SUICIDE SCREENING

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.

Screening Recommendations

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, 2023)