Every new client or patient is screened for suicidal thoughts and behaviors when health and behavioral health care organizations are committed to safer suicide care.
The purpose of the screening is not to predict suicide but rather to plan effective suicide care. Once a screening shows 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 persons receiving care are screened for suicidal thoughts and behaviors at intake.
- Whenever a patient screens positive for suicide risk, a full risk formulation is completed for the client.
How will we screen for suicide risk in the people we serve? What standard format will we use to develop a risk formulation for those who screen to be at risk for suicide?
To Implement Zero Suicide
Screening for Suicide Risk
- Policies and procedures clearly describe screening patients for suicide risk, including:
- The frequency of screening
- Documenting risk screenings
- Screening and identification workflows
- How staff will be alerted when their patients screen positive for suicide risk
- A written policy and procedure specifies that patients are provided timely access to clinically trained staff after screening positive for suicide risk.
- A standardized screening measure is used by all staff.
- Staff receives formal training on suicide screening and documentation.
In inpatient treatment, in addition to the above:
- Patients 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.
Formulating a Risk Assessment
- A written policy and procedure states that a comprehensive suicide risk formulation is completed during the same visit whenever a patient screens positive for suicide risk.
- All staff use the same risk formulation model.
- The comprehensive risk formulation is conducted by a trained clinician.
- All clinical staff receive formal training on risk formulation and documentation.
- Information for risk formulation is taken from multiple sources, including treatment professionals, case workers, and people who are significant in the patient’s life.
- Risk formulation decisions are based on observations by multiple staff members.
- The risk formulation is reevaluated and documented in the patient’s record at every client visit.
In addition to the above, in inpatient settings:
- 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.
- Risk formulation is repeated at discharge, with articulated follow-up post-discharge referral and contact plan.
It’s important to supplement a suicide screening with additional information and a complete risk formulation to inform treatment planning. Click on the Risk Formulation tab above to see an example of a risk formulation model developed by suicide prevention researchers and practitioners.
Screening for and Assessing Suicide Risk
In a Zero Suicide organization, all patients 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 clients at suicide risk are identified.
The standard of care in suicide risk assessment requires that clinicians conduct thorough suicide risk assessments when patients 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 to the right demonstrates how these beliefs might produce resistance to screening and presents ideas for responding to and overcoming that resistance.
When standardized procedures are in place to assess patients for suicide risk, staff are able to use the same language, which is understood by all, to discuss a patient’s status and make plans for appropriate care.
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 the patient’s context and history
- Synthesize this information into a prevention-oriented suicide risk formulation anchored in the patient’s life context2
The purpose of assessment is not to predict which patient might take his or her own life but, rather, to do the best job we can to increase safety, reduce risk, and promote wellness and recovery.
The following sections address the gathering of information about suicidal ideation and behavior. You’ll find more information about gathering information on the patient’s context and history and synthesizing a risk formulation at the tab Risk Formulation.
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 a patient is found to be at risk.
For example, once patients 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:
- Little interest or pleasure in doing things?
- Feeling down, depressed, or hopeless?4
- 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.
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
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 and a training module is available to the right.
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.
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.8
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_Engli...
- 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-Q...
- 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. 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.
- 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/10.1037/1076-8922.214.171.1247
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 plan these next actions:
Quick Guide to Getting Started with Zero Suicide. This one-page tool lists ten basic actions to take to implement a Zero Suicide initiative. Use this tool to get an overall vision of the path you will take to adopt this comprehensive suicide care approach.
Zero Suicide Organizational Self-Study. 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 on the Lead section of the Zero Suicide online toolkit, it’s provided again here for your convenience.
Zero Suicide Work Plan Template. 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.
Screen and assess every new and existing patient for suicidal thoughts and behaviors in an ongoing and systematic way using standardized tools.1
Overview: Finding Those At Risk
An estimated 9.3 million adults (3.9 percent of the total U.S. population) reported having suicidal thoughts in the past year. Approximately 2.7 million people (1.1 percent) reported making a plan about how they would attempt suicide.2 An estimated 4.6 percent of the overall U.S. population reported a lifetime suicide attempt.3
We know that these individuals at risk for suicidal behaviors are seen in health care settings for a wide variety of concerns. Of people who die by suicide, 77 percent of individuals had contact with their primary care provider in the year before death.4 45 percent of individuals had contact with their primary care provider in the month before death. A meta-analysis concluded that screening lowers suicide rates in adults.5
As the Joint Commission notes in its 2016 alert,1 failure to assess suicide risk was the most common root cause of suicides qualifying as sentinel events. Screening for suicide risk should be included in health and mental health care visits. The known risk factors that should trigger screening for suicide include mental health or substance use diagnoses, psychosocial trauma or conflict, recent loss (e.g., of a job or the death of a family member), family history of suicide, and personal history of suicide attempts.1
Recommendation: Systematic Screening & Assessment
Evidence-based screening and assessment tools should be incorporated into clinical practice as the use of such tools coupled with clinical judgment has been found to be more accurate than clinician judgment alone.1 Screening can improve identification and treatment of mental health and suicide risk.1,6,7 Comprehensive screening occurs in multiple settings: primary care, urgent care, specialty clinics, mental health, crisis care, and other settings where individuals at risk are seen. These screenings should occur with every patient, including existing patients, especially when risk factors or life events determine screening is appropriate. Whenever a patient screens positive for suicide risk, a full risk assessment, including risk formulation, should be completed for the patient.
It is important to develop policies and procedures for screening and assessing patients and to train staff on evidence-based screening, assessment, and documentation tools, policies, and procedures. Simon, et al. examined the relationship between elevated responses to question 9 of the Patient Health Questionnaire-9 (PHQ-9) screening questionnaire and suicide deaths.6 They found a tenfold increase in suicide within the following year for patients reporting frequent thoughts of self-harm, suggesting that routine screening does detect suicidal individuals who should then be engaged for ongoing treatment and care.6
Use of an assessment such as the Columbia-Suicide Severity Rating Scale (C-SSRS) can help reduce the burden on the provider, encourage and streamline follow-up, and improve documentation of risk. The tool can be useful in increasing the quality of information gathered from the patient, encouraging self-disclosure, while also improving care delivery, treatment planning, and outcomes.7 Systematic use of the C-SSRS has been shown to decrease burden and false positives while improving detection.8 The C-SSRS has been used in the U. S. Marine Corps and the U. S. Army with other suicide prevention strategies and has been associated with a decrease in suicidal ideation and behaviors.9
Further, the research shows that prediction leads to prevention:
“It [the C-SSRS] was able to show, for the first time, that behaviors beyond previous suicide attempts–such as self-injury or making preparations for an attempt–may be used as predictors of subsequent suicide attempts. … It also was able to determine clinically meaningful points at which a person may be at risk for an impending attempt, something that other scales have been unable to consistently determine.”
— NIMH Science Update, Nov. 28, 2011
In the Zero Suicide model, the Zero Suicide elements are interrelated. It is key to conduct a risk assessment using risk formulation, develop a collaborative safety plan, and use evidence-based treatments in the least restrictive setting.
Conclusion: Take Steps Toward Efficient & Effective Identification
Systematic screening, identification, and assessment of suicide risk among people receiving care dramatically increases the efficiency and effectiveness of interventions. Developing policies and procedures around identification of risk that leverage evidence-based tools is a crucial step toward safer suicide care.
- 1. a. b. c. d. e. The Joint Commission. (2016). Sentinel Event Alert, Issue 56: Detecting and treating suicide ideation in all settings. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf
- 2. National Center for Injury Prevention and Control. (2015). Suicide: Facts at a Glance. Retrieved from https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
- 3. Kessler, R.C., Borges, G., & Walters, E.E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56, 617–626.
- 4. Abed-Faghri, N., Boisvert, C.M., & Faghri, S. (2010). Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): Enhancing the assessment and treatment of psychiatric conditions. Mental Health in Family Medicine, 7(1), 17-25.
- 5. Mann, J.J., Apter, A., Bertolote, J., Beautrais, et al. (2005). Suicide prevention strategies: a systematic review. JAMA, 294(16), 2064-2074. Retrieved from http://www.daveneefoundation.org/wp-content/uploads/Suicide-Prevention-S...
- 6. a. b. c. Simon, G.E., Rutter, C.M., Peterson, D., Oliver, M., Whiteside, U., Operskalski, B., & Ludman, E.J. (2013). Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death? Psychiatric services, 64(12), 1195-1202. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24036589
- 7. a. b. Mundt, J.C., Greist, J.H., Jefferson, J.W., Federico, M., Mann, J.J., & Posner, K. (2013). Prediction of suicidal behavior in clinical research by lifetime suicidal ideation and behavior ascertained by the electronic Columbia-Suicide Severity Rating Scale. The Journal of Clinical Psychiatry, 74(9), 887-893. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24107762
- 8. Viguera, A. C., Milano, N., Laurel, R., Thompson, N. R., Griffith, S. D., Baldessarini, R. J., & Katzan, I. L. (2015). Comparison of electronic screening for suicidal risk with the Patient Health Questionnaire Item 9 and the Columbia Suicide Severity Rating Scale in an outpatient psychiatric clinic. Psychosomatics, 56(5), 460-469. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26278339
- 9. Posner, K. (2016). Evidence-based assessment to improve assessment of suicide risk, ideation, and behavior. Journal of the American Academy of Child & Adolescent Psychiatry, 55(10), S95. Retrieved from http://www.jaacap.com/article/S0890-8567(16)30400-2/fulltext