Because suicide is exceedingly rare in comparison to associated risk factors, predicting who may be at risk is extremely difficult. Nevertheless, healthcare providers should be aware of warning signs and risk factors and be prepared to screen, refer, and document suicide risk (DVA/DOD, 2013). Screening by healthcare professionals takes on particular importance because it is estimated that 75% of individuals who die by suicide are in contact with a primary care physician in the year before their death, and nearly 45% within one month of their death (Health and Human Services, 2012).
Screening for suicidal ideation and behavior can ensure that those requiring services get the help they need (CSAT, 2015). Washington State recommends that clients be screened for suicidal ideation and behavior. A screening tool can help a clinician gauge the immediacy of the risk, the need for a more thorough assessment, and the need for referral.
How and When to Screen
Screening for suiciderisk in a clinic or community setting (such as an outpatient pharmacy) requires a caring, non-judgmental approach. The overall goal is to identify people who have thoughts of self-harm but have not yet formulated a plan or acted on those thoughts. If the screen indicates increased risk, be prepared to make an immediate referral, making sure your client transitions safely from your office or clinic to the point of actual service.
Any healthcare provider in any setting may be called upon to ask a client about suicide. Because this is not easy, it is recommended that providers use a simple screening tool and practice the questions until they are comfortable leading a client through a suicide screen. Understanding when a referral is needed is a critical part of the screen—anyone thought to be at risk for suicide should be referred.
Something as simple as a waiting room questionnaire or a quick, two-question screening tool can identify high-risk individuals who otherwise may not be identified. In fact, research has shown that a brief screening tool can identify individuals at risk for suicide more reliably than leaving the identification up to a clinician’s personal judgment or by asking about suicidal thoughts using vague or softened language (JC, 2016).
For those working in outpatient clinics, social services, counseling services, dental offices, or community pharmacies, clients should be screened regularly, preferably at each visit. For these individuals, the prevalence of suicidal ideation and suicide attempts is higher than the general population.
For screening to be effective, healthcare providers must:
- Use a simple screening tool.
- Practice questions ahead of time.
- Understand suicide warning signs, risk factors, and protective factors.
- Be empathic and nonjudgmental.
- Understand how your own attitudes impact your clients.
- Check that referral appointments are kept.
- Coordinate services with mental health providers, other practitioners, and family members. (CSAT, 2015)
Did You Know . . .
Dallas’s Parkland Memorial Hospital became the first U.S. hospital to implement universal screenings to assess whether patients are at risk for suicide. Through preliminary screenings of 100,000 patients from its hospital and emergency department, and of more than 50,000 outpatient clinic patients, the hospital has found 1.8 percent of patients there to be at high suicide risk and up to 4.5 percent to be at moderate risk (Joint Commission, 2016).
According to The Joint Commission, all patients should be screened for suicide ideation, using a brief, standardized, evidence-based screening tool (JC, 2016).
Patient Health Questionnaire 2 (PHQ2)
One widely used, validated screening tool is the Patient Health Questionnaire 2 (PHQ2). It is simple and quick tool used by many large hospital organizations, including Washington’s Kaiser Hospital system. This tool was originally designed to screen for depression but is being widely used as a suicide screen. The PHQ2 asks a client to answer 2 questions and indicate—over the last 2 weeks—how often he or she has been bothered by either of the following problems:
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
Answers are given as 0 to 3, using this scale: 0 = Not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day.
If a client responds “not at all” to both questions on the PHQ2, then no additional screening or intervention is required, unless otherwise clinically indicated. If a client responds yes to one or both questions on the PHQ2, then an additional assessment should be initiated (NYSDOH, 2016). Your organization will need to identify the score that necessitates intervention in your particular setting.
Patient Health Questionnaire (PHQ9)
A more comprehensive version of the Patient Health Questionnaire—called the PHQ9—is used to screen or diagnose depression, measure the severity of symptoms, and measure a client’s response to treatment (NYSDOH, 2016). The PHQ9 is administered if a client answers yes to any of the PHQ2 questions. A study using the PHQ9 found that those who expressed thoughts of death or self-harm were 10 times more likely to attempt suicide than those who did not report those thoughts (Joint Commission, 2016).
Columbia Suicide Screen
Another commonly used, brief screening tool is the Columbia Suicide Screen. It is an 11-item measure validated by the National Institute of Mental Health and is used to evaluate mood, substance abuse, and suicidal ideation and attempts. This tool reportedly has lower rates of false positives (results that falsely suggest suicide risk) than other screening tools (NREPP, 2015).
Emergency Medicine Network’s EDSAFE Patient Safety Screener
A brief screening tool—primarily used as part of an initial inpatient nursing assessment— is the Emergency Medicine Network’s EDSAFE Patient Safety Screener for emergency departments (JC, 2016). This tool can also be used in outpatient and other settings. It contains three questions:
- Over the last 2 weeks, have you felt down, depressed, or hopeless?
- Over the last 2 weeks, have you had thoughts of killing yourself?
- In your lifetime, have you ever attempted to kill yourself? If so, when?
If a client screens positive on the EDSAFE Patient Safety Screener, a secondary screen is recommended to help guide the decision to refer to a mental health specialist. The secondary screen asks:
- Did the patient screen positive on the PSS items—active ideation with a past attempt?
- Has the individual begun a suicide plan?
- Has the individual recently had intent to act on his/her ideation?
- Has the patient ever had a psychiatric hospitalization?
- Does the patient have a pattern of excessive substance use?
- Is the patient irritable, agitated, or aggressive?
All individuals who screen positive on the Patient Safety Screener should: (1) have appropriate precautions in place to ensure safety during the visit, and (2) receive a written Safety Plan at discharge from the emergency department (EMN, 2017).
Suicide Behaviors Questionnaire–Revised (SBQ-R)
The Suicide Behaviors Questionnaire–Revised (SBQ-R), a screening tool used mostly in emergency departments, asks clients four questions:
- Have you ever thought about or attempted to kill yourself?
- How often have you thought about killing yourself in the past?
- Have you ever told someone you were going to commit suicide, or that you might do it?
- How likely is it that you will attempt suicide someday?
University of Washington Behavioral Health and Therapy Clinics
The University of Washington Behavioral Health and Therapy Clinics offers a variety of assessment instruments for screening and assessment of suicide risk. These tools can be found at this link: http://depts.washington.edu/uwbrtc/resources/assessment-instruments/.
Using Screening Information
All persons addressing suicidality among patients at risk must have full knowledge of screening and assessment results, and knowledge of steps taken to work with the patient. To the degree possible, care decisions should be made in a team environment with shared decision making and shared responsibility for care. The team must include the patient and his or her family, whenever possible and appropriate.
National Action Alliance for Suicide Prevention
If a client screens positive for suicide risk, the standard of care established by The Joint Commission requires a thorough suicide risk assessment. To determine the proper course of treatment for a client determined to be at risk for suicide, either conduct a more comprehensive assessment or refer your client for secondary screening and assessment (JC, 2016).
A client in acute suicidal crisis must be kept in a safe healthcare environment under one-to-one observation. Do not leave these clients by themselves. Provide immediate access to care through an emergency department, inpatient psychiatric unit, respite center, or crisis resources. Check these clients and their visitors for items that could be used to make a suicide attempt or harm others. Keep them away from anchor points for hanging and material that can be used for self-injury. Some specific lethal means that are easily available in general hospitals and that have been used in suicides include: bell cords, bandages, sheets, restraint belts, plastic bags, elastic tubing, and oxygen tubing (JC, 2016).
For clients who screen positive for suicidal ideation and deny or minimize suicide risk or decline treatment, try to obtain corroborating information by requesting the patient’s permission to contact friends, family, or outpatient treatment providers. If the client declines consent, HIPAA permits a clinician to make these contacts without the patient’s permission when the clinician believes the client may be a danger to self or others (JC, 2016).
For clients at lower risk of suicide, make personal and direct referrals and linkages to outpatient behavioral health and other providers for followup care within one week of initial assessment, rather than leaving it up to the patient to make the appointment (JC, 2016).
Valeria Cuts Her Wrists (Again)
Joanna is a physical therapist working in a small rural outpatient rehab clinic in northern Washington. She recently had a client referred for evaluation and treatment of low back pain. When her client, Valeria, walked in from the waiting room, Joanna noticed she was hunched over a little, had her head down, walked slowly, and had bandages on both wrists.
Before beginning the physical examination, Joanna asked if Valeria ever thought about harming herself. Valeria’s direct and frank response startled Joanna. With her eyes downcast and in a timid voice, Valeria said that, yes, she had hurt herself in the past and often thought about suicide. She nervously related, “The first time I tried to hurt myself, I took a bottle of aspirin. The second time I was 17 and I slit my wrists but I screamed when I saw the blood.”
Joanna asked her if anything had happened recently that had affected her well-being or mood. Valeria tearfully said, “Last week my boyfriend broke up with me and it really upset me. Two days ago I drank 2 bottles of whiskey and slit my wrists in the bathtub. When I saw the blood in the water I got scared and jumped out of the tub and drained the water. I taped my wrists but I didn’t tell anyone what had happened.” She asked Joanna why she was asking her about suicide when she was at the clinic for back pain.
Test Your Learning
What do you think stands out in Valeria’s description of her suicide attempts?
- She is very calm and articulate.
- She seems upset but not depressed.
- Her suicide attempts have become more sophisticated.
- She doesn’t seem to really want to harm herself.
Joanna noted that Valeria’s attempts have accelerated and become more sophisticated. This increased her concern about Valeria’s safety because the more times a person attempts suicide, the more likely they are to complete the event. It is the clinic’s policy to screen all clients for suicidal ideation and behaviors using the Patient Health Questionnaire 2 so Joanna asked Valerie: “Over the last 2 weeks, how often have you been bothered by any of the following problems?”
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
Valeria indicated she has these feelings every day (3) on both of the screening questions.
Joanna’s outpatient physical therapy clinic has no mental health services but her clinic has a policy that anyone who marks a 2 or 3 on either PHQ2 screening question should receive a more thorough assessment and be referred to a mental health specialist. Joanna’s supervisor tells her to either use the PHQ9 for a more thorough assessment or refer her client to the local emergency department for assessment by a mental health professional. Because Joanna is not a mental health professional and has not been trained on the PHQ9, she decides to refer Valeria to the local emergency department.
Because Valeria has no family living nearby and Joanna feels she is a danger to herself, she decides to call the police to transport Valeria to the emergency department. She also provides Valeria with the phone number for a suicide hotline. Joanna follows up with a call the ED and learns that Valeria arrived safely at the hospital.