Universal Suicide Risk Screening Research Articles

Suicide Risk Screening in Pediatric Outpatient Neurodevelopmental Disabilities Clinics.

The purpose of this study was to describe the implementation of universal suicide risk screening in pediatric neurodevelopmental disabilities (NDD) medical clinics, analyze demographic and clinical characteristics of eligible patients, describe outcomes of positive screenings, and describe factors that influenced participation in screenings. A suicide risk screening protocol was developed and implemented for medical clinic patients aged 8 to 18 years. Registered nurses screened patients using the "Ask Suicide-Screening Questions" tool during triage. Positive screenings were referred for further assessment and mental health management. Demographics and clinical data were extracted from medical records using retrospective chart reviews. During the 6-month study period, 2961 individual patients presented for 5260 screening eligible patient visits. In total, 3854 (73.3%) screenings were completed with 261 (6.8%) positive screenings noted. Screenings were declined in 1406 (26.7%) visits. Parents of children with cognitive impairments were more likely to decline screening. Clinics serving children with autism spectrum disorder had higher rates of positive screenings compared with all other clinic attendees. Seventy-two of 187 children (38.5%) with positive screenings were identified and referred to outpatient mental health referrals. Seven (2.5%) of these children required acute psychiatric treatment. Routine screening, identification of increased suicide risk, and referral to mental health care among children with NDD are feasible. It remains unclear whether variation in rates among youth with and without NDD may indicate true differences in suicide risk or cognitive impairments or reflect psychiatric comorbidities. High rates of declined participation may have influenced identification of children with NDD and suicide risk. Preliminary findings identified groups of children with NDD at heightened risk for suicidal ideation and behavior. Further research is needed to assess the validity of suicide risk screening tools in children with neurodevelopmental disorders.

Barriers to Universal Suicide Risk Screening for Youth in the Emergency Department.

Given the increasing rates of youth suicide, it is important to understand the barriers to suicide screening in emergency departments. This review describes the current literature, identifies gaps in existing research, and suggests recommendations for future research. A search of PubMed, MEDLINE, CINAHL, PsycInfo, and Web of Science was conducted. Data extraction included study/sample characteristics and barrier information categorized based on the Exploration, Preparation, Implementation, Sustainment model. All studies focused on inner context barriers of implementation and usually examined individuals' attitudes toward screening. No study looked at administrative, policy, or financing issues. The lack of prospective, systematic studies on barriers and the focus on individual adopter attitudes reveal a significant gap in understanding the challenges to implementation of universal youth suicide risk screening in emergency departments.

Youth suicide risk screening in an outpatient child abuse clinic.

Child abuse is an important independent risk factor for suicide. The purpose of the project was to evaluate the implementation of a universal suicide risk screening and assessment tool in an outpatient child abuse evaluation clinic. Participants consisted of all patients between the ages of 10 and 18 years who received services at the study site within a 3-month period (n = 162). The study site implemented a tool created for the sole purpose of detecting suicide risk, the Ask Suicide-Screening Questions (ASQ) tool. Data was retrospectively collected using electronic health records; rates of compliance with screening and screen positive rates were calculated. Suicide risk screening with the ASQ was conducted on 90.7% (147) of the patients. Forty-three (29.2%) patients screened positive for suicide risk. This is a significant increase in detection rates compared to baseline preimplementation data. Of the 67 preteens, 10-12 years of age, that were screened, 14.9% (10/67) screened positive for suicide risk, making up 23% of the positive screens. Implementing a universal suicide risk screening tool was a successful strategy for detecting suicide risk. A quarter of the youth who screened positive on the ASQ were preteens, highlighting the importance of screening the 10- to 12-year olds for suicide risk.

Universal Suicide Risk Screening for Youths in the Emergency Department: A Systematic Review.

To address escalating youth suicide rates, universal suicide risk screening has been recommended in pediatric care settings. The emergency department (ED) is a particularly important setting for screening. However, EDs often fail to identify and treat mental health symptoms among youths, and data on implementation of suicide risk screening in EDs are limited. A systematic review was conducted to describe the current literature on universal suicide risk screening in EDs, identify important gaps in available studies, and develop recommendations for strategies to improve youth screening efforts. A systematic literature search of PubMed, MEDLINE, CINAHL, PsycINFO, and Web of Science was conducted. Studies focused on universal suicide risk screening of youths served in U.S. EDs that presented screening results were coded, analyzed, and evaluated for reporting quality. Eleven studies were included. All screening efforts occurred in teaching or children's hospitals, and research staff administered suicide screens in eight studies. Thus scant information was available on universal screening in pediatric community ED settings. Large variation was noted across studies in participation rates (17%-86%) and in positive screen rates (4.1%-50.8%), although positive screen rates were influenced by type of presenting concern (psychiatric versus nonpsychiatric). Only three studies concurrently examined barriers to screening, providing little direction for effective implementation. STROBE guidelines were used to rate reporting quality, which ranged from 51.9% to 87.1%, with three studies having ratings over 80%. Research is needed to better inform practice guidelines and clinical pathways and to establish sustainable screening programs for youths presenting for care in EDs.

Implementing Universal Suicide Risk Screening in a Pediatric Hospital

Health care providers are in a prime position to identify teens at risk for suicide, yet many do not. The research team developed and implemented a hospitalwide program to identify teens at elevated risk for suicide and connect them with services. Screening was implemented at both locations of a pediatric hospital, including two emergency departments, three urgent care clinics, and ambulatory clinics. Patients aged 12 years and older presenting for care were screened for suicide risk using the Ask Suicide-Screening Questions (ASQ) in most settings, while the Columbia-Suicide Severity Rating Scale (C-SSRS) was used in mental health areas. A social worker responded to positive screens to complete a more thorough assessment and determine next steps. Social workers also completed outreach to patients in the weeks following a positive screen. Implementation began with pilot locations and expanded after refinements were made. Stakeholders provided screening recommendations, and education was provided prior to implementation. The cost of implementation was calculated based on the time screening required from nursing and social work. Review of the program focused on implementation fidelity, quality improvement, and trends among screening results. During the first year of screening, 138,598 screens were completed, and 6.8% of screens were positive for elevated risk. The annualized cost of the program was estimated to be $887,708.65 for personnel directly involved in screening and following up on positive screens. Early involvement of stakeholders and hospital leaders and a robust response plan were essential to successful implementation of this suicide-screening program.

Geospatial identification of high youth suicide risk areas via electronic health records: Avenues for research and prevention efforts.

As suicide risk screening becomes more common in healthcare settings, geospatial coding of behavioral health data may offer a means for identifying areas of elevated suicide risk for use in public health prevention efforts. The present study demonstrates an analytic approach for using universal suicide risk screening data to identify areas of elevated suicide risk. Data were drawn from standard suicide risk screens recorded in electronic health records of a large pediatric emergency department. A total of 12,400 suicide risk screening responses were recorded, among youth aged 11-19years (mean=14.60, SD=2.16; 57.2% girls, 47.8% Hispanic/Latinx, 72.1% White). A total of 86 unique ZIP codes had at least 50 completed screens, representing 9139 respondents. Rates of positive screens ranged from 6.17% to 31.03% (mean=18.33, SD=5.14) for any suicide-related behavior and from 0.0% to 19.61% (mean=9.14, SD=3.43) for suicide attempt. Rates of positive screens approximated a normal distribution. Results demonstrated several areas with elevated rates of positive suicide risk screens, within the hospital catchment area. The proposed method capitalizes on large-scale screening data, provides an estimate of areas of relative increased risk, and may be used to inform public health responses to suicide prevention.

Universal suicide risk screening: Views of rural adults on acceptability and implementation in primary care

ObjectiveThis study gathered data from rural adult primary care patients regarding the acceptability of universal suicide risk screening and preferred methods of implementation. MethodPatients from a rural primary care clinic in southern West Virginia participating in a pilot test of a suicide risk screening program were administered a Screening Opinions Survey and resulting data were evaluated using descriptive and content analyses. ResultsThe majority of participants (96%) believed that primary care providers (PCPs) should screen patients for suicide and noted multiple benefits to screening. Most participants described the experience of screening in primary care as positive or neutral and preferred a personalized screening process where the provider asked questions directly. Demographic analyses indicated that males and older adults were less likely to report being previously screened for suicide and that older adults were less likely to support the practice of screening. ConclusionsResults provide support for the acceptability of universal suicide risk screening programs to patients in rural primary care and suggest that PCP involvement in the screening process may encourage patient participation. Additional training for PCPs and psychoeducational interventions for older adults may help to address demographic influences on screening practices and engagement.

PCP Opinions of Universal Suicide Risk Screening in Rural Primary Care: Current Challenges and Strategies for Successful Implementation.

Universal suicide risk screening has the potential to address the disproportionately high rates of suicide in the rural United States, as 83% of people who have died by suicide have visited a health care provider in the year prior to their deaths, and rural patients are more likely to visit medical professionals than behavioral health professionals for mental health concerns. This study describes the opinions of primary care providers (PCPs) practicing in a primarily rural state regarding universal suicide risk screening, barriers to implementation, and strategies to increase the feasibility of screening in their practices. In-depth, individual semistructured qualitative interviews were conducted with a sample of PCPs practicing in West Virginia (N = 15). Applied thematic analysis of the data was completed by a team of 3 coders using a consensus-coding methodology. The majority of PCPs supported the practice of screening, but they identified multiple barriers, including a lack of access to mental health and crisis support services, concerns about clinic flow and follow-up with suicidal patients, cultural beliefs specific to rural Appalachia, and provider discomfort with screening. Strategies suggested to address these barriers included the use of technology for screening, a multidisciplinary team approach, streamlined methods for screening and risk assessment, co-located behavioral health, and additional trainings for PCPs on the topic of suicide. Future research should examine the efficacy of universal suicide risk screening programs in rural adult primary care that utilize these strategies in diverse samples with longitudinal data.

Universal mental health screening with a focus on suicidal behaviour using smartphones in a Mexican rural community: protocol for the SMART-SCREEN population-based survey

IntroductionMental disorders represent the second cause of years lived with disability worldwide. Suicide mortality has been targeted as a key public health concern by the WHO. Smartphone technology provides a...

Emergency department safety assessment and follow-up evaluation 2: An implementation trial to improve suicide prevention

BackgroundEmergency departments (EDs) are important for preventing suicide. Historically, many patients with suicide risk are not detected during routine clinical care, and those who are often do not receive suicide-specific intervention. The original Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE 1) study examined the implementation of universal suicide risk screening and a multi-component ED-initiated suicide prevention intervention. PurposeThe ED-SAFE 2 aims to study the impact of using a continuous quality improvement approach (CQI) to improve suicide related care, with a focus on improving universal suicide risk screening in adult ED patients and evaluating implementation of a new brief intervention called the Safety Planning Intervention (SPI) into routine clinical practice. CQI is a quality management process that uses data and collaboration to drive incremental, iterative improvements. The SPI is a personalized approach that focuses on early identification of warning signs and execution of systematic steps to manage suicidal thoughts. ED-SAFE 2 will provide data on the effectiveness of CQI procedures in improving suicide-related care processes, as well as the impact of these improvements on reducing suicide-related outcomes. MethodsUsing a stepped wedge design, eight EDs collected data cross three study phases: Baseline (retrospective), Implementation (12 months), and Maintenance (12 months). Lean methods, a specific approach to pursuing CQI which focuses on increasing value and eliminating waste, were used to evaluate and improve suicide-related care. ConclusionsThe results will build upon the success of the ED-SAFE 1 and will have a broad public health impact through promoting better suicide-related care processes and improved suicide prevention.

From Pilot to Practice: Implementation of a Suicide Risk Screening Program in Hospitalized Medical Patients

Hospitals have become an important venue for identifying medical patients with occult suicidality. This article describes the implementation of a quality improvement project at the National Institutes of Health Clinical Center (NIHCC) to systematically screen medical/surgical inpatients for suicide risk. Using the Plan-Do-Study-Act method, questions from the Ask Suicide-Screening Questions (ASQ) tool were deployed with medical inpatients aged 10 years and older between April 2018 and April 2019. Goals included the development of a training program, policy and procedure review, electronic medical record integration and data collection, and ongoing management and troubleshooting. A total of 4,284 patients were screened for suicide risk with a nurse screening compliance rate of 94.3%. Prevalence data on patients aged 10 years and older revealed an overall screen positive rate of 2.3% (97/4,284), with 3.1% of youth aged 10 to 24 years and 2.2% of adults screening positive. Of the 97 patients who screened positive, 96 were non-acute positive screens. Of the full sample, only 1 patient (0.02%) was deemed acute positive, requiring a 1:1 observer and full safety precautions. Universal suicide risk screening was successfully implemented in the NIHCC without incurring a need for additional resources. The intermediate step of a brief suicide safety assessment is a critical part of the workflow, providing guidance for determining appropriate follow-up in a safe and efficient manner that spares limited mental health and hospital resources. Given the increasing suicide rates in the general population, medical venues offer important opportunities for early detection, assessment, and referral.

Primary and Secondary Prevention of Youth Suicide.

Youth suicide is a national and global public health crisis. Pediatricians can use primary and secondary prevention strategies to intervene with youth before or after the onset of suicidal behaviors. Universal suicide risk screening programs can be used to identify youth in medical settings who may otherwise pass through the health care setting with undetected suicide risk. Pediatricians are uniquely positioned to help foster resilience in their young patients and equip families of at-risk youth with safety plans and lethal means safety counseling. Pediatricians on the frontlines of this critical public health crisis require education and training in detecting suicide risk, managing those who screen positive, and connecting their patients to much needed mental health interventions and treatments. Evidence-based suicide risk screening and assessment tools, paired with interventions, are feasible and potentially life-saving in the medical setting.

Suicide and Substance Use Disorder

Premature mortality trends in the United States are alarming, and years of life lost are mainly attributable to substance-related deaths and suicide. Suicide risk is significantly elevated among those with substance use and substance use disorder, even after adjusting for co-occurring mental health disorders and other social determinants of suicide risk. Potential mechanisms underlying these associations include the acute intoxication effects of substances on disinhibition, impulsivity, aggression, and psychosis; overlapping social and medical risk factors associated with both substance use disorder and suicide risk; and possibly overlapping genetic determinants in stress response circuitry and neurotransmitter functioning. Evidence-based treatments for substance use disorder (both medication interventions and psychosocial treatments) are effective in reducing substance use and suicide risk. Further development of universal suicide risk screening protocols and prevention training and education is especially important for the person at risk for using substances. [ Psychiatr Ann . 2020;50(4):158–162.]

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes. To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes. In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition). Positive ASQ screen at baseline ED visit. The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk. The complete sample was 15 003 youths (7044 [47.0%] male; 10 209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]). Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.

Emergency Department patients with suicide risk: Differences in care by acute alcohol use

ObjectiveTo compare Emergency Department (ED) care of suicidal patients with and without documented acute alcohol use. MethodsRetrospective chart review of randomly sampled patient visits (n = 800; January 2014 to December 2015) at an urban ED with universal screening for suicide risk. Eligible visits were by adults (18+ years) who screened positive for suicide risk at the ED visit (i.e., suicidal ideation in past two weeks or suicide attempt in past six months). Analyses compared those with and without documentation of acute alcohol use. ResultsAmong these patients with suicide risk, 19% had documented acute alcohol use (versus 43% with no use and 38% without documentation); individuals with acute alcohol use were more often male and aged 35–59 years. Overall, 62% were evaluated by a mental health professional in the ED. Individuals with acute alcohol use were significantly less likely (vs those without use) to be evaluated by a mental health professional in the ED (odds ratio 0.49, 95%CI 0.28–0.87) after adjustment for age, recent suicide ideation, current suicide plan, self-harm as a chief complaint, contact with family, and ED disposition. ConclusionsAlthough alcohol use can increase suicide risk, ED patients with acute use appear to receive less thorough suicide risk assessments.

The Development of a Brief Suicide Screening and Risk Assessment Training Webinar for Rural Primary Care Practices.

Although primary care practices have the potential to be crucial intervention points for suicide prevention in rural areas of the United States, primary care staff are often underequipped to deal with suicide and have limited access to high-quality training opportunities on this topic. This manuscript reports on posttest data collected from a sample of primary care staff (N = 16) regarding the acceptability of a brief, online interactive training webinar designed for primary care practices in rural West Virginia. The majority of participants reported the webinar was relevant to their practices (73.3%) and that they would recommend it to a fellow professional (75.0%). Higher proportions of participants reported confidence (75.0%) and comfort (68.8%) asking patients about suicide than they did regarding their ability to complete a risk assessment (50.1%) and a safety plan (56.3%) with a suicidal individual. Only half (56.3%) thought it was important to screen all primary care patients for suicide. Future research should use tracked pre- and posttest data to evaluate the effectiveness of trainings that include a focus on risk assessment and safety planning, education about the potential benefits of universal suicide risk screening, and that can be delivered through asynchronous methods.

Development and Implementation of a Universal Suicide Risk Screening Program in a Safety-Net Hospital System

Many individuals who die by suicide present for nonbehavioral health care prior to death. The risk is often undetected. Universal suicide screening in health care may improve risk recognition. A quality improvement project involving a universal suicide screening program was designed and developed in a large safety-net health care system. The steps in developing and implementing this quality improvement program were gathering intelligence, examining resources, designing the screening program, creating a clinical response, constructing an electronic health record screening protocol, clinical workforce education, and program implementation. This project used the Columbia-Suicide Severity Rating Scale, Clinical Practice Screener-Recent, and a preliminary clinical decision support system. Prevalence data on suicide risk levels are provided for 328,064 adult encounters from the first six months of the screening program. Approximately half of the screens were completed in the outpatient clinics, more than 40% in the emergency department (ED), and slightly less than 5% in the hospital inpatient units. In the ED, 6.3% of the screens were positive, as were 1.6% in the inpatient units, and 2.1% in the outpatient clinics. The odds of a positive suicide screening in the ED was 4.29 times higher than the inpatient units and 3.13 times higher than the outpatient clinics. A new quality improvement program for universal suicide screening was successfully implemented in a large safety-net health care system. The burden to the system from universal screening was not overwhelming and was managed effectively through thoughtful allocation of clinical resources.

Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen

Prior work from surveys and limited populations suggests many emergency department (ED) patients with suicide risk do not have documented lethal means assessments (e.g., being asked about home firearms). The specific objectives of this study were to, in an ED with universal screening for suicide risk: (1) estimate how often ED providers documented lethal means assessment for suicidal patients, and (2) compare patients with and without documented lethal means assessments. We reviewed 800 total charts from a random sample of adults in three a priori age groups (18–34 years; 35–59 years; ≥ 60 years) with a positive suicide risk screen from 8/2014 to 12/2015. Only 18% (n = 145) had documentation by ≥ 1 provider of assessment of lethal means access. Among these 145, only 8% (n = 11) had documentation that someone discussed an action plan to reduce access (most commonly changing home storage or moving objects out of the home). Among 545 suicidal patients discharged home from the ED, 85% had no documentation that any provider assessed access to lethal means. Our findings highlight an important area for improving care: routine, documented lethal means assessment and counseling for patients with suicide risk. There is an urgent need for further exploration of barriers and facilitators.

Suicide Prevention in an Emergency Department Population

Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped. To determine whether an ED-initiated intervention reduces subsequent suicidal behavior. This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013. Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk. The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed. A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99). Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.

Suicide Risk Screening in Healthcare Settings: Identifying Males and Females at Risk.

Suicide is the tenth leading cause of death in the United States, accounting for more than 42,000 deaths in 2014. Although this tragedy cuts across groups defined by age, gender, race/ethnicity, and geographic location, it is striking that nearly four times as many males as females die by suicide in the U.S. We describe the current regulations and recommendations for suicide risk screening in healthcare systems and also describe the aspirational goal of "Zero Suicide," put forth by the National Action Alliance for Suicide Prevention. We then provide information about suicide risk screening tools and steps to take when a patient screens positive for suicide risk. Given the substantially higher suicide rate among males than females, we argue that it is important to consider how we could optimize suicide risk screening strategies to identify males at risk and females at risk. Further research is needed to accomplish this goal. It is recommended that we consider multi-factorial suicide risk screens that incorporate risk factors known to be particularly important for males as well as computerized, adaptive screens that are tailored for the specific risk considerations of the individual patient, male or female. These strategies are not mutually exclusive. Finally, universal suicide risk screening in healthcare settings, especially primary care, specialty medical care, and emergency department settings, is recommended.