Screening for Suicide Risk
Standardized Procedures
In a Zero Suicide approach, procedures to screen 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. These are more thoroughly explored below and we include a list of commonly used screening 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.
Collaboration and Empathy
Screening 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 create a safe environment so the individual feels able to be transparent about their suicidal thoughts and behaviors.
Staff Barriers to Screening
One barrier to consistent screening risk is often about mistaken beliefs about suicide and its causes. The Overcoming Resistance to Zero Suicide activity below can walk through how some of these beliefs might contribute to barriers to suicide risk screening.
The Overcoming Resistance to Zero Suicide activity can help you think about ways to talk to staff about their barriers to implementing different aspects of Zero Suicide.
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 for 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.
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.
Screening Tools
Different organizations and settings use different tools to screen for suicide risk. Which tool is selected depends on who is screening, the setting (e.g., outpatient, inpatient, ED, primary care, etc.) and whether the person screening will follow up with an assessment, if applicable, or if the individual will be transferred to someone else for the assessment. Below are some of the common tools used to screen for suicide risk.
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.
The ASQ toolkit includes the Brief Suicide Safety Assessment Guide (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 as a secondary screener when an individual screens positive on the ASQ.
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.
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.
Computerized Adaptive Screen for Suicidal Youth (CASSY)
The CASSY is a cloud-based universal screening tool that has the capacity for large scale screening in settings such as pediatric hospitals and emergency departments. CASSY can be completed by the youth in typically under 2 minutes and is available in English and Spanish.
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 department1 with individuals 18 and older, and has been implemented with individuals 12 and older in both emergency department and inpatient medical settings.
The ED-Safe Secondary Screener-6 (ESS-6) is a 6 question tool that is a secondary screener 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.
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 (PHQ)
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?”2
PHQ-A
The PHQ-A was developed for use with adolescents. It measures severity of depression and includes a single question that asks about the presence of suicide ideation in the past month, and any previous suicide attempts.
- 1Boudreaux, 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
- 2Spitzer, 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…