Asking a patient, friend, or co-worker about suicide requires a thoughtful, caring, and non-judgmental approach. The goal is to identify a person who has thoughts of self-harm but has not yet formulated a plan or acted on those thoughts.
Nurses are in a key position to prevent suicide. However, to enable nurses to act, they need to feel confident assessing suicidal risk. Given that the majority of people with suicidal ideation or behaviors have seen a health professional in the month before their death, it is highly likely nurses will have to provide care for someone who is potentially suicidal (Davison et al., 2017).
Yet nurses report feeling unconfident and ill-prepared to discuss suicide or suicidal ideation. As a result, people are rarely identified as being at-risk. Education is vital. Knowing how to identify an at-risk person—and understanding the level of risk—is the first step in preventing suicide (Davison et al., 2017).
Because risk occurs on a continuum, screening, assessment, management, and referrals are different for each situation. Identifying at-risk individuals, accessing services, and relying on evidence-based care remain key challenges (Stone et al., 2017).
Identifying and caring for someone thought to be at risk for suicide involves five key steps:
- Safety Planning
This pathway to care should be standardized across an organization, ensuring that anyone at risk for suicide receives the same level of care and support. It must also ensure that privacy is respected and an individual’s risk for suicide is not disclosed to others without their consent.
Asking a person about suicide starts with open-ended questions that invites the patient or co-worker to provide more information. If warning signs are noted, or there is a concern about suicide, screening should be initiated—whether or not you can pinpoint the reason for concern. (CSAT, 2017).
Any actions taken by the screener should make good sense in light of the seriousness of suicide risk. Judgments about the degree of seriousness should be made in consultation with a supervisor or a treatment team, not by a healthcare provider acting alone (CSAT, 2017). A critical part of any screen is understanding when a referral is needed; if the initial screen indicates increased risk, be prepared to make an immediate referral.
Screening is a key element of the Zero Suicide framework, which encourages healthcare organizations to (Corr, 2022):
- Identify individuals with suicide risk using a comprehensive screening and assessment tool.
- Use evidence-based, standardized screening and assessment tools to screen all patients at every visit.
- Have protocols in place for those who screen positive.
A simple screening questionnaire can identify high-risk individuals who otherwise may not be identified. In fact, a brief screening tool can more effective and reliable than leaving the identification up to a clinician’s personal judgment or by asking about suicidal thoughts using vague or softened language.
The Ask Suicide-Screening Questions (ASQ), approved by the Joint Commission for all ages, is one such tool. It is brief, validated, and takes about 20 seconds to administer; it contains four screening questions (NIMH, 2021).
ASQ Screening Tool
Ask the patient:
- In the past few weeks, have you wished you were dead?
- In the past few weeks, have you felt that you or your family would be better off if you were dead?
- In the past week, have you been having thoughts about killing yourself?
- Have you ever tried to kill yourself?
- Are you having thoughts of killing yourself right now?
- For more detailed information about the ASQ Screening Tool, please go here.
In a National Institute of Mental Health study, a “yes” response to one or more of the four questions on the ASQ questionnaire identified 97% of youth at risk for suicide. A multisite research study has demonstrated that the ASQ is also a valid screening tool for adult medical patients (NIMH, 2021).
Additional validated screening tools include the ED Safe Secondary Screener, the Patient Health Questionnaire-9 (PHQ-9), the Patient Safety Screener, and the TASR Adolescent Screener. The Columbia-Suicide Severity Rating Scale can be used for both screening and more in-depth assessment of patients who screen positive for suicidal ideation using another tool (JC, 2019).
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 the screening tools (DVA/DoD, 2019).
Positive screens result in a referral to a trained behavioral health expert for a comprehensive assessment. This may involve establishing relationships with local behavioral health providers, including crisis centers.
National Action Alliance for Suicide Prevention
If a client screens positive for increased risk, the standard of care established by the Joint Commission requires a suicide risk assessment. To determine the proper course of treatment, either conduct a more comprehensive assessment or refer your client for secondary screening and assessment (JC, 2019).
Assessing suicide risk should evaluate suicidal thoughts, intent, and behaviors. Warning signs are an important consideration, as well as the presence of risk and protective factors that may increase or decrease the patient’s risk of suicide (DVA/DoD, 2019).
Patients determined to be at a high level of risk should be evaluated by a behavioral health specialist, which can include treatment of co-occurring mental health conditions. Psychiatric hospitalization may be needed if related risk factors—such as acute psychosis—are responsive to inpatient treatment. Outpatient management should include frequent contact, regular re-assessment of risk, and a well-designed safety plan (DVA/DOD, 2019).
In extreme circumstances, if a client or co-worker is judged to meet the criteria as a “danger to self”, a legal process can be initiated whereby a person can be held against their wishes in a locked facility for up to 72 hours. During this time a more in-depth medical assessment will be completed, and medication management and other safety strategies initiated.
The Suicide Prevention Resource Center and the Joint Commission, among others, recommend safety planning as a standard of care for individuals identified as at-risk for suicide-related behaviors. Safety planning is a brief intervention to help individuals survive suicidal crises by having them develop a set of steps to reduce the likelihood of engaging in suicidal behavior (Moscardini et al., 2020).
Safety planning produces a written plan that restricts access to lethal means. It encourages problem-solving and coping strategies, enhances social support, and identifies a network of emergency contacts. Safety plans should include specific warning signs as well as coping strategies that have been effective in the past (DVA/DOD, 2019).
Safety Planning Intervention has gained widespread acceptance in the suicide prevention community and has been incorporated into numerous treatment guidelines and interventions. The plan is collaboratively built by a clinician and a patient and encourages individuals to engage in six sequential steps when feeling suicidal:
- Identify early warning signs.
- Employ internal coping strategies.
- Distract with social engagement or change of environment.
- Access suicide-protective social support.
- Seek help through crisis resources.
- Restrict access to lethal means.
Harmer et al., 2023
Every Kentuckian can become a suicide prevention gatekeeper. Gatekeepers learn to recognize situational and behavioral clues of someone in a suicidal crisis, how to talk with someone about suicidal thoughts, and how to persuade that person to get help.
Any provider with an ethical duty to assess client safety can initiate the referral process. If clients are referred for hospitalization and agree to be hospitalized, they must be placed in the least restrictive environment. Determining whether a patient is safe (and whether they can be held against their will) is left to providers who are legally licensed to make that determination.
A confidential referral to appropriate mental health resources should be completed for anyone identified as being at high risk for suicide. Anyone making a referral must assure that the co-worker or patient has all the necessary information to make an informed decision about seeking help.
Recognition and referral training—also called gatekeeper training—can play a critical role in suicide prevention. It teaches educators, coaches, clergy, as well as emergency responders, primary and urgent care providers, health professionals, and others in the community how to identify and refer people who may be at risk of suicide.
Recognition and referral training can be a valuable training tool even for healthcare providers who already have mental health training. It provides additional education, support, access to resources, and opportunities to practice assessment skills. Despite the comorbidity of mental health disorders and suicide, the vast majority of mental health professionals do not typically receive routine training in suicide assessment, treatment, or risk management.
Follow-Up and Continuity of Care
Because a variety of healthcare providers, friends, and family members may be associated with the care of a person at risk for suicide, follow-up and continuity of care can be easily lost. Maintaining continuity across facilities and providers can be helped by electronic medical records; however, not everyone has access to this information. A confounding factor is that mental health information has higher levels of consent for accessing records.
Nevertheless, follow-up is critically important after the initial intervention. This includes regular check-ins, follow-up assessments, and monitoring for any changes in the person’s risk for suicide.
Follow-up is often interrupted when patients who are or have been at risk for suicide transition between care facilities or between other health systems or provider organizations. Patients have expressed frustration with seeing multiple providers, both within a treatment facility and across multiple locations (DVA/DOD, 2019).
A common misconception is that suicide risk is an acute problem that, once dealt with, ends. Unfortunately, individuals who are suicidal commonly experience a return of suicide risk following any number of setbacks, including relapse to substance use, a distressing life event, increased depression, or any number of other situations. Sometimes suicidal behavior even occurs in the context of substantial improvement in mood and energy. Monitoring for signs of a return of suicidal thoughts or behavior is essential (CSAT, 2017).
It is a mistake to think that once a referral has been made, the issue is settled. It is essential to follow up with other providers to determine that appointments are kept. Follow-up emphasizes the importance of watching for a return of suicidal thoughts and behaviors, following up with referrals, and continually coordinating with providers who are addressing the patient’s suicidal thoughts and behaviors (CSAT, 2017).
Additional follow-up should include:
- Keeping family members engaged.
- Confirming that the client and family have emergency contacts.
- Removing access to lethal means.
- Completing a treatment termination summary when this stage of care is reached.
Following Up with Margo
Margo is a 27-year-old woman who presented in your office for treatment following a suicide attempt. She had slit her wrists 2 weeks before and was recently discharged from the hospital psych ward.
Screening and Assessment
When Margo is asked if she ever tried to harm herself in the past—how many times and in what ways—she replied: “The first time I thought about suicide, 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. Two weeks ago, I was upset when my boyfriend broke up with me and I slit my wrists in a warm bathtub.”
When assessing a person for suicidal ideation and behaviors, start by asking broad questions and get more specific as the interview proceeds. Avoid yes/no questions, which can communicate an expectation in favor of either a yes or no response.
At this point in your assessment, it may be unclear whether Margo has a clear intention of taking her life or if she requires higher levels of protection than someone with less inclination toward dying.
The key point about Margo is that her attempts have accelerated and become more sophisticated. Keep in mind that the more times a person attempts suicide, the more likely they are to complete the event. In Margo’s case, this should increase your concerns about future risk. Understanding the level of risk will guide your decision about safety, which is the first priority.
What Actions Should You Take?
Margo has just been released from protective custody. What do you think is the most effective care she should receive?
- A follow-up phone call every month from her doctor.
- Monitoring, outreach, therapy, and case management.
- Threatening her with protective custody if she is unable to handle the stresses in her life.
- Encouraging her to move back home with her parents so they can closely monitor her behavior.
Correct answer: b
Because previous suicide attempts are known to be a strong predictor of future attempts and deaths by suicide, continuity of care is critical. For Margo, who has survived a suicide attempt, effective clinical care and follow-up should focus on community and family support, therapy, and lethal means restriction.