Screening and Assessment
In a Zero Suicide approach, procedures to screen and assess individuals for suicide risk are standardized. When procedures are standardized, staff can use the same language to discuss an individual’s risk status and coordinate appropriate care. T are more thoroughly explored below and we include a list of commonly used screening and assessment tools.
In a Zero Suicide approach:
- All individuals are screened for suicide risk at 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 risk of suicide are identified.
- Clinicians conduct a thorough suicide risk assessment when an individual screens positive for suicide risk.1 All staff members use a standardized assessment tool and procedure to gather relevant information to fully assess an individual’s suicide risk and create a plan to address that risk.1
Collaboration and Empathy
Screening and assessing for suicide risk is more than just asking the right questions in the right order and documenting the answers. As one person with lived experience has stated, "Don’t treat it like a checklist on a clipboard."
When organizations develop a caring, confident, and competent workforce then staff members are comfortable talking with individuals about suicidal thoughts and behaviors. When staff have confidence in their ability to manage an individual’s suicide risk they can determine the least restrictive and supportive environment for the individual.
Training for staff should include:
- How to adopt a collaborative stance that reflects empathy, genuineness, and hope.
- How to express understanding of the individual’s ambivalence and that their desire to die is to relieve their intolerable pain.
- Engender confidence that there are alternatives to suicide and how to empower the individual in care to use the available services to help reduce their pain.
- How to treat the screening and assessment process as an exploration of what happened to the individual, not as a task to complete or an examination of what is wrong with the individual.
One barrier to consistent screening and assessing risk is mistaken beliefs about suicide and its causes. The Attitudes and Beliefs about Suicide activity can walk through how some of these beliefs might contribute to barriers to suicide risk screening.
Screening is about standardization. All staff use the same tool and process. The frequency of screening is formalized in a policy/procedure so it is clear to staff when and how to screen individuals in care. This policy does not need to be separate from the rest of the process related to individuals at risk of suicide, but the screening process should be detailed within it.
Screeners vary in the number of questions included. If a screener is used in a medical setting where a full assessment is often done by behavioral health staff (which requires time for a consult), sometimes a secondary screening is also used to determine what level of assessment may be needed.
What “screener” is used will be dependent on the organization, staff, and population needs. See below for a list of commonly used tools for screening and assessing suicide risk.
The SPRC resource Screening and Assessment for Suicide in Health Care Settings provides a comprehensive discussion of the subject, with sections on expert recommendations and how to choose a screening tool.
There are three aspects to fully assessing for suicide risk which provide a foundation for treatment planning:
- Gather complete information about present, recent and past suicidal ideation and behavior.
- Gather information about the individual’s current context, relevant risk factors, and history.
- Synthesize this information into a prevention-oriented suicide risk formulation anchored in the individual’s life context.2
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.
In inpatient behavioral health treatment, the assessment process will be unique to that setting. Even if the admission is not due to suicide risk, the admission process should include a suicide risk assessment. It is important to understand the individual’s history with suicidal thoughts and behaviors as well as other risk factors. Also, it is important that policies and procedures address the frequency of observation, when to rescreen and what prompts a full reassessment.
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. It recommends asking all individuals reporting suicidal ideation or with suspected suicide risk if they would like a mental health evaluation that includes a comprehensive suicide risk assessment (provided a mental health specialist is available to complete one in a timely manner).
The risk formulation tab further explores how to conceptualize an individual's context and history and synthesize a risk formulation based on multiple points of information.
The 988 Suicide and Crisis Lifeline Suicide Safety Policy, contains suggestions for "prompt questions" (see Appendix B) and other suggestions about eliciting information from individuals who may be at risk for suicide.
Billing Codes for Screening and Assessing
Screening and assessing for suicide takes time and healthcare providers are already struggling to fit everything they need to do into the allotted time. However, there are ways to bill for screening and assessing for suicide risk. 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. Also, some medical providers are able to use procedure codes for a 15-minutes screen for depression for Medicare patients.3
Tools to Screen and Assess
Different organizations and settings use different tools to screen and assess for suicide risk. Which tool is selected depends on who is screening and assessing, the setting (e.g., outpatient, inpatient, ED, primary care, etc.) and whether the organization provides comprehensive care or transitions the individual somewhere else for that care. Below are some of the common tools used to screen or assess for suicide risk.
Columbia Suicide Severity Rating Scale (C-SSRS)
The C-SSRS offers multiple versions for different settings and populations and has been translated into many languages. Some versions are used by organization as a screener and other, longer versions are used as part of an assessment. For example, the C-SSRS screen is a 6 question tool that is often used as a screening too. The C-SSRS Full Scale Lifetime/Recent also includes an exploration of current and lifetime suicidal thoughts (intensity and duration) as well as a thorough examination of the individual’s current and lifetime suicidal behaviors.
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.
Ask Suicide-Screening Questions (ASQ)
The ASQ screening tool was designed for medical settings (e.g., emergency department, inpatient medical/surgical units, outpatient clinics/primary care and specialty clinics) to identify youth at risk for suicide. It was designed to screen youth ages 10-24 but recommends using it for those 10 and younger who present with primary mental health concerns. The ASQ consists of four questions and the tool includes decision-making guidance after a positive result.
All ASQ resources are free and in multiple languages. NIMH has also developed ASQ for youth and adults to be used over telehealth.
ASQ Brief Suicide Safety Assessment Guide (BSSA)
The ASQ toolkit includes the BSSA which incorporates suggestions on what questions to ask, examples of how to respond to and ask questions, and what areas should be explored to develop a fuller understanding of an individual’s suicide risk. It also includes ways to safety plan and counsel about access to lethal means. The BSSA is intended to be used when an individual screens positive on the ASQ.
Patient Safety Screener-3 (PSS-3)
The (PSS-3) is a three item screening tool for use in acute care settings. It can be administered to all individuals in care, not only those presenting for psychiatric care. The three screening questions 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 department4 with individuals 18 and older, and has been implemented with individuals 12 and older in both emergency department and inpatient medical settings.
ED-Safe Secondary Screener (ESS-6)
The ESS-6 is a 6 question tool that is used after a positive screen on the PSS-3. It is intended to help providers determine if a psychiatric evaluation is needed or other safety precautions should be used while caring for the individual. This is intended to be used alongside clinical judgement to plan for an individual’s care.
Decision Support Tool
The Decision Support Tool was developed as an additional screening tool to be used by ED providers with adults. This would be used after an individual screens positive on a brief screening tool (like the PSS-3) and this tool helps providers determine if consultation with a mental health specialist is needed or what other interventions could be helpful.
Patient Health Questionnaire-9 (PHQ-9)
The PHQ-9 is often used to assess for depression and many organizations use question #9 on this tool as their suicide screening tool. This question 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?”5
Some organizations use a shorter version (PHQ-2) which contains two items asking about depression symptoms. If an individual answers 'yes' to either of the PHQ-2 questions, then the PHQ-9 is administered.
One concern about this approach is that an individual could answer 'no' to the PHQ-2 questions and still have suicidal thoughts or behaviors. In addition, the wording of item 9 is indirect and only asks about passive thoughts of wanting to die. It does not directly ask about suicidal thoughts and behaviors.
If an organization uses the PHQ-2, it should consider including a direction question about suicide. For example, a possible very brief screening for suicide risk might be:
Over the past two weeks, have you been bothered by:
- Little interest or pleasure in doing things?
- Feeling down, depressed, or hopeless?6
- Thoughts that you want to kill yourself, or have you attempted suicide?5
The SAFE-T is a thorough assessment of the nature and extent of an individual’s suicidal thoughts and behaviors and when used in conjunction with information from other sources is likely to yield the detailed information needed to develop a full picture of an individual’s suicide risk. The items in the SAFE-T 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 live.7
- 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.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-…
- 4.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
- 5. 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…
- 6.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
- 7.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