Toolkit: Identify

Identification

When health and behavioral health care organizations are committed to safer suicide care every new individual to an organization is screened for suicidal thoughts and behaviors.

The purpose of the screening is not to predict suicide but rather to plan effective suicide care. Once a screening indicates some risk for suicide, further information is gathered with the aim of producing a “risk formulation” based on the patient's specific context.1

In a Zero Suicide approach:

• All individuals in care are screened for suicidal thoughts and behaviors at intake and at every subsequent encounter.
• A full assessment of suicide risk is completed at intake to gather information about past suicide thoughts and behaviors and other risk factors.
• Whenever an individual screens positive for suicide risk, an assessment and full risk formulation are completed.

The purpose of the screening is not to predict suicide but rather to plan effective suicide care.

Implementing Suicide Risk Screening

Policies and procedures clearly describe:

• What standard screening tool is used
• Timing and frequency of screening (e.g., at the initial appointment and every appointment thereafter)
• How is the screening provided (e.g., in person, on paper, online/through an app)
• What is a positive screen
• Who reviews the results and determines if further assessment is needed
• How are individuals further assessed (timing, role of assessor)
• How frequently an individual who screens negative is rescreened
• How is screening documented
• How often staff are trained on suicide screening and documentation
• How fidelity is assessed

In inpatient treatment, in addition to the above:

• When individuals are screened during their inpatient stay (i.e., when there is a change in affect or presentation)
• When Individuals are screened prior to discharge

For more discussion about the use of standardized screening tools and information about specific tools, go to the Screening Options tab above.

Implementing Suicide Risk Assessments

Policies and procedures clearly describe:

• What standard assessment tool(s) are used
• Timing and frequency of assessment (e.g., at initial appointment and when there is a positive screen)
• The transition from screening to assessing (i.e., who does what, when, how)
• Who completes the assessment
• How the assessment is documented
• How the assessment tool(s) used connect with the risk formulation
• How often clinical staff are trained on suicide assessment and documentation
• How fidelity is assessed

For more discussion about the use of assessment tools and information about specific tools, go to the Screening Options tab above.

Implementing Risk Formulation

Policies and procedures clearly describe:

• Timing of initial risk formulation completion (e.g., during the same visit when an individual screens positive)
• Frequency of re-evaluation of risk formulation
• What standard risk formulation model is used
• Who completes the risk formulation (e.g., trained/licensed clinician)
• How clinical staff are trained on risk formulation and documentation (i.e., initial training and refresher trainings)
• What information is used in risk formulation (i.e., multiple sources, including treatment professionals, caseworkers, and people who are significant in the individual's life)
• How the risk formulation guides treatment decisions
• How the risk formulation is communicated to individuals in care and other appropriate people (e.g., family, support persons).

In inpatient settings, in addition to the above, risk formulation and reassessment are based on multiple, continuous observations, supported by:

• Timely psychiatric consult
• Family member input
• Means-restricted environment
• Up to line-of-sight supervision (or other environmental safety precautions)
• Timely clinical team consultation when increased risk may be present
• Reassessment at discharge and completion of a follow-up post-discharge referral and contact plan
• Multiple observations of reduced risk are required to formally reduce risk status

Click on the Risk Formulation tab above to see an example of a risk formulation model developed by suicide prevention researchers and practitioners.

• 1.Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2016). Reformulating suicide risk formulation: From prediction to prevention. Academic Psychiatry 40(4), 623–629. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26667005

Screening and Assessing for Suicide Risk

In a Zero Suicide organization, all individuals are screened for suicide risk on their first contact with the organization and at every subsequent contact. All staff members use the same tool and procedures to ensure that individuals at suicide risk are identified. 

The standard of care in suicide risk assessment requires that clinicians conduct  thorough suicide risk assessments when individuals screen positive for suicide risk and then make reasonable formulations of risk.1

One barrier to ensuring that staff are consistently screening and assessing risk is mistaken beliefs about suicide and its causes. The activity Attitudes and Beliefs about Suicide on the bottom of this page demonstrates how these beliefs might contribute to barriers to screening.

When standardized procedures are in place to assess individuals for suicide risk, staff are able to use the same language, which is understood by all, to discuss an individual's risk status and make plans for appropriate care. 

Full Assessment

There are three aspects of creating a full assessment of suicide risk and providing a foundation for treatment planning:

• Gather complete information about past, recent, and present suicidal ideation and behavior
• Gather information about context and history
• Synthesize this information into a prevention-oriented suicide risk formulation anchored in the individual’s life context2

The purpose of assessment is not to predict which person might take their own life but, rather, to do the best job we can to increase safety, reduce risk, and promote wellness and recovery.

The assessment tab addresses the gathering of information about suicidal ideation and behavior. The risk formulation tab includes information on how to conceptualize an individual's context and history and and synthesize a risk formulation based on multiple points of information.

Gather Information about Suicidal Thoughts and Behaviors

Different kinds of organizations and settings may use different tools, based in part on whether the organization itself will provide the comprehensive care after an individual s found to be at risk. 

PHQ

For example, once individuals are found to be at risk for suicide in a primary care setting, they would often be referred for behavioral health care. In this case, a brief, basic screening tool such as a Patient Health Questionnaire (PHQ) may be used to identify at-risk patients.

The PHQ-9 is used extensively in primary care. The PHQ-9 contains nine items, and item 9 asks, “Over the past two weeks, have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way.”3

Many primary care practices use a shorter version called the PHQ-2, which contains two items asking about depression symptoms. If a patient answers 'yes' to either of the PHQ-2 questions, then the PHQ-9 is administered. 

One concern about this approach is that a patient could answer 'no' to the PHQ-2 questions and still be having suicidal thoughts. In addition, the wording of item 9 is somewhat indirect—it does not directly ask about suicidal thoughts and behaviors. 

Organizations should consider adding a more direct question about suicide to the PHQ-2 and substituting that same question for question 9 in the PHQ-9 if the PHQ-9 is the only screen used. For example, a possible very brief screening for suicide risk might be:

Over the past two weeks, have you been bothered by: 

1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?4
3. Thoughts that you want to kill yourself, or have you attempted suicide?3

Medical providers may be able to use procedure codes for screening and assessment. For example, medical providers are able to use procedure codes for a 15-minutes screen for depression for Medicare patients.5

The SAMHSA-HRSA Center for Integrated Health Solutions offers a set of state billing and financial worksheets to help clinic managers, integrated care project directors, and billing/coding staff at community mental health centers and community health centers identify the available current procedural terminology codes they can use in their state to bill for services related to integrated primary and behavioral health care. The worksheets can be found in the Tools below.

You can find more information about the PHQ-9 at the Readings and Tools links at the bottom of this page.
 
Once it is established that a patient is having suicidal thoughts or has attempted suicide, a complete assessment of suicidal thinking and behavior, including the nature and extent of the risk, should be done immediately. 

SAFE-T

It may make sense in a different setting, such as outpatient behavioral health care clinic, to use the SAFE-T or another tool that offers a thorough assessment of the nature and extent of suicidal thoughts and behaviors. 

The more extensive items contained in the SAFE-T interview are likely to yield the detailed information needed to develop a full picture of a patient’s suicide risk. The items explore:

• Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever
• Plan: timing, location, lethality, availability, preparatory acts
• Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self-injurious actions
• Intent: extent to which the patient, one, expects to carry out the plan and, two, believes the plan/act to be lethal vs. self-injurious. Explore ambivalence: reasons to die vs. reasons to live6

C-SSRS

The Columbia-Suicide Severity Rating Scale (C-SSRS) is another tool that can be used in many settings, including medical, inpatient, and outpatient behavioral health. The C-SSRS looks at identified suicide attempts and also assesses the full range of evidence-based ideation and behavior. It can be used in initial screenings or as part of a full assessment.7  More information about the C-SSRS is in Tools and Readings at the bottom of this page.

Free Training

There is a free, online course from the New York State Office of Mental Health and Columbia University that provides an overview of the C-SSRS instrument and teaches how and when to administer it in real world settings:

Assessment of Suicidal Risk Using the Columbia Suicide Severity Rating Scale

ASQ

The Ask Suicide-Screening Questions (ASQ) screening tool is a free resource for medical settings (emergency department, inpatient medical/surgical units, outpatient clinics/primary care) that can help nurses or physicians successfully identify youth at risk for suicide. The ASQ is a set of four screening questions that takes 20 seconds to administer and was validated for use in emergency departments with pediatric populations.8  The Ask Suicide-Screening Questions (ASQ) toolkit is designed for screening youth ages 10-24 (for patients with mental health chief complaints, consider screening below age 10); the toolkit also includes resources and tools for use in assessment and decision-making, as well for use in various settings and with additional patient populations. All ASQ resources are available free of charge and in multiple languages. In response to the increased need for telehealth tools, NIMH has also developed ASQ youth and adult telehealth screening pathways.

PSS-3

The Patient Safety Screener (PSS-3) is a three item screening tool for use in acute care settings to assist providers in screening for suicide risk. It can be administered to all patients, not only those presenting for psychiatric care. The three screening questions included in the PSS-3 pertain to depression, active suicidal ideation within the past two weeks, and lifetime suicide attempt. The tool has been validated for use in the emergency department9  with patients 18 and older, and has been implemented with patients 12 and older in both emergency department and inpatient medical settings.  Additionally, the PSS-3 is has been utilized by healthcare organizations implementing universal screening.10

Inpatient

In inpatient behavioral health treatment, the assessment process will also be unique to that setting. Even if the admission is due to suicide risk, the admission process should include a suicide risk assessment. Policies should specify not only when to physically check on a patient but also when to complete a full reassessment. Inpatient organizations may use the C-SSRS or SAFE-T questions to guide these assessments. 

Emergency Departments

The SPRC report Caring for Adult Patients with Suicide Risk: A Consensus-Based Guide for Emergency Departments provides comprehensive guidelines for screening and assessment in emergency departments (ED) and offers a quick guide tool for screening and assessment. One of the report’s recommendations is that where consultation by a mental health professional is readily available, ED settings should consider asking all patients who have suicidal ideation or suspected suicide risk if they would like to have a mental health evaluation that includes a comprehensive suicide risk assessment.11

How to Choose a Screening Tool

Whatever screening tool is used, it should be given to all patients, either before they come in for a first appointment or at that first appointment. The SPRC resource Screening and Assessment for Suicide in Health Care Settings, available in Readings, provides a comprehensive discussion of the subject, with sections on expert recommendations and how to choose a screening tool.  

The Patient in the Information-Gathering Process

Health and behavioral health organizations implementing screening and assessment should attend to more than just what tool or set of questions is used. The staff person conducting the patient interview should:

• Adopt a collaborative stance, reflecting empathy and genuineness
• Express an understanding of the ambivalence in the patient’s desire to die to relieve intolerable pain 
• Engender confidence that there’s an alternative to alleviating that pain and that the patient can be empowered to use care and services to do so
• Treat the interview as an exploration of what has happened to the patient, not as a task to complete or an examination of what's wrong with the patient. As one person with lived experience has stated,  "Don’t treat it like a checklist on a clipboard."

The National Suicide Prevention Lifeline Suicide Risk Assessment Standards, available in Tools, contains suggestions for "prompt questions" and other advice about how to elicit information from people who may be at risk for suicide.

• 1.The Joint Commission. (2016). Detecting and treating suicide ideation in all settings. Sentinel Event Alert, (56). Retrieved from http://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf
• 2.Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2016). Reformulating suicide risk formulation: From prediction to prevention. Academic Psychiatry 40(4), 623–629. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26667005
• 3. a b Spitzer, R. L., Williams, J. B. W., Kroenke, K., et al. (2001) Patient health questionnaire-9 (PHQ-9). Retrieved from http://www.phqscreeners.com/sites/g/files/g10016261/f/201412/PHQ-9_Engl…
• 4.Kroenke K., Spitzer R. L., & Williams J. B. (2003). The patient health questionnaire-2: Validity of a two-item depression screener. Medical Care, 41(11), 1284–1292. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/14583691
• 5.U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2016). Medicare preventive services. Retrieved from https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-…
• 6.Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2009). SAFE-T (HHS Publication No. [SMA] 09-4432). Retrieved from http://store.samhsa.gov/shin/content//SMA09-4432/SMA09-4432.pdf
• 7.Research Foundation for Mental Hygiene, Columbia Lighthouse Project. (2008). Columbia suicide severity rating scale. Retrieved from http://cssrs.columbia.edu/
• 8.Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., ... & Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of pediatrics & adolescent medicine, 166(12), 1170-1176. Retrieved from https://jamanetwork.com/journals/jamapediatrics/fullarticle/1363508
• 9.Boudreaux, E. D., Jaques, M. L., Brady, K. M., Matson, A., & Allen, M. H. (2015). The Patient Safety Screener: Validation of a Brief Suicide Risk Screener for Emergency Department Settings. Archives of Suicide Research, 19(2), 151–160. doi: 10.1080/13811118.2015.1034604
• 10.Boudreaux, E. D., Camargo, C. A., Arias, S. A., Sullivan, A. F., Allen, M. H., Goldstein, A. B., … Miller, I. W. (2016). Improving Suicide Risk Screening and Detection in the Emergency Department. American Journal of Preventive Medicine, 50(4), 445–453. doi: 10.1016/j.amepre.2015.09.029
• 11.Suicide Prevention Resource Center. (2015). Caring for adult patients with suicide risk: A consensus guide for emergency departments. Waltham, MA: Education Development Center. Retrieved from http://www.sprc.org/sites/default/files/EDGuide_full.pdf

Forming a Clinical Judgment of Risk

Clinicians are often faced with having to make judgment calls about suicide risk with insufficient or contradictory information. Information obtained in a suicide screen is just one part of what is needed to fully assess risk and develop the best care plans to engage clients. Establishing a collaborative and shared perspective is essential to obtaining a comprehensive understanding of the client’s suffering and strengths.

One prevalent method of assessment attempts to put people into predictive categories such as a low, medium, or high risk. Despite many efforts to define these terms, definitions were usually difficult to apply, and the terms lack predictive validity, cross-clinician consistency, and clinical utility in treatment planning.1

The high-medium-low model of formulating risk also was not anchored in a context. One could ask, “high compared to what?” or “low compared to when?” In newer, contextual risk formulation methods, the primary purpose is planning rather than prediction of suicide.1

The model pictured below draws from prevention research and advances in violence assessment.2  While the figure from Assessing and Managing Suicide Risk (AMSR) shows just one way of organizing a risk formulation, the goal is to develop a personalized plan for each individual that is anchored in the clinical or community setting and in the individual’s own history over time. The clinical judgment about risk, combined with the entire formulation, can help with decision-making about what intervention or treatment setting the person needs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The column at the left in the diagram shows the key information needed to support a risk formulation.

Risk status, risk state, coping resources, and potential triggers comprise the “risk formulation” in this model.

A well-documented risk formulation can demonstrate that clinical decisions were sound and aid in communication with the client, other clinical staff, and important people in the client’s life. Clear documentation also helps to show the rationale behind your formulation, discussions with the client about your risk formulation, and treatment decisions. As new information becomes available and circumstances change, the assessment of risk also should be reconsidered and possibly modified. Clear documentation of risk and the rationale for treatment recommendations will provide a better defense against legal challenges than poor or incomplete documentation.

This interactive is best experienced on desktop browsers and may not work on all mobile devices.

• 1. a b Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2016). Reformulating suicide risk formulation: From prediction to prevention. Academic Psychiatry 40(4), 623–629. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26667005
• 2.Douglas, K. S., & Skeem, J. L. (2005) Violence risk assessment: Getting specific about being dynamic. Psychology, Public Policy, and Law, 11(3), 347–383. Retrieved from http://dx.doi.org/10.1037/1076-8971.11.3.347

Identify and Assess Patients at Risk

The basic next steps to identify patients at risk are to:

• Review and develop processes and policies for screening, assessment, and risk formulation.
• Establish use of the EHR or paper record to monitor patients at risk for suicide.

At the same time, examine the use of electronic and/or paper health records to support these processes.

There are several additional items to help you with implementation.

This one-page tool lists ten actions you can take at the start of implementation of Zero Suicide.

• Getting Started with Zero Suicide

This tool lists several actions you can take if you have been implementing Zero Suicide for a while and are not sure what to do next or need help taking your Zero Suicide work a little further.

• Getting Further with Zero Suicide

Every organization should complete the self-study as one of the first steps in adopting a Zero Suicide approach. While the self-study is available in the Lead section of the Zero Suicide online toolkit, it’s provided again here for your convenience.

• Zero Suicide Organizational Self-Study

This form contains an expanded list of action steps to guide your implementation team in creating a full work plan to improve care and service delivery in each of the seven core Zero Suicide components.

• Zero Suicide Work Plan Template