Suicide Screening

Suicide Risk Screening

Description

This skill helps administer and interpret validated suicide risk screening instruments. The ASQ provides a brief initial screening, while the C-SSRS (Columbia-Suicide Severity Rating Scale) offers comprehensive assessment of suicidal ideation and behavior.

Clinical Context: These tools help identify individuals at risk for suicide, assess severity of suicidal thinking, and guide clinical decision-making about safety interventions. They are support tools that supplement, not replace, comprehensive suicide risk assessment and clinical judgment.

⚠️ CRITICAL SAFETY NOTICE

ANY positive suicide screen requires IMMEDIATE action. DO NOT leave patient alone. Comprehensive risk assessment and safety planning required before patient leaves your care.

Universal crisis protocols: ../../docs/references/crisis-protocols.md

Quick Reference

Assessment Comparison

For detailed comparison: See references/screening-comparison.md

Risk Level Quick Reference

For detailed risk levels: See references/risk-levels.md

Interactive Administration (Optional)

Use this mode when the clinician says "start" or "administer" ASQ or C-SSRS.

1. Confirm readiness and ensure a safe setting; if the patient is in crisis, initiate emergency protocols immediately.
2. Ask one item at a time (verbatim from the asset file) and wait for a response before continuing.
3. If any response is positive, pause the screening and move immediately to comprehensive risk assessment and safety planning.
4. For ASQ: any "yes" requires the acuity question and full assessment.
5. For C-SSRS: follow the sections in order; if imminent risk is identified, stop and implement safety interventions.
6. Document risk level, protective factors, and immediate actions.

Assessment Tools

ASQ (Ask Suicide-Screening Questions)

Complete assessment: assets/asq.md

4 questions (20 sec), Ages 10+. Any "yes" = positive → comprehensive assessment required.

Questions: (1) Wished dead? (2) Family better off without you? (3) Thoughts of killing yourself? (4) Ever tried? If positive → Ask: "Thoughts right now?"

C-SSRS (Columbia-Suicide Severity Rating Scale)

Complete assessment: assets/c-ssrs.md

5-15 minutes. Multiple sections: ideation (severity 0-5), intensity, behavior (attempts, prep acts), timeline. Determines risk level with clinical judgment.

Clinical Workflow

1. Choose Assessment

digraph assessment_selection {
    rankdir=LR;
    node [shape=box, style=rounded];

    start [label="Need Suicide\nScreening", shape=ellipse];
    time_check [label="Time\navailable?", shape=diamond];
    phq9_check [label="PHQ-9 Item 9\npositive?", shape=diamond];
    asq [label="Start with\nASQ\n(20 sec)", style="filled", fillcolor=lightblue];
    asq_result [label="ASQ\nPositive?", shape=diamond];
    cssrs [label="C-SSRS\nFull Assessment\n(5-15 min)", style="filled", fillcolor=orange];
    negative [label="Negative Screen\n(Still assess\nclinically)", style="filled", fillcolor=gray90];

    start -> time_check;
    time_check -> asq [label="<1 min"];
    time_check -> phq9_check [label="5-15 min\navailable"];
    phq9_check -> cssrs [label="yes"];
    phq9_check -> cssrs [label="no\n(suspected\nrisk)"];
    asq -> asq_result;
    asq_result -> cssrs [label="yes"];
    asq_result -> negative [label="no"];
}

2. Administer Assessment

ASQ: assets/asq.md - 4 questions, 20 seconds C-SSRS: assets/c-ssrs.md - Multiple sections, 5-15 minutes

3. Determine Risk Level

Risk Assessment Decision Tree

digraph risk_determination {
    rankdir=TB;
    node [shape=box, style=rounded];

    ideation [label="Suicidal\nIdeation?", shape=diamond];
    passive [label="Passive Only\n(wishes to die)", shape=diamond];
    active [label="Active Ideation\n(thoughts of\nkilling self)", style="filled", fillcolor=yellow];

    plan_intent [label="Plan AND\nIntent?", shape=diamond];
    means [label="Access to\nMeans?", shape=diamond];
    recent_behavior [label="Recent\nAttempt/Prep?", shape=diamond];
    immediate [label="Imminent\nPlan?", shape=diamond];

    low [label="LOW RISK\n• Safety plan\n• 1-week f/u\n• Resources", style="filled", fillcolor=lightgreen];
    moderate [label="MODERATE\n• Same-day eval\n• Safety planning\n• Remove means\n• Close monitoring", style="filled", fillcolor=yellow];
    high [label="HIGH RISK\n• Psychiatric eval\n• Hospitalization\n  likely\n• Do not leave\n  alone", style="filled", fillcolor=orange];
    imminent [label="IMMINENT\n• Call 911\n• Emergency\n  hospitalization\n• Constant\n  observation", style="filled", fillcolor=red, fontcolor=white];

    ideation -> passive [label="yes"];
    ideation -> low [label="no\n(denied)"];
    passive -> low [label="yes"];
    passive -> active [label="no\n(active)"];
    active -> plan_intent;
    plan_intent -> recent_behavior [label="no"];
    plan_intent -> means [label="yes"];
    means -> immediate [label="yes"];
    means -> high [label="no"];
    immediate -> imminent [label="yes"];
    immediate -> high [label="no"];
    recent_behavior -> moderate [label="no"];
    recent_behavior -> high [label="yes"];
}

Use comprehensive protocol: → references/risk-assessment-protocol.md

Integrate all factors:

• Ideation (presence, frequency, intensity)
• Plan and intent (specificity, access to means)
• Behavior (attempts, preparatory acts)
• Protective factors (reasons for living, social support)
• Risk factors (prior attempts, mental illness, substance use)
• Mental status (hopelessness, agitation, impulsivity)

Risk levels: See references/risk-levels.md

4. Immediate Safety Interventions

ALL risk levels:

• Create safety plan (see references/safety-planning.md)
• Provide crisis resources
• Remove means when possible
• Document thoroughly

Moderate-High risk:

• Same-day psychiatric evaluation
• Intensive monitoring
• Remove ALL lethal means
• Involve support system

High-Imminent risk:

• Call 911 or crisis team
• DO NOT leave alone
• Emergency hospitalization

5. Document

Use documentation templates in:

• assets/asq.md
• assets/c-ssrs.md
• references/risk-assessment-protocol.md

Documentation standards: ../../docs/references/documentation-standards.md

⚠️ CRITICAL SAFETY PROTOCOLS

ANY positive response: (1) DO NOT leave patient alone, (2) Comprehensive assessment, (3) Assess plan/intent/means, (4) Remove lethal means, (5) Determine risk level, (6) Intervene appropriately, (7) Document thoroughly, (8) Ensure continuous safety.

Essential questions: Plan? Access to means? Intent to act? When? What's kept you safe? Prior attempts? Complete protocol: references/risk-assessment-protocol.md

Crisis resources (provide ALL patients): 988 Lifeline (call/text), Text HOME to 741741, Veterans: 988 press 1 or text 838255, Trevor Project (LGBTQ+ youth): 1-866-488-7386, Emergency: 911.

Safety planning (required all risk levels): Warning signs, coping strategies, distraction, support contacts, crisis services, means restriction, reasons for living. Guide: references/safety-planning.md

Means restriction (CRITICAL, saves lives): Firearms—remove completely (preferred) or lock separately from ammunition with someone else controlling access. Medications—remove excess, family/pharmacy holds, weekly dispensing. Other—remove based on plan (ropes, cords, chemicals).

NEVER: Leave patient alone, assume others will handle, accept "I'm fine" without assessment, discharge without safety plan, minimize suicidal statements, skip means restriction, use "no-suicide contracts" (not evidence-based).

Special Considerations

High-risk populations: Adolescents (impulsivity, social media), LGBTQ+ individuals (minority stress), veterans (combat trauma, firearm access), older adults (isolation, higher lethality), post-discharge patients (first weeks post-hospitalization).

Screen when: Severe depression (PHQ-9 ≥15), psychosis, substance use, PTSD, chronic pain, terminal illness, recent loss. See PHQ-9 Item 9 protocol.

Cultural: Ask directly across cultures; expression varies; use interpreters; understand protective factors.

Referral Guidelines

When to Refer/Hospitalize

Immediate (Emergency Services/911):

• Imminent risk (plan, intent, means, immediate)
• Attempt in progress
• Cannot keep self safe
• Psychosis with command hallucinations

Urgent (Same-Day Psychiatric Evaluation):

• High risk (plan and intent but not imminent)
• Moderate risk unable to safety plan
• Recent attempt (past week)

Routine (Within 1-3 Days):

• Low risk needing mental health treatment
• Moderate risk with good safety plan
• Follow-up after higher level of care

Complete referral guidance: ../../docs/references/referral-guidelines.md

Limitations

Cannot predict suicide with certainty. Patients may not disclose; risk changes rapidly. Tools support clinical judgment, not replace it. Negative screen ≠ no risk. When in doubt: assess thoroughly, consult, err on side of safety.

Usage Examples

Example requests: "Screen for suicide risk", "ASQ positive—what now?", "Guide C-SSRS", "Create safety plan", "Assess risk level"

References

Primary Literature:

• Horowitz LM, et al. Ask Suicide-Screening Questions (ASQ). Arch Pediatr Adolesc Med. 2012;166(12):1170-1176.
• Posner K, et al. The Columbia-Suicide Severity Rating Scale. Am J Psychiatry. 2011;168(12):1266-1277.
• Stanley B, Brown GK. Safety Planning Intervention. Cognitive and Behavioral Practice. 2012;19(2):256-264.

Clinical Guidelines:

• American Psychiatric Association. Practice guideline for assessment and treatment of patients with suicidal behaviors. 2003.
• VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. 2019.

Resources:

• NIMH ASQ Toolkit: nimh.nih.gov/asq
• C-SSRS: cssrs.columbia.edu
• 988 Suicide & Crisis Lifeline: 988lifeline.org

Freely available - NIMH (ASQ) and Columbia University (C-SSRS)

⚠️ This skill addresses life-threatening situations. ALL safety protocols must be followed without exception.