SUICIDE SCREENING AND ASSESSMENT

Because a significant proportion of individuals who die by suicide have seen a health professional within a few days prior to their suicide attempt, suicide screening and assessment of risk for suicide are important steps to be taken in all healthcare settings.

Suicide prevention screening refers to a quick procedure in which a standardized instrument or tool is used to identify individuals who may be at risk for suicide and in need of assessment. It can be done independently or as part of a more comprehensive health or behavioral health screening. Suicide assessment, as opposed to screening, refers to a more comprehensive evaluation done by a clinician to confirm a suspected suicide risk, to estimate imminent danger, and to decide on a course of treatment.

Suicide Screening

There is debate about the benefits of screening all patients (universal screening) for suicide risk factors and whether screening actually reduces suicide deaths. The general view, however, is that such screening should only be undertaken if there is a strong commitment to provide treatment and follow-up, since there is some evidence that screening improves outcomes when it is associated with close follow-up and treatment. Instead of universal screening, some recommend that screening be done only for those presenting with known risk factors (selective or targeted screening). Despite this lack of uniform guidance, health systems are implementing suicide screening protocols, and screening tools are already widely used in primary care settings (O’Rourke et al., 2022).

U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS

Previously the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. The USPSTF, however, recommended screening for major depressive disorder in adolescents ages 12–18 years and in the general adult population, including pregnant and postpartum persons, noting that screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow up. The 2022 draft recommendation statements are consistent with these previous recommendations (USPSTF, 2022).

JOINT COMMISSION RECOMMENDATIONS

The Joint Commission requires that all individuals from age 12 and above in all medical settings be screened for suicidal ideation using a validated tool. Patients who are screened and found positive for suicide risk on the screening tool should receive a brief suicide safety assessment conducted by a trained clinician to determine whether a more comprehensive mental health evaluation is required (TJC, 2023).

AMERICAN ACADEMY OF PEDIATRICS

The American Academy of Pediatrics’ age recommendations for screening state:

• Youth ages 12 and over: Universal screening
• Youth ages 8–11: Screen when clinically indicated
• Youths under age 8: Screening not indicated; assess for suicidal thoughts/behaviors if warning signs are present

Young people require screening more frequently than adults, as adolescence and young adulthood are times of rapid developmental change, and circumstances can shift frequently (AAP, 2022).

SCREENING TOOLS

The following are validated, evidence-based suicide risk screening tools:

• Beck Fast Scan: Seven questions that can help determine the intensity and severity of depression
• Suicide Risk Screen: 10-item questionnaire often used to screen for suicide in young people
• Patient Health Questionnaire (PHQ): Nine questions about self-harm, also used to identify patients at high risk of suicide
• SAFE-T: Can be used in an outpatient setting; offers insight into the extent and nature of suicidal thoughts and harmful behavior
• Columbia-Suicide Severity Rating Scale (C-SSRS): Available in multiple languages for prehospital use to assess for the presence of harmful behavior; also assesses for any known suicide attempts and suicide ideations and behaviors
• Ask (ASQ) Suicide Screening: Four brief questions to screen medical patients ages 8 years and above
• SBQ-R: A psychological, four-item questionnaire to identify risk factors for suicide in adolescents and adults
  (NIMH, 2022; Columbia University, 2021; CEBC, 2020)

Recognizing Suicide Warning Signs

Besides screening for risk factors for suicide, it is important to be able to recognize statements, behaviors, and moods that indicate an individual may be at immediate risk for suicide.

Statements by a patient that constitute a suicide warning sign include language about:

• Killing oneself
• Feeling hopeless
• Having no reason to live
• Being a burden to others
• Feeling trapped
• Having unbearable pain

Behaviors that may signal risk—especially when related to a painful event, loss, or change—include:

• Increased use of alcohol or drugs
• Searching for a method to end their life, e.g., online search
• Withdrawing from activities
• Risky behaviors
• Isolating from family and friends
• Sleeping too much or too little
• Visiting or calling people to say goodbye
• Giving away prized possessions
• Aggression
• Fatigue
• Writing a will and making final arrangements

People considering suicide often display one or more of the following moods:

• Depression
• Anxiety
• Loss of interest
• Irritability
• Humiliation/shame
• Agitation/anger
• Relief/sudden improvement
  (AFSP, 2023a)

Suicide Risk Assessment

The purpose of a suicide risk assessment is to determine a patient’s risk and protective factors with a focus on identification of targets for intervention. The most effective assessment begins with the establishment of a therapeutic relationship with the patient.

ESTABLISHING RAPPORT

The initial contact with a person with suicidal thoughts may occur in many different settings—home, telephone, inpatient unit, outpatient clinic, practitioner’s office, rehabilitation unit, long-term care facility, or hospital emergency department. Being skilled at establishing rapport quickly is essential for all clinicians. It is imperative that the person be given privacy, be shown courtesy and respect, and be made aware that the clinician wants to understand what has happened or is happening to them.

Basic Attending Skills

Basic attending and listening skills are valuable in establishing rapport and a therapeutic alliance in order to obtain information, set the foundation for the treatment plan, and assist in determining interventions. These skills range from nondirective listening behaviors to more active and complex ones.

Positive attending behaviors are nonverbal and include:

• Eye contact. Maintaining eye contact communicates care and understanding and can show empathy and an interest in the person’s situation. Cultures vary in what is considered appropriate. Asian and Native Americans, for example, may view eye contact as aggressive.
• Body language. Usually leaning slightly toward the patient and maintaining a relaxed but attentive posture is effective. This may also include mirroring, which involves matching the patient’s facial expression and body posture.
• Vocal qualities. These include tone and inflections of the interviewer’s voice. Tonal quality may move toward “pacing,” which is matching the patient’s vocal qualities. Vocal qualities can be used to lead the patient.
• Verbal tracking. This involves using words to demonstrate that the interviewer has accurately followed what the patient is saying, such as restating or summarizing what the patient has said.

Negative attending behaviors include:

• Overuse of positive attending behaviors, which can become negative or annoying
• Turning away from the patient
• Making infrequent eye contact
• Leaning back from the waist up
• Crossing the legs away from the patient
• Folding the arms across the chest
  (Grieve, 2023)

Listening Skills and Action Responses

Effective interviewing also requires nondirective and directive listening as well as directive action responses.

Nondirective listening responses are described below:

• Silence is a skill requiring practice to be comfortable with. It is very nondirective, and if used appropriately, it can be very comforting for the patient.
• Nondirective questioning includes asking for clarification, more facts, and details, best done by using open-ended questions.
• Paraphrasing, or reflection, is a verbal tracking skill that involves restating or rewording what the patient has said. There are three types of paraphrasing that can be utilized:
• Simple paraphrasing gives direction but involves rephrasing the core meaning of what the patient has said.
• Sensory-based paraphrasing involves the interviewer using the patient’s sensory words in the paraphrase (visual, auditory, kinesthetic, etc.).
• Metaphorical paraphrasing involves making an analogy or metaphor to summarize the patient’s core message.
• Intentionally directive paraphrasing is solution-focused and attempts to lead the patient toward more positive interpretations of reality.
• Empathizing is used to show that the listener identifies with the patient’s information and allows the patient the right to their feelings.
• Supporting includes agreement, offers to help, reassurance, and focusing on the here and now.
• Analyzing is helpful in gaining different alternatives and perspectives by offering an interpretation of the patient’s message, making sure the person will be receptive.
• Summarization is an informal summary of what the patient has said. It should be interactive, encouraging, and supportive, and include positives or strengths that may help the patient cope.
  (Wrench et al., 2022)

Directive listening skills:

• Validating feelings involves acknowledgement and approval of the patient’s emotional state. It can help patients accept their feelings as normal or natural and can enhance rapport.
• Interpretive reflection of feeling, also referred to as advanced empathy, goes beyond surface feelings or emotions to uncover deeper, underlying feelings, which can bring about strong emotional insights or defensiveness.
• Interpretation, also known as reframing, is a classic psychoanalytic technique that can produce patient insight or a solution-focused way to help patients view their problems from a new and different perspective.
• Confrontation involves pointing out perceptual inaccuracies or inconsistencies to help the patient see reality more clearly. It works best when excellent rapport has been established, and it can be either gentle or harsh.
  (Panna, 2020)

When attempting to elicit information from suicidal persons, it should be remembered that challenging or direct questions, which could be interpreted as critical, will rarely be of benefit. The individual with suicidal thoughts should be encouraged and given the opportunity to express thoughts and feelings and be allowed to discharge pent-up and repressed emotions. Asking open-ended questions encourages the person to elaborate on their answers, which can provide important context on their level of risk, access to means, and presence of intent (Aamar, 2021).

OPEN-ENDED QUESTIONING IN RESPONSE TO PERSONS WITH SUICIDAL IDEATION

Person’s Statement	Appropriate Responses
Everyone will be better off without me.	Who would be better off? What would be better for those people? Where are you planning to go?
I just can’t bear it anymore.	What is so hard to bear? What would make your life better? When did you begin to feel this way?
I just want to go to sleep and not deal with it again.	What do you mean by “sleep”? What is it you don’t want to deal with anymore?
I want it to be over.	What is it you want to be over? How can you make it be over?
I won’t be a problem much longer.	How are you a problem? What is going to change in your life so you won’t be a problem any longer? When will you no longer be a problem?
Things will never work out.	What can you do to change that? What, then, do you propose to do?
It is all so meaningless.	What would make life more meaningful? What are some aspects of your life that make it worth living? What is happening in your life that makes it so meaningless?

ASSESSING SUICIDAL INTENT

Once it is determined that suicidal ideations are present, the next step is to determine whether the patient has active (thoughts of taking action) or passive (wish or hope to die) intent. The patient should be asked if the thoughts are new and if there are changes in the frequency or intensity of chronic thoughts. It is also important to inquire about the patient’s ability to control these thoughts.

The next step is to determine if the patient has developed a suicide plan and their degree of intent. This includes asking whether or not they have made any preparations and what they are. It is also important to determine whether the patient has a history of impulsive behaviors or substance use that may increase impulsivity, and whether they have a past history of suicidal ideation and behavior.

In addition, the clinical interview includes observing whether the patient is disconnected, disengaged, or shows a lack of rapport, as these signs are associated with an increased risk of suicide (Schreiber & Culpepper, 2022).

Suicide Risk Assessment Tools

Although various suicide risk assessment tools are available, experts have repeatedly come to the conclusion that there is not any one tool that can predict who will die by suicide to any useful degree.

There are many tools available to assist healthcare professionals in determining suicidal intent. These assessment tools are used to assess a person’s intent to carry through. They are often used when positive results have been obtained with one of the screening tools mentioned above. The following are validated/evidence-based suicide risk assessment tools:

• Ask Suicide Screening Questions (ASQ) Toolkit is a four-item suicide screening tool designed to be used for people of all ages in emergency departments, inpatient units, and primary care facilities.
• Columbia-Suicide Severity Rating Scale (C-SSRS), Risk Assessment version. The risk assessment version of this tool provides a checklist of protective and risk factors for suicide and is used along with the C-SSRS screening tool. It is appropriate in all settings for all ages and for special populations in different settings. The tool features a clinician-administered initial evaluation form, a “since last visit” version, and a self-report form. The Columbia protocol questions have also been incorporated into the SAMHSA SAFE-T model with recommended triage categories.
• Beck Scale for Suicide Ideation (BSI). This 21-item self-report instrument can be used in inpatient and outpatient settings for detecting and measuring the current intensity of the patient’s specific attitude, behaviors, and plans to die by suicide during the preceding week. It assesses the wish to die, desire to make an active or passive suicide attempt, duration and frequency of ideation, sense of control over making an attempt, number of deterrents, and the amount of actual preparation for the contemplated attempt.
  (TJC, 2023)

Clinical Interview

The clinical interview is the “gold standard” for suicide assessment and intervention. Topics covered during this interview include suicidal ideation, plans, self-control, intent, and safety planning.

There are three effective approaches to asking about suicide:

• Use a normalizing tone. About 60% of people who died by suicide denied suicidal ideation when asked by a healthcare provider, indicating the presence of psychological and interpersonal barriers to disclosure. It is helpful to use a statement that normalizes suicide ideation, such as: “I asked you this question because almost all people at one time or another have thoughts about suicide.”
• Use gentle assumption. To make it easier for patients to disclose suicidal ideation, the interviewer assumes that certain thoughts and behaviors are already occurring in the person and gently structures questions accordingly. So, instead of asking if the person has been thinking about suicide, ask “When was the last time you had thoughts about suicide?”
• Assess the person’s mood. An exploration of mood states might include asking permission to discuss mood, and then asking patients to rate their mood using a zero–10 scale. This is followed by questions that refer to the worst or lowest mood rating the person has ever had as well as what was happening at those times that made them feel so down. In order to end with a positive note, the patient is asked about the best mood rating they’ve ever had.

Explore suicidal ideation. When the patient discloses the presence of suicidal ideation, collaboratively explore the frequency, triggers, duration, and intensity of the suicidal thoughts. During this process, it is important to show curiosity, empathy, and interest instead of judgment. If the patient denies suicidal thoughts and the denial appears to be genuine, acknowledge and accept the denial, but if the denial seems forced or is combined with symptoms of depression or other risk factors, acknowledge and accept the denial but return to the topic later.

Explore suicide plans. Once rapport is established and the patient has talked about suicidal ideation, it is important to explore suicide plans. If patients admit to a plan, further exploration is crucial. Evaluation includes assessing the specificity of the plan, its lethality, availability of the means, and proximity of social support (i.e., availability of individuals who might intervene and rescue the patient) (see “Assessing the Plan, Lethality, and Risk” below).

Assess self-control. This requires asking directly about self-control and observing for agitation, arousal, or impulsivity. Arousal and agitation adversely affect self-control and are the inner push that drives persons toward suicidal acts (Sommers-Flanagan, 2022).

ASSESSING THE PLAN, LETHALITY, AND RISK

The evaluation of a suicide plan is extremely important in order to determine the degree of suicidal risk. When assessing the lethality of a plan, it is important to learn all the details about the plan, the method chosen, and the availability of means. People with definite plans for a time, place, and means are at high risk for suicide. Someone who is considering suicide without making a plan is at lower risk.

Suicidal deaths are more likely to occur when persons use highly damaging, fast-acting, and irreversible methods—such as jumping from heights or shooting—and do so when rescue is fruitless.

Methods of Suicide and Lethality

The desire for a painless method of suicide often leads individuals to choose a method that tends to be less lethal. This results in attempted suicides that do not end in death. For every 25 attempts, there is one death. For drug overdoses, the ratio is around 40 to 1.

The following are methods of suicide and the likelihood that they will result in death:

• Firearms: 82.5%
• Drowning/submersion: 65.9%
• Suffocation/hanging: 61.4%
• Gas poisoning: 41.5%
• Jumping: 34.5%
• Drug/poisoning: 1.5%
• Cutting/piercing: 1.2%
• Other: 8.0%
  (HSPH, 2023b)

It is of utmost importance for clinicians to recognize that these methods, as well as other highly lethal suicide methods, are widely accessible and must be considered when determining the disposition of someone who has suicidal ideations.

Factors that influence the lethality of a chosen method include:

• Intrinsic deadliness. A gun is intrinsically more lethal than a bottle of pills.
• Ease of use. If a method requires technical knowledge, for example, it is less accessible than one that does not.
• Accessibility. Given the brief duration of some suicidal crises, a gun in the cabinet in the hall is a greater risk than a very high building 10 miles away.
• Ability to abort mid-attempt. More people start and stop mid-attempt than carry through. It is easier to interrupt a hanging or to call 911 after overdosing than to stop a method such as jumping off a bridge or using a gun.
• Acceptability to the individual. The method must be one that does not cause too much pain or suffering. For example, fire is readily accessible, but it is a method seldom used in the United States.
  (HSPH, 2023b)

Level of Risk

A clinical judgment that is based on all the information obtained during assessment should help to assign a level of risk for suicide and determine the setting of care.

Patients who are low risk of suicide:

• Are experiencing recent suicidal ideation or thoughts
• Have no specific current suicide plan
• Have no clear intent to act
• Have not planned or rehearsed a suicide act
• Have identifiable and multiple protective factors
• Have limited risk factors
• Have no history of suicidal behaviors
• Have evidence of self-control
• Have supportive family members or significant others
• Have a high degree of ambivalence

Most people with suicidal ideation do not necessarily want to die; they just do not want to continue living in an intolerable situation or state of mind. This ambivalence is one of the most important tools for working with such persons. Almost everyone with suicidal thoughts is ambivalent about dying, leaning toward suicide at one moment in time, and then leaning toward living the next. The healthcare professional can use this ambivalence to help focus the person on the reasons why they should live.

Patients who are at moderate risk:

• Have current suicide ideation
• Have no clear plan for suicide
• Have had no preparatory behavioral or rehearsal of act
• Have limited or no intention to act
• Have limited identifiable protective factors
• Are able to control the impulse
• Have the ability to maintain safety, independent of external support
• Have no recent suicidal behavior
• Have supportive family or significant others
• Have a high degree of ambivalence

Patients who are at high/severe/imminent risk:

• Have strong, persistent suicidal ideation
• Have strong intention to plan or act
• Have a specific suicide plan
• Have access to lethal means
• Have minimal protective factors
• Have impaired judgment
• Have poor self-control either at baseline or due to substance use
• Have inability to maintain safety, independent of external support
• Have a poor social support network
• Have severe psychiatric symptoms and/or an acute precipitating event
• Have a history of prior suicide attempt
  (VA, 2022b)

Differentiating between Non-Suicidal Self-Injury and Suicide Attempt

Healthcare professionals are increasingly confronted with another problem related to suicide attempts called non-suicidal self-injury (NSSI). DSM-5 defines NSSI as the “deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned” (APA, 2013).

Self-harm is a sign of emotional distress, and adolescents are at the highest risk, with approximately 15% of teenagers and 17%–35% of college students having been found to inflict self-harm injury. Both males and females have similar rates of NSSI. Studies have found the following reasons given for engaging in self-harm behavior:

• To feel a sense of control over the body or life situations
• To punish oneself for perceived faults
• To reduce negative emotions
• To feel “something” instead of numbness or emptiness
• To avoid certain social situations
• To receive social support

The greatest difference between suicide and self-harm is intent. Suicide is a method that can end pain, but self-harm is an act to enhance coping with feelings and stressors. Some individuals find that pain from self-injury is reassuring when they are feeling numb or disconnected from the world around them. NSSI, however, can increase the risk of suicide because of the emotional problems that trigger self-injury and the pattern of damaging the body in times of distress.

It is important to keep in mind that the act of self-harm induces pain receptors that trigger the brain to feel an adrenaline “rush.” This can readily become addictive and highly dangerous (Discovery Mood & Anxiety Program, 2023; Mayo Clinic, 2022).

ASSESSMENT OF NSSI PATIENTS

Assessment of the patient who presents with non-suicidal self-injurious behavior includes:

• Determining what type of injury and how many types of injuries the patient has inflicted
• Determining how often non-suicidal self-injury occurs and how long it has been occurring
• Determining the function of NSSI for the patient
• Assessing for coexisting psychiatric disorders
• Estimating the risk of suicide attempt
• Determining how willing the patient is to participate in treatment

The most common examples of NSSI include cutting or stabbing the skin with a sharp object and burning the skin. Patients often injure themselves repeatedly in a single session, creating multiple lesions in the same location, typically in areas that are easily hidden but accessible, such as the forearms, chest, abdomen, or front of the thighs. The behavior is often repeated, resulting in extensive patterns of scarring (Moutier, 2022).

Signs of NSSI that may be found during the physical examination include:

• Scars, often in patterns
• Fresh cuts, scratches, bruises, bite marks, or other wounds
• Wearing long sleeves or long pants to hide self-injury, even in hot weather
• Frequent reports of accidental injury
  (Mayo Clinic, 2022)

Once signs of NSSI are identified, an assessment tool can be used to aid in diagnosing NSSI and differentiating patients who are at increased risk of suicide. These may be either self-administered or clinician-administered. Examples include:

• Self-Harm Behavior Questionnaire (SHBQ)
• Suicidal Behaviors Questionnaire (SBQ)
• Self-Injurious Thoughts and Behaviors Interview (SITBI)
• Suicide Attempt Self-Injury (SASSI)
• The Ottawa Self-Injury Inventory (OSI)
• The Child Behavior Checklist (CBCL)
  (Wikiversity, 2021)

Documentation of Suicide Risk Assessment

Good documentation is basic to clinical practice. Accurate, sufficiently detailed, and concise records of a patient’s treatment allow for quality care and communication among providers. The best records reflect awareness of risk and the process of professional judgement that recognized it, took steps to reduce it, and balanced it with patient needs. The following documentation should be present in the record:

• Reason for suicide assessment
• Review of past available records
• Evaluation of warning signs and risk and protective factors
• Initial and ongoing suicide risk assessment
• Access to lethal means and mitigation
• Consultations with colleagues
• Referrals to behavioral health
• Rationale and follow-up for treatment options
• Safety planning and discharge coordination
• Plans for follow-up
  (Stefan, 2020)