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What Can I Do?

 

Module 2: What Can I Do?

What does S.A.V.E.S. stand for?

S.A.V.E.S.14 is an acronym for action that identifies the five components of helping someone experiencing suicidal behavior:

  • Signs of suicide
  • Ask about suicide
  • Validate feelings
  • Expedite referral
  • Set a reminder to follow up

Click each of the tabs below to learn more about S.A.V.E.S.

 

Signs of suicide

Warning signs are behaviors that indicate someone may be at immediate risk for suicide.15 It is not always easy to recognize when someone is suicidal, but there are some warning signs that you may be more likely to observe in a pharmacy setting. Some people who die by suicide may only exhibit one, others may show several signs, and some may show no signs at all.

 
Signs of Suicide
Verbal Warning Signs
Behavioral Warning Signs
Person talks about:
  • Death or suicide
  • Feeling hopeless
  • Feeling trapped
  • Being a burden to others
  • Unbearable pain
  • No reason for living
  • No sense of purpose in life
 Person exhibits:
  • Increased drug or alcohol use/abuse
  • Visible decline in appearance
  • Withdrawing from friends, family, society
  • Distress (anxious/crying)
  • Dramatic mood changes
  • Difficulty sleeping or sleeping all the time
  • Giving away possessions
  • Saying goodbye to friends and family
“The patient said he didn’t know why he was even buying any of the medication because hopefully he wouldn’t be around long enough to take it.”
-Community Pharmacy Technician
“We had a patient we absolutely loved. They would come in every time to pick up their medicine with a cheerful attitude. They were always well dressed, and they always would stand around and talk to us for a little bit before leaving. Recently this patient has come in upset, fatigued, and looking disheveled all the time.”
-Community Pharmacy Technician
  

Signs of an IMMEDIATE EMERGENCY13
  • Threatening to hurt or kill oneself
  • Looking for ways to kill oneself (i.e., seeking access to pills, weapons, or other means)
  • Exhibiting self-destructive or risk-taking behaviors
“A patient asked about how much of her antidepressants she could take in order to slip into a comatose state. Personally, I did not know exactly what to say, and she responded with something along the lines of, ‘My life would be better if I weren’t here.’”
—Community Pharmacist


Ask about suicide

“Are you thinking about killing yourself?”

In 2019, suicide was a Top 10 cause of death in the U.S. It is time for suicide to become a part of our conversations. If you think that your patient is at risk, asking the question up front is important, even if it is uncomfortable.

Think about it another way. Imagine you are in the patient’s position. How would you feel if you were in crisis or considering suicide, and your pharmacist had not asked? Or ignored the signs?

“Are you thinking about killing yourself?” can be an awkward and uncomfortable question to ask, but it is an effective method to find out if a person needs help. Tips for how to make this potentially life-saving inquiry are provided below.

 
If you feel awkward about asking the question, remember:
  • Ask the question in a natural way.
  • Ask whenever there are warning signs.
  • People experiencing a crisis want someone to ask.
    • Asking reduces the stigma associated with having suicidal thoughts.
  • Don’t ask the question in a way that sounds like you are expecting a “No” answer.
    • Example: “You aren’t thinking about killing yourself, are you?”
“I had a patient who was becoming more and more withdrawn and disheveled. I asked her what was going on, and she made a vague statement about not seeing the point in living. So then I asked her if she was thinking about suicide, and she said yes. Then I knew I had to do something to make sure she didn’t follow through with it.”
-Community Pharmacist

Other things to consider when talking with a potentially suicidal person:

  • Remain calm
  • Listen more than you speak
  • Be confident
  • Do not argue
  • Use open body language (maintain eye contact, nod to show attentiveness, uncross your arms)
  • Use supportive and encouraging comments
“We had a patient we absolutely loved. They would come in every time to pick up their medicine with a cheerful attitude, they would always stand around and talk to us for a little bit before leaving, and they were well dressed. Recently this patient has come in upset, fatigued, and looking disheveled all the time. We constantly remind them that we are there for them and would do anything to help. They thank us, get their medicine, and walk away.”
-Member of Community Pharmacy Staff

Validate feelings

Validation means that you recognize, acknowledge, and value your patient’s feelings. Engage in active listening, give the patient your full attention, and do the following:

  • Acknowledge their feelings
  • Listen and allow the person to talk
  • Do not judge
  • Reassure the person that help is available, and you will help them find it
“If I feel a patient is in crisis, I will offer an ear.”
-Community Pharmacy Technician
“She (the cashier) asked if I would take some time to meet with the patient in our private consultation room, which I agreed to do. She was absolutely broken. She gave me a very detailed history of her experience (on two separate occasions) while on an involuntary hold at a facility. I may have gotten in ten words. But I didn’t need to say more. She didn’t need me to say more.”
-Community Pharmacist

Expedite referral

  • Connect the individual with services. Even for individuals who deny suicidal behavior, provide them with information for the Crisis Line.
  • Encourage the patient to stay in the pharmacy. If you think they may leave before you can connect them to help, try asking them to hold something, like a pen or a pamphlet, to keep them at the counter while you call the Crisis Line.
  • If you can’t reach someone immediately on the Crisis Line, please go to the Referral Tool located in the Resources tab for additional national, state, and local resources.

How to connect with a crisis responder
Call
1-800-273-8255
Veterans: press 1
Text
Veterans text: 838255
Non-veterans text: 741741
Support for deaf and hard of hearing

The Veterans Crisis Line is for veterans, servicemembers, and anyone concerned about their well-being. Support is…

  • Free
  • Confidential
  • Available every day, 24/7
Adapted from https://www.veteranscrisisline.net/

The current Crisis Line number is due to change to a simple 3-digit number in 2022

Assist the person in finding a care facility by personally referring them, arranging transportation, calling, or providing the appropriate resource(s). Do not leave the person alone. Stay with them until they are safe.

  • We have included a resource referral tool on this website. Here you will find national resources, as well as resources by county or zip code readily available for people in crisis. These services include help for mental health crisis, substance use disorders, and veteran specific services.
  • Click here to learn what to expect when calling the Crisis Line.

Making a Referral to the Crisis Line16
Process
Examples
Action

Patient exhibits warning signs

 
Ask
“Are you considering suicide?”
If No
  • Offer empathy for the patient’s situation.
  • Consult the referral resource tool.
  • Provide the patient with the Crisis Line number.
If No Response

Provide the patient with the Crisis Line number.

If Yes
 
 

Unsure of immediate danger or passive suicidal behavior:

Ask if you can call the Crisis Line for the patient or provide the Crisis Line number.

Provide referral resource tool information.

Click here for an example.

Patient has shared a plan:

Call the Crisis Line or encourage the patient to call the Crisis Line.

Monitor the patient until they connect with crisis services.

Click here for an example.

Patient has shared they have taken harmful action:

Call 911.

If at pharmacy, stay with the patient.

If on the phone, try to stay on the line until emergency personnel arrives.

Click here for an example.

 

Set a reminder to follow up with the patient the next day.

 
Signs
  • “How much of this medicine would it take to kill me?”
Ask 
  • “Are you thinking about killing yourself?”
  • “With the question that you are asking, I am wondering if you are thinking about suicide?”
  • “When you say that you are at the end of your rope, are you thinking of killing yourself?”
Validate/empathize 
  • “It sounds like you are overwhelmed with everything going on.”
  • “Tell me more about that.”
Expedite referral 
  • “I don’t want anything bad to happen to you. Would it be all right if I called the Crisis Line for you?”
  • “I could connect you with someone who can help. It’s anonymous and free.”
Set a reminder to follow up 
  • Make a note to connect with the patient the next day.
  • Use a method that fits within the clinical workflow. The solution can be as simple as writing a sticky note or setting a reminder in your calendar to call.
  • The follow-up conversation should be short and to the point. Just take a moment to check in.
Practice responding ahead of time
Try to remain calm
Be direct
Allow the patient to talk
Show that you care

Click the button below if you are interested in learning more about specific resources for veterans.

  • The Veterans Administration (VA) and Department of Defense (DOD) both provide employees who work at the Crisis Line.
  • Service members, veterans, and their families or friends who are concerned about them are encouraged to call the Crisis Line and press “1” or text 838255 for immediate crisis resources.
    • ANY veteran or service member can be served by option 1, regardless of eligibility for VA benefits.
    • An advantage to choosing option 1 is that the VA and DOD staff have access to the same protocols as the main number, in addition to scheduling and other resources only available to veterans and service members.
  • The Veterans Administration also has an online chat service that is available 24 hours a day.
“He was an elderly patient, a VA member, and (he) primarily lived alone. He told the pharmacist how he had these thoughts, and it was troubling him, and he wasn’t sure what to do. My pharmacist contacted the VA suicide line and asked for them or a physician to reach out to the patient. The patient talked to my pharmacist several times throughout the day and before closing he let the pharmacist know that he was feeling better, and a close friend (would) stay at home with him for some time.”
-Pharmacy Technician

Set a reminder to follow up

Current best practice recommends following up the next day with patients who show suicide warning signs. It’s easy to forget to do this, so it’s important to remind yourself to follow up:

  • Make a note to connect with the person the next day
  • Use a method that works within your clinical workflow

The note to follow up could be as simple as leaving a sticky note on your computer or setting a calendar reminder to follow up.

Your follow-up conversation can be short and to-the-point. (See the videos in the “How does it work?” section for examples.) Just let the person know who you are and that you wanted to check in to see if they are okay.

“We had a new mother call the pharmacy. She expressed hopelessness. As technicians we had to keep the patient on the phone while another staff member got the pharmacist. After speaking with her, the pharmacist provided the number for the Crisis Line and some local resources. The next day we did a follow-up call for the patient, just to make sure she was doing ok.”
-Pharmacy Technician
  1. Carpenter, D. M., Lavigne, J. E., Colmenares, E. W., Falbo, K., & Mosley, S. L. (2020). Community pharmacy staff interactions with patients who have risk factors or warning signs of suicide. Research in social and administrative pharmacy, 16(3), 349-359.
  1. Risk and Protective Factors. (2020, October). In Suicide Prevention Resource Center. Retrieved from https://www.sprc.org/about-suicide/risk-protective-factors
  1. Carpenter, D. M., Lavigne, J. E., Colmenares, E. W., Falbo, K., & Mosley, S. L. (2020). Community pharmacy staff interactions with patients who have risk factors or warning signs of suicide. Research in social and administrative pharmacy, (3), 349-359.
  1. Carpenter, D. M., Lavigne, J. E., Colmenares, E. W., Falbo, K., & Mosley, S. L. (2020). Community pharmacy staff interactions with patients who have risk factors or warning signs of suicide. Research in social and administrative pharmacy, 16(3), 349-359.
  1. Risk and Protective Factors. (2020, October). In Suicide Prevention Resource Center. Retrieved from https://www.sprc.org/about-suicide/risk-protective-factors
  1. Suicide Prevention (2021, June 16). In Department of Veterans Affairs. Retrieved from https://www.mentalhealth.va.gov/suicide_prevention/
  1. Suicide Prevention (2020, December 22). In Department of Veterans Affairs. Retrieved from https://www.mentalhealth.va.gov/suicide_prevention/
  1. Carpenter, D. M., Lavigne, J. E., Colmenares, E. W., Falbo, K., & Mosley, S. L. (2020). Community pharmacy staff interactions with patients who have risk factors or warning signs of suicide. Research in social and administrative pharmacy, 16(3), 349-359.
  1. Carpenter, D. M., Lavigne, J. E., Colmenares, E. W., Falbo, K., & Mosley, S. L. (2020). Community pharmacy staff interactions with patients who have risk factors or warning signs of suicide. Research in social and administrative pharmacy, 16(3), 349-359.
  1. Risk and Protective Factors. (2020, October). In Suicide Prevention Resource Center. Retrieved from https://www.sprc.org/about-suicide/risk-protective-factors
  1. Risk and Protective Factors. (2020, October). In Suicide Prevention Resource Center. Retrieved from https://www.sprc.org/about-suicide/risk-protective-factors
  1. Risk and Protective Factors. (2020, October). In Suicide Prevention Resource Center. Retrieved from https://www.sprc.org/about-suicide/risk-protective-factors
  1. Murphy, A. L., Ataya, R., Himmelman, D., O’Reilly, C., Rosen, A., Salvador-Carulla, L., … & Gardner, D. M. (2018). Community pharmacists’ experiences and people at risk of suicide in Canada and Australia: a thematic analysis. Social psychiatry and psychiatric epidemiology, 53(11), 1173-1184.
  1. Murphy, A. L., Ataya, R., Himmelman, D., O’Reilly, C., Rosen, A., Salvador-Carulla, L., … & Gardner, D. M. (2018). Community pharmacists’ experiences and people at risk of suicide in Canada and Australia: a thematic analysis. Social psychiatry and psychiatric epidemiology, 53(11), 1173-1184.
“A patient presented to the pharmacy with a prescription for an antidepressant after being seen at outpatient. He was extremely emotional (crying and sobbing). He was brought to the private counseling room in the pharmacy where he expressed his concern and stated that he didn’t know how much longer he can live.”
-Community Pharmacy Technician
“The patient said, ‘I am afraid that if I go home, I will kill myself.’ I told the patient it was (all right) to stay at the pharmacy, we would help in any way we could, and I called the Crisis Line to request help. The patient admitted the need for help and was admitted to a mental health facility.”
-Pharmacy Technician
“[The] patient phoned to ask how much drugs she would have to take to kill herself. I asked if she had taken anything and she said yes, the whole bottle. She told me her name and I looked up what she had taken – Effexor XL [venlafaxine]. I explained that this is a slow-acting drug and she really needed to get to ER. She hung up on me. I then called all the local ER departments and found the one she had gone to – gave them the info they needed, and they treated her immediate OD [overdose] situation and got her into therapy.”
-Community Pharmacist