Revised Suicidal Ideation Protocol Helps Clinicians Respond with Confidence

For patients living with multiple sclerosis (MS), comprehensive disease management extends well beyond the treatment of neurological symptoms. Behavioral health is an essential component of caring for people with MS and other chronic central nervous system disorders, who face a suicide risk approximately twice that of the general population.

To address these vulnerabilities, a multidisciplinary team of behavioral health providers at Cleveland Clinic's Mellen Center for Multiple Sclerosis has updated the center's suicidal ideation (SI) protocol to provide clinicians with a clearer, more streamlined approach to assessing risk and connecting patients with appropriate care.

Improving accessibility and preparedness

Originally developed 15 years ago by Amy Sullivan, PsyD, and Elias Khawam, MD, the Mellen protocol has long served as a guide for evaluating suicide risk in patients with MS and determining when hospitalization is necessary. As the center's interdisciplinary team has grown, however, the need to make these screening resources more accessible to clinicians across specialties has become increasingly important.

“One of our chief goals when revising the framework was to empower providers whose expertise falls outside of behavioral medicine,” explains Cleveland Clinic psychologist Brianne Markley, PhD. “We felt it was essential to equip caregivers in every discipline – from neurologists and rehabilitation therapists to speech-language pathologists and advanced practice providers – with practical recommendations for confidently addressing suicidal ideation in patients with MS.”

Although there are several validated screening tools designed to identify suicidal ideation, including the Patient Health Questionnaire-9 (PHQ-9), Dr. Markley says most stop short of providing actionable steps to prevent self-harm. The updated Mellen SI protocol aims to bridge this gap by helping clinicians go from recognizing risk to initiating timely, evidence-based interventions.

"Identifying suicide risk is only the first step,” she says. “Our responsibility extends beyond screening to taking meaningful action — working with patients to develop a personalized safety plan, reducing immediate risks and ensuring they leave with the support and resources they need to navigate moments of crisis.”

Looking beyond neurological symptoms

Dr. Markley notes that caring for patients with MS also requires clinicians to consider risk factors that may be less common in other patient populations. In particular, she stresses the importance of monitoring for the presence of depression, anxiety, social isolation, progressive disease subtypes and other symptoms — both visible and invisible.

Of note, the risk of suicide is particularly high among younger patients with MS and during the period immediately following the initial diagnosis.

“There are a variety of disease-specific challenges that can negatively affect emotional health, including changes in physical functioning or cognition and the daily realities of living with a chronic neurological condition,” she says. “In particular, it’s imperative to understand the level of social support available to each patient and take steps to prevent isolation, which is among the most significant risk factors.”

Putting safety first

Dr. Markley says the protocol promotes collaboration among clinicians while encouraging them to partner closely with patients when determining the best course of action.

"Suicide prevention is most effective when it's built on collaboration and trust,” she explains. “By working alongside patients to identify their strengths, warning signs and coping strategies, we can create safety plans that are both meaningful to the individual and more likely to be used during times of crisis.”

The revised protocol also establishes a clearer process for communicating with Cleveland Clinic's emergency departments, a potentially necessary part of the care plan for patients with active suicidal ideation. These updates, which include procedures for safe transport and the relay of critical clinical information, can help reduce confusion during what is often a stressful situation for both patients and caregivers, Dr. Markley says.

She also emphasizes that interest in the new SI protocol has spread beyond the Mellen Center. Teams at other Cleveland Clinic locations have begun exploring how the framework can be adapted to their own environments, particularly at facilities where resources and emergency response processes differ from those at the medical center’s Main Campus.

In addition to standardizing the clinical response to suicidal ideation, Dr. Markley believes the Mellen Center’s approach can also help reduce stigma surrounding the relationship between mental health and chronic neurological disease.

“Suicide prevention begins with creating an environment where people feel safe talking about their struggles without fear of judgment,” she says. “When we can provide clear, compassionate guidance that normalizes conversations about mental health, we reduce stigma, encourage people to seek help earlier and remind them they are not alone.”