Screening requires a thoughtful, caring, and non-judgmental approach. The 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 suicide screen indicates increased risk, be prepared to make an immediate referral, making sure your patient transitions safely from your office or clinic to the point of actual service.
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, 2019).
The Joint Commission has established a screening requirement for all accredited organizations. The requirement is intended to improve the quality and safety of care for those who are being treated for behavioral health conditions and those who are identified as high risk for suicide (JC, 2019).
Joint Commission-accredited organizations are required to (JC, 2019):
- Identify features in the physical environment that could be used to attempt suicide.
- Screen all individuals for suicidal ideation using a validated screening tool.
- Conduct a suicide risk assessment of individuals who have screened positive for suicidal ideation.
- Document the level of risk and the plan to mitigate the risk for suicide.
- Follow written policies and procedures addressing staff training, reassessment, and monitoring.
- Follow written policies and procedures for counseling and follow-up care at discharge.
- Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of individuals at risk for suicide.
Since the implementation of these requirements for suicide screening in 2019, an analysis by the Joint Commission found that some organizations are failing to use validation screening tools. Some are using “home-grown” screening tools that may not have been tested for reliability, validity, sensitivity, and specificity. In some cases, when using a validated tool, healthcare providers omitted questions (JC, 2022, March 23).
3.1 How and When to Screen
Any healthcare provider in any setting may be called upon to ask a patient about suicide. Because this is not easy, it is important to practice the questions ahead of time until you are comfortable leading a patient through a suicide screen. Evaluation of suicidal thoughts, intent, behaviors, and warning signs, as well as risk and protective factors that may decrease the patient’s risk of suicide should be included.
Something as simple as a validated waiting room questionnaire or a quick, two-question screening tool can identify high-risk individuals who otherwise may not be identified. 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.
For screening to be effective:
- Practice questions ahead of time.
- Understand suicide warning signs.
- Learn about risk and protective factors.
- Understand how your own attitudes impact your patients.
Did You Know. . .
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.
If a referral to another medical professional is made, check that referral appointments are kept. Coordinating with mental health providers, other practitioners, and family members provides needed support for patients at risk for suicide.
3.2 Screening Tools
Unfortunately, many screening tools do not accurately predict risk of suicide. These tools tend to yield an unacceptably high false-positive prediction rate—many of those determined to be “at risk” never experience clinically significant suicidal thoughts or behavior. This is coupled with an unacceptably low degree of accuracy when identifying true cases—a substantial portion of those individuals who die by suicide were not identified by a screening tool (DVA, 2019).
Nevertheless, it is recommended that all patients be screened for suicide ideation, using a brief, standardized, evidence-based screening tool. The following screening tools have been tested and validated by various healthcare organizations.
3.2.1 Ask Suicide-Screening Questions (ASQ)
The Ask Suicide-Screening Questions (ASQ) tool is a brief, validated tool for use among both youth and adults. The Joint Commission has approved the use of the ASQ for all ages. It contains four screening questions that take 20 seconds to administer. In a National Institute of Mental Health study, a “yes” response to one or more of the four questions identified 97% of youth (aged 10 to 21 years) at risk for suicide (NIMH, 2024 June 30).
A multisite research study demonstrated that the ASQ is also a valid screening tool for adult medical patients. By enabling early identification and assessment of patients at high risk for suicide, the ASQ toolkit can play a key role in suicide prevention (NIMH, 2024 June 30). You can access the ASQ screening toolkit here:
3.2.2 The Columbia-Suicide Severity Rating Scale (C-SSRS)
The Columbia-Suicide Severity Rating Scale (C-SSRS) screening tool was developed by Columbia University, the University of Pennsylvania, and the University of Pittsburgh. The C-SSRS Triage version features questions that help determine whether an individual is at risk for suicide. There are brief versions of the C-SSRS (first two questions) that, based on a patient’s response, can lead to additional questions for triage purposes. The protocol and the training on how to use it are available free of charge.
3.2.3 Patient Health Questionnaire 2
The Patient Health Questionnaire 2 (PHQ2) is a widely used, validated screening tool used by many large hospital organizations, including Washington State’s Kaiser Hospital system. It was originally designed to screen for depression but is being widely used as a suicide screen.
The PHQ2 asks a patient to answer 2 questions and indicate—over the last 2 weeks—how often they have been bothered by either:
- 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 patient responds “not at all” to both questions on the PHQ2, then no additional screening or intervention is required, unless otherwise clinically indicated. If a patient responds “yes” to one or both questions on the PHQ2, then an additional assessment should be initiated. Your organization will need to identify the intervention score that is appropriate for its setting.
3.2.4 Patient Health Questionnaire 9
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 patient’s response to treatment. The PHQ9 is administered if a patient 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.
3.2.5 EDSAFE Patient Safety Screener
The Emergency Medicine Network’s EDSAFE Patient Safety Screener for emergency departments is a brief screening tool primarily used as part of an initial inpatient nursing assessment. 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 patient 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 Patient Safety Screener items—active ideation with a past attempt?
- Has the individual begun a suicide plan?
- Has the individual recently had intent to act on their 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.
3.2.6 Suicide Behavior Questionnaire-Revised (SBQ-R)
The SBQR is a 4 item self-report questionnaire that asks about future anticipation of suicidal thoughts or behaviors as well as past and present ones, and includes a question about lifetime suicidal ideation, plans to commit suicide, and actual attempts. Item 1 evaluates lifetime ideation and attempt, Item 2 assesses frequency of ideation in the past 12 months, Item 3 explores suicide threats, and Item 4 evaluates the likelihood of future suicidal behavior.
3.2.7 Additional Assessment and Screening Tools
Dr. Marsha Linehan and her colleagues at the University of Washington Behavioral Research and Therapy Clinics have published a comprehensive list of screening and risk assessment tools. The tools are available for research, clinical, and educational use at no charge. They can be accessed here:
3.3 Using Screening Information
Anyone addressing suicidality among patients must have knowledge of screening and assessment results. Care decisions should be made in a team environment with shared decision making and shared responsibility for care. Whenever possible, the patient and his or her family should be included.
National Action Alliance for Suicide Prevention
Healthcare providers must know what to do if a screen indicates that a patient is at immediate risk of self-harm. The overreaching goal is not to diagnose, but to be ready to talk, keep the person safe, and have referral information readily available. Immediate access to care should be provided through an emergency department, inpatient psychiatric unit, or crisis center.
A patient in acute suicidal crisis must be kept in a safe environment under one-to-one observation and should not be left alone. Objects such as cords, bandages, sheets, restraint belts, plastic bags, elastic tubing, and oxygen tubing that might be used in a suicide attempt, for self-injury, or to harm others must be removed.
If a patient has screened positive for suicidal ideation but declines treatment, request their permission to contact friends, family, or outpatient providers. If the patient declines consent, HIPAA permits a provider to make these contacts without the patient’s permission when the provider believes the patient may be a danger to self or others.
For patients at lower risk of suicide, personal and direct referrals to outpatient behavioral health and other providers for follow-up care is important. Do not leave it up to the patient to make the appointment.
Case Example: Valeria Cuts Her Wrists (Again)
Serena is a physical therapist working in a small, rural outpatient rehab clinic in northern Washington. She recently had a patient referred for evaluation and treatment of low back pain. When her patient, Valeria, walked in from the waiting room, Serena noticed she was hunched over a little, had her head down, walked slowly, and had bandages on both wrists.
Before beginning the physical examination, Serena asked if Valeria ever thought about harming herself. Valeria’s direct and frank response startled Serena. 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 1st time I tried to hurt myself, I took a bottle of aspirin. The 2nd time I was 17 and I slit my wrists, but I screamed when I saw the blood”.
Serena 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 Serena why she was asking her about suicide when she was at the clinic for back pain.
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.
Serena 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 be successful. It is the clinic’s policy to screen all patients for suicidal ideation and behaviors using the Patient Health Questionnaire 2 so Serena 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 screening questions.
Serena’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. Serena’s supervisor tells her to either use the PHQ9 for a more in-depth assessment or refer her patient to the local emergency department for assessment by a mental health professional. Because Serena 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 Serena feels she is a danger to herself, she decides to call the police to transport Valerie to the emergency department. She also provides Valeria with the phone number for a suicide hotline. Serena follows up with a call the ER and learns that Valeria arrived safely at the hospital.