Suicide in AmericaPage 7 of 14

5. The Screening and Assessment Process

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 found that 1.8 percent of patients were at high suicide risk and up to 4.5 percent were at moderate risk.

Joint Commission, 2016

A good clinical assessment can in itself be the start of a suicide prevention effort. However, determining who is at risk, using either screening tests or clinical judgment, is extremely difficult, primarily because suicide is a relatively rare event (CSAT, 2015). Screening and assessment tools typically have two goals: (1) to identify current suicidal ideation, and (2) to assess the potential for future suicidal behaviors (Harris et al., 2015).

No matter which tool is used, screening for and assessing risk depends heavily on the skills and philosophical approach of the individual clinician; it requires a caring, non-judgmental approach. The way questions are asked and the words and phrasing used influence the patient’s response (McCabe et al., 2017).

If the screen indicates increased risk or if harm appears imminent, complete a more thorough assessment or make an immediate referral, making sure your client transitions safely from your office or clinic to the point of actual service.

The Joint Commission recommends that all patients be screened for suicidal ideation using a brief, standardized, evidence-based screening tool (JC, 2016). 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.

A screen can be as simple as waiting room questionnaire or a quick, two-question screening tool, which can help identify high-risk individuals. 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).

Screening is most effective when:

  • A simple screening tool is used.
  • Questions are practiced ahead of time.
  • Suicide warning signs, risk factors, and protective factors are understood.
  • Clinicians are aware of their own attitudes about suicide.
  • Services are coordinated with other practitioners and family members.
  • Referral appointments are kept. (CSAT, 2015)

Importance of Secondary Suicide Risk Screening

In a multicenter study of 1,376 emergency department patients with recent suicide attempts or ideation, an intervention consisting of secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls resulted in a small but meaningful reduction (5%) in the proportion of patients subsequently attempting suicide over the 12-month observation period and a 30% decrease in the overall number of suicide attempts.

Source: Miller et al., 2017.

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).

Screening Tools

A number of screening and assessment tools have been validated for use in healthcare settings. The Patient Health Questionnaire 2 and 9 (screens for depression) are increasingly being used for suicide screening. Although not intended to be a comprehensive list, other examples of screening and assessments tools include the Columbia Suicide Screen, the EDSAFE Patient Safety Screener, the Suicide Behaviors Questionnaire, and the Beck Suicide Intention Scale.

Patient Health Questionnaire 2 (PHQ2)

The Patient Health Questionnaire 2 (PHQ2) is a validated screening tool used by many large hospital organizations to screen patients for suicide risk. This tool was originally designed to screen for depression. The PHQ2 asks a client to answer two questions and indicate—over the last 2 weeks—how often he or she has been bothered by either of the following problems:

  1. Little interest or pleasure in doing things
  2. 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. 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 Severity Rating Scale

Another commonly used, brief screening tool is the Columbia Suicide Screen. It is an 11-item measure, created by researchers at Columbia University and validated by the National Institute of Mental Health. It 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.

The Columbia-Suicide Severity Rating Scale (C-SSRS), supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs. Users of the tool ask people:

  • Whether and when they have thought about suicide (ideation)
  • What actions they have taken—and when—to prepare for suicide
  • Whether and when they attempted suicide or began a suicide attempt that was either interrupted by another person or stopped of their own volition (Columbia Lighthouse Project, 2016)

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:

  1. Over the last 2 weeks, have you felt down, depressed, or hopeless?
  2. Over the last 2 weeks, have you had thoughts of killing yourself?
  3. 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:

  1. Did the patient screen positive on the PSS items—active ideation with a past attempt?
  2. Has the individual begun a suicide plan?
  3. Has the individual recently had intent to act on his/her ideation?
  4. Has the patient ever had a psychiatric hospitalization?
  5. Does the patient have a pattern of excessive substance use?
  6. 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:

  1. Have you ever thought about or attempted to kill yourself?
  2. How often have you thought about killing yourself in the past?
  3. Have you ever told someone you were going to commit suicide, or that you might do it?
  4. How likely is it that you will attempt suicide someday?

Beck Suicide Intention Scale

The Beck Suicide Intention Scale (SIS) examines subjective and objective aspects of the suicide attempt, the circumstances at the time of the attempt, and the patient’s thoughts and feelings during the attempt. It is based on a clinical interview using an instrument with 15 items referring to the patient’s precautions and beliefs of the act. Each item is scored on a scale from 0 to 2, with a possible total score of 30 indicating the highest intention of suicide and a wish to die (Grimholt et al., 2017).

The SIS questionnaire covers precautions, planning, communication, and expectations regarding medication load, the degree of planning, and wish to die or live. It is divided into two sections: the first eight items constitute the “circumstances” section (part 1) and are concerned with the objective circumstances of the act of self-harm; the remaining seven items, the “self-report” section (part 2), are based on the patients’ own reconstruction of their feelings and thoughts at the time of the act (Grimholt et al., 2017).

When Harm Is Imminent

The potential for imminent self-harm exists when a person feels he is a burden, when there is no longer a sense of belonging, and when there is a history of self-injury. Imminent harm means a person is at immediate risk of self-harm or suicide.

The risk of imminent harm is elevated during the days and weeks following hospitalization for a suicide attempt, especially for people diagnosed with major depression, bipolar disorder, and schizophrenia. If a screen indicates that a patient is at immediate risk of self-harm be ready to talk, keep the person safe, and have referral information readily available. The overreaching goal is not to diagnose but to keep the patient safe until help arrives.

It is important to ask if a patient has recently engaged in self-injurious behaviors—deliberate acts done with the knowledge that they can or will result in some degree of physical or psychological injury. This includes direct and intentional self-injury that causes tissue damage, injury to oneself, or injury to health. It also includes suicide attempts (Xin et al., 2016).

The concern is that these behaviors can become chronic and evolve into other forms of self-harm, such as suicide attempts. Because non-suicidal, self-injurious behavior and suicidal behavior often occur together, it is important to consider the nature of the link between these two types of behavior (Grandclerc et al., 2016).

Assessing a Patient’s Safety

Safety is an important aspect of your initial screen. Safety means there is an absence of suicide risk, that patients are protected and have a sense of control over their lives (Berg et al., 2017).

To assess safety, begin with an open-ended question: “Has something happened recently that has affected your well-being?” The response might be: “My mother just died—I’m very depressed. All my family is gone now.” If there is no response or the response is delayed, ask a more direct question: “Now that your mother has died, what else in your life brings you joy?” Follow with a question of concern: “I wonder—have you ever thought of hurting yourself?” Asking about suicidal behavior does not plant a seed.

Develop a series of questions that help you determine the level of care needed for patient safety. Ask if patients has ever harmed theselves, as well as how many times and in what ways. Practice on a regular basis—otherwise, you’ll be tongue-tied when confronted with a potentially suicidal patient. To develop fluency, practice questions with co-workers, friends, or family members.

If attempts have accelerated and become more sophisticated, this should increase your concerns about safety. The more times a person attempts suicide, the more likely he or she is to complete the event.

Taking Lethality into Account

Lethality is related to the severity of physical consequences as well as the amount of medical intervention needed following an attempt (Kar et al., 2014). It focuses on the method being considered and the circumstances surrounding the attempt. Clients who have a clear intention of taking their life, who feel unsafe, or who have chosen a lethal method require higher levels of protection than those with less inclination toward dying.

There is often a mismatch between a patient’s intent and the lethality of the method chosen. Clients who genuinely want to die (and expect to die) may survive because the chosen method was not foolproof or because they were interrupted or rescued (CSAT, 2015).

Levels of Risk

The decision to refer a patient to a mental health professional or the ED depends on the patient’s presentation and level of risk. Patients with serious thoughts of suicide, a plan or intent to engage in self-directed violence, a recent suicide attempt, or those with prominent agitation, impulsivity, or psychosis, are at high acute risk.

A patient in acute suicidal crisis must be kept in a safe healthcare environment under one-to-one observation. Immediate access to care should be provided through an emergency department, inpatient psychiatric unit, respite center, or crisis unit. These clients (and their visitors) should be checked for items that might be used to make a suicide attempt or to harm others. They should be kept 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).

Patients with suicidal ideation and a plan but with no intent or preparatory behavior are considered to be at intermediate acute risk and an evaluation by a behavioral health specialist is recommended. If closer evaluation warrants a higher level of care, the patient may be hospitalized. If a patient feels capable of maintaining safety using non-injurious coping methods and a safety plan, the patient may be managed in outpatient care.

For patients 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).

Low acute risk patients, those with recent suicidal ideation who have no specific plans or intent to engage in self-directed violence and have no history of active suicidal behavior, can be referred to a behavioral health specialist to determine the need for treatment and to address symptoms and safety issues.

Patients that at some point in the past had reported thoughts about death or suicide, but currently don’t have any of these symptoms are generally not at an elevated risk for suicide. These individuals can be followed in routine care, continue to receive treatment for their disorder, and be re-evaluated periodically for thoughts and ideation.

If a client is thought to be 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).

Level of Risk and Appropriate Action in Primary Care

High Acute Risk
Indicators of suicide risk
  • Persistent suicidal ideation or thoughts
  • Strong intention to act or plan
  • Not able to control impulse or
  • Recent suicide attempt or preparatory behavior††
Contributing Factors†
  • Acute state of mental disorder or acute psychiatric symptoms
  • Acute precipitating event(s)
  • Inadequate protective factors
Initial action based on level of risk
  • Maintain direct observational control of the patient
  • Limit access to lethal means
  • Immediate transfer with escort to Urgent/ED care setting for hospitalization
Intermediate Acute Risk
Indicators of suicide risk
  • Current suicidal ideation or thoughts
    • No intention to act
    • Able to control the impulse
  • No recent suicide attempt or preparatory behavior or rehearsal of act
Contributing Factors†
  • Existence of warning signs or risk factors†† and
  • Limited protective factors
Initial action based on level of risk
  • Refer to Behavioral Health provider for complete evaluation and interventions
  • Contact Behavioral Health provider to determine acuity of referral
  • Limit access to lethal means
Low Acute Risk
Indicators of suicide risk
  • Recent suicidal ideation or thoughts
  • No intention to act or plan
  • Able to control the impulse
  • No planning or rehearsing a suicide act
  • No previous attempt
Contributing Factors†
  • Existence of protective factors and
  • Limited risk factors
Initial action based on level of risk
  • Consider consultation with Behavioral Health to determine:
    • Need for referral
    • Treatment
  • Treat presenting problems
  • Address safety issues
  • Document care and rationale for action

Modifiers that increase the level of risk for suicide of any defined level:
Acute state of substance use: Alcohol or substance abuse history is associated with impaired judgment and may increase the severity of the suicidality and risk for suicide act
Access to means: (firearms, medications) may increase the risk for suicide act
Existence of multiple risk factors or warning signs or lack of protective factors

††Evidence of suicidal behavior warning signs in the context of denial of ideation should call for concern (eg, contemplation of plan with denial of thoughts or ideation).

In some instances, an immediate response is required. Examples of immediate actions include: arranging transportation to a hospital ED for evaluation, asking a mental health specialist to evaluate a client further, or contacting a spouse to have a gun removed from the home. Examples of non-immediate, but important, actions include making a referral for a client to an outpatient mental health facility for evaluation, scheduling the client to see a psychiatrist for possible medication management, and ordering past mental health records from another provider.

Valeria Cuts Her Wrists (Again)

Joanna is a physical therapist working in a small rural outpatient rehab clinic in northern California. 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 had 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 Knowledge

What do you think stands out in Valeria’s description of her suicide attempts?

  1. She is very calm and articulate.
  2. She seems upset but not depressed.
  3. Her suicide attempts have become more sophisticated.
  4. She doesn’t seem to really want to harm herself.

Answer: C

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 Valeria: “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.

What should Joanna do?

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.

Valeria has no family living nearby and Joanna feels she is a danger to herself, so 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. Joanna follows up with a call the ED and learns that Valeria arrived safely at the hospital.

Understanding Intent

Screening for suicide can be very awkward and success depends upon your ability to ask difficult questions that help you understand a person’s intentions. Often people who intend to harm themselves are relieved to be able to share their feelings and get help.

Intentions guide a behavior or lead to an outcome. Intent is a measure of how hard a person is willing to try or the likelihood a person will perform or try to perform a particular behavior. Intention is an important underlying driver of behavior (Williams, 2016).

If a patient clearly intends to harm himself, refer him to someone who is licensed to decide about an involuntary hold. A person who agrees to be hospitalized must be placed in the least restrictive environment. However, depending on the level of risk, a patient can be held against his wishes. 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.

Understanding Stigma

There is a misconception—even among some healthcare providers—that people who harm themselves choose to suffer. This creates stigma regarding self-harm. General psychiatric admission for self-harming is of uncertain therapeutic value and suicidal individuals and may even be harmful for patients with borderline personality disorder, especially if admissions are lengthy and unstructured. Although often lacking, specialized services are essential—particularly in situations of unique vulnerability, such as suicidal crisis. When the risks of suicide and severe self-harm are acute, it is essential that services are offered in a compassionate manner that honors the human dignity of the person who is suffering (Liljedahl et al., 2017).

About Self-Harm—A Nurse Practitioner’s Perspective

Nonsuicidal self-injury often involves people with borderline personality disorders; self-harm is an antidote to psychological numbing. This doesn’t let providers off the hook in terms of assessing safety and lethality but this sort of situation requires a different kind of assessment.

A clinician must decide what direction the self-harm is heading—from superficial and visible self-harm to deeper and less visible self-injury. People with certain types of mental illness are more likely to be associated with escalating self-harm, with an ever-greater likelihood of a completed suicide.

Unintentional vs. Intentional Overdose

[Material from this section is from DVA/DOD, 2013.]

Intentional overdose is a common method of attempted suicide and the possibility that an overdose was intentional should always be considered. When a patient is forthcoming, differentiating between unintentional and intentional overdose is generally straightforward. However, even if it was, some patients insist an overdose was not intentional; also, determining a person’s intention is especially challenging in patients with a history of substance abuse.

There is limited data on the differentiation between unintentional overdose and suicidal behavior in substance abusers. Available data indicate that risk factors for suicide attempt (compared to unintentional overdose) include female gender, comorbid depression, interpersonal distress or disruption, and use of substances other than one’s drug of choice. Prior suicide attempts also increase the likelihood that a recent overdose event was intentional.

A recent loss of tolerance can be a risk factor for unintentional overdose, for example due to incarceration or detoxification. Individuals using recreational drugs with high potential for miscalculation (eg, intoxicants sold in head shops as “bath salts”) are more likely to experience unintentional overdose.

There are instances when intentionality is unclear or ambiguous even among substance abusers who are forthcoming. This can occur when an individual was experiencing suicidal ideation when she overdosed but appeared not to have intended to attempt suicide, or when a distressed person knowingly pushed the limits of dosage and stated “I don’t care if I live or die” but seemed to have no clear agenda for suicide.

Obtaining information from family members, treatment providers, and medical records can be invaluable in making the determination between intentional and unintentional overdose. Intoxicated or psychotic patients who are unknown to the clinician and who are suspected to be at acute risk for suicide should be transported securely to the nearest crisis center or ED for evaluation and management. These patients can be dangerous and impulsive; assistance in transfer from law enforcement may be needed.