard South Shore Psychiatry Residency Program. She is currently practicing at Massachusetts General Hospital within their Team-Based Outpatient Psychiatry Clinic and is an instructor in psychiatry at Harvard Medical School.

Dr. Sulzer’s clinical interests lie particularly in suicide and trauma and stressor-related disorders.