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Screening for and Addressing Suicide Risk in Clinical Settings

Routine screening is a key component for identifying and providing appropriate care for individuals at risk of suicide. Screening can be conducted in a variety of settings by trained individuals. In rural communities, settings for screening may include mental health and primary care clinics, substance use disorder treatment clinics, emergency departments, schools, or community-based settings like a Boys and Girls Club, YMCA, or an American Legion. Whether screening is done initially, at every visit, for everyone, or only specific individuals depends on the setting and the expected level of risk among the individuals within that setting.

It is important to select an appropriate screening tool for accurate identification and provision of suicide intervention and treatment services. Many screening tools exist and some are specific to particular populations or settings. Examples of common screening tools for suicide risk:

  • The Patient Health Questionnaire (PHQ-9) is the most widely used screening tool for depression; the last question of the PHQ-9 addresses passive suicidal ideation. The PHQ-9 is often used in primary care settings where fewer patients will screen positive for suicide risk among the total clinic population. If a patient endorses passive ideation on the PHQ-9, it is important to administer a more detailed suicide risk screen.
  • The Columbia-Suicide Severity Rating Scale (C-SSRS) is a standardized suicide risk screening tool validated for use with children, adolescents, and adults. It assesses for both passive and active suicidal ideation, method, plan, intent to act on the plan, and suicidal behavior. This detailed information helps the individual administering the screen to better understand the level of risk and how to provide the best, most appropriate care in the least restrictive environment. Training on how to administer the C-SSRS is available online free-of-charge.
  • The Ask Suicide Screening Questions (ASQ) Toolkit, developed by the National Institute of Mental Health (NIMH), is a standardized suicide risk screening tool validated for use with medical patients ages 8 and older. It includes four yes/no screening questions, takes 20 seconds to administer, and comes with a toolkit with safety guides, worksheets, scripts, flyers, and pathways. Quick and easy to use, it is ideal for busy medical practices.

If an individual screens positive for suicide risk, a trained provider should intervene and develop an individualized safety plan for the patient. In the event of a suicidal crisis, the at-risk individual follows the six sequential steps of their individualized safety plan:

  1. Recognize warning signs
  2. Utilize internal coping strategies
  3. Reach out to social contacts who may distract them from the crisis
  4. Reach out to family members or friends who may offer help
  5. Connect with professionals and agencies for help
  6. Make the environment safe

Training on how to conduct a safety planning intervention is available online free-of-charge.

It is essential that providers follow up with patients identified as being at risk of suicide. Follow-up efforts may include: visits, structured follow-up phone calls, updating safety plans, and connecting via caring contact postcards, letters, emails, or texts. These follow up efforts contribute to ensuring patients are engaged and feel cared for. In addition, providers can refer patients to mental health providers for suicide-specific treatments when necessary. Examples of these treatments include Dialectical Behavioral Therapy (DBT), Cognitive Therapy for Suicide Prevention, or Collaborative Assessment and Management of Suicide Risk (CAMS). Patients should receive education on warning signs as well as talk and text line resources regardless of screening or assessment result.

Implementation Considerations

Rural primary care providers may lack adequate training, capacity, or resources to implement available screening tools or provide appropriate care or referral based on the results. However, it is relatively common for individuals to be in contact with their primary care provider in the weeks leading up to a suicide. This makes it especially important for providers to be well-trained in identifying and addressing suicidal ideation.

Providers may also be reluctant to use screening tools or intervene with risk for fear of a poor outcome, liability, and if there is confusion about how to document the screening or bill for it. Thus, efforts centered on offering educational tools and resources for providers to treat patients at risk of suicide may increase the use of suicide risk screenings in primary care. It is also important to involve rural mental health providers in these services when available and appropriate. Integrated care settings, which combine mental health and primary care under one roof, are one useful avenue for doing so.

Community health workers (CHWs) can also play an integral part in screening for depression and suicide risk. They can assist with screening and assessment, follow up with patients discharged after a suicide attempt, and act as a bridge between hospitals, communities, law enforcement, and schools. With CHWs or other community gatekeepers, screening can also reach beyond the clinical setting to meet individuals within their communities, reducing common barriers for accessing care including long travel distances, lack of transportation, and stigma associated with mental health treatment.

Program Clearinghouse Examples

Resources to Learn More

NowMattersNow Caring Contacts
Document
Provides templates and examples of caring contact messages that can be used to communicate with individuals in need of support.
Organization(s): NowMattersNow
Date: 2018

SAFE-T Pocket Card: Suicide Assessment Five-Step Evaluation and Triage for Clinicians
Document
Outlines a five-step evaluation and triage process for clinicians to use when conducting a suicide assessment.
Organization(s): Substance Abuse and Mental Health Services Administration
Date: 9/2009

Suicide Prevention Toolkit for Primary Care Practices
Website
Provides information, tools, and resources to help primary care providers implement a suicide prevention practice. Topics covered include educating clinicians and staff, developing partnerships with mental health professionals, incorporating patient management interventions, and optimizing strategies for reimbursement for mental health services.
Organization(s): Suicide Prevention Resource Center (SPRC), Western Interstate Commission for Higher Education Mental Health Program (WICHE)