Table 3.

Proposal for suicide risk stratification and recommended interventions

‘White code’–no suicide risk
	• Absence of SI	• Clinical observation
	• Negative personal and/or family history of suicide, previous SA	• Periodic suicide risk evaluation (including the occurrence of new situations, e.g., the presence of suicide risks before not present)
	• Symptomatological stability
	• Absence of specific suicide risk (Table 1)
‘Green code’–low suicide risk
	• Presence of SI (occasional, inconstant, fleeting, reported to clinician with scarce credence/conviction (e.g., with the aim at requesting attention and help; e.g., present but criticized by the patent in a credible manner)	• Careful and periodic clinical observation by clinicians and all components of the multi-disciplinary team (i.e., physicians, nurses, psychiatric rehabilitators, auxiliary staff, psychologists, etc.) of the patient, especially if he/she is almost silent (and/or he/she does not ask for help/support)
	• Acute depressive episode in MDD, mild severity (not stable, not remitted, without comorbid anxiety and/or mixed symptoms)	• Actively listen to or support even only with our presence, by ensuring a peaceful atmosphere and inviting the patient to call and ask for help in the case he/she may experience negative thoughts
	• Positive family history of suicide and/or SA in MDD	• Developing a good therapeutic alliance and relationship
	• Positive personal history of SHB and/or ST (single and/or recurrent, with low lethality)	• Encouraging the expression of thoughts and/or feelings (also negative)
	• Negative personal history for SA	• Providing information and support to patient and his/her family members regarding the management of a potential emotional crisis and/or instability and about the alternative coping strategies useful for managing and solving critical problem(s)
		• Carefully observing family, personal and group dynamics and identifying specific potential trigger factors
		• Monitoring and alerting about the occurrence of potential symptoms and/or behaviours at risk (e.g., anxiety, agitation, irritability, hypervigilance and/or mood instability)
		• If possible, do not leave the patient alone (e.g., choose a room with a mate)
		• Carefully evaluating the correct intake of medications (do not leave the medications to patient without checking its assumption)
		• Carefully monitoring about personal potentially risky duties
‘Yellow code’–moderate suicide risk
	• Presence of SI (constant, with low intensity)	• As for ‘green code’ plus
	• Presence of SI (partially criticized by the patent in a credible manner)	• Informing and involving family members
	• Positive and recent personal history of SA without current SI	• Providing a personalized supervision and vigilance
	• Acute depressive episode in MDD, moderate severity (not stable, not remitted, with comorbid anxiety and/or mixed symptoms, without psychotic symptomatology)	• Evaluating the safety of personal duties (assisting the patient during the use of potential risky objects)
		• Eventually, if any, evaluating if changing the room, the position of the bed, in order to increase the visibility for clinical observation
		• Encouraging the patient to objectively evaluate the positive aspects of the current situation, by analyzing the success experiences (self-motivating statement)
		• Correcting his/her sensorial and/or situation/circumstantial wrong perceptions, without belittle his/her fears and without showing disapproval of his/her convictions
		• Limiting frustrating situations if patient is not currently able to express the anger feeling in a constructed and balanced manner
		• Facilitating the expression of anger feelings in a more functional manner (e.g., sports)
		• Stimulating the patient in identifying values of life, the meaning of life, by doing open-questions, e.g., what do you think it should be your tasks in your life? Which are your dreams’ life? etc.
		• Encouraging the patient that ‘changing is possible’
		• Involving the patient in some positive activity, by facilitating the social interaction
		• Encouraging the patient in communicating SI and/or self-harm thoughts to clinicians
		• Identifying potential initial agitation and/or anxiety and/or irritability and/or impulsivity
‘Red code’–severe suicide risk
	• Positive and recent personal history of SA with active, current and intensive SI	• As for ‘green’ and ‘yellow’ code plus
	• Presence of SI (constant, with high intensity but not criticized by the patent in a credible manner)	• Providing a more careful and intense clinical supervision and vigilance (eventually, providing a continuous, 24h monitoring of patient)
	• Acute depressive episode in MDD, severe severity (not stable, not remitted, with and/or without psychotic symptomatology, e.g., guilt or ruin delusion, with an intense psychomotor agitation, impulsivity, with mixed symptoms, higher introversion levels, with auditory imperative hallucinations of self-harm)	• Evaluating hospitalization

SI: suicide ideation, SA: suicide attempt, ST: suicide threat, SHB: self-harm behaviour, MDD: major depressive disorder