Psychosomatics Review

IN THIS ISSUE: Suicide Tools | Psychosomatics Review | Editor-in-Chief Appointment | History Project

“Identifying risk does not alone decrease risk for suicide”

Review of suicide-prevention tools emphasizes the need for an appropriate response plan

A timely analysis of suicide prevention tools available to the C-L psychiatrist is presented by Robyn Thom, MD, and colleagues at the Department of Psychiatry, Massachusetts General Hospital, Boston, in the January/February edition of Psychosomatics.

Robyn Thom, MD

Coinciding with the federal recommendation that suicide ideation and risk should be assessed (via the Ask Suicide-Screening Questions [ASQ] tool) in all patients aged 10-24 in general hospitals to reduce youth suicide, Dr Thom and colleagues review key suicide-prevention tools available for people of all ages.

The ASQ, provided in a free resource toolkit by the National Institute of Mental Health, is shown in the review to have had a sensitivity of 96.9% and a specificity of 87.6%—and is validated as appropriate for its specific age group.


“Perhaps the most important requirement given the service demands for clinicians is that the tool must be easy to administer.”


Universal suicide screening trend

Dr. Thom’s paper, Suicide Risk Screening in the Hospital Setting: A Review of Brief Validated Tools, sets out to summarize key psychometric and clinical properties of validated suicide risk-screening scales, as well as to discuss the benefits and limitations of using suicide risk-screening tools for universal screening in general hospitals.

As suicide became a leading cause of death, both globally and in the US, The Joint Commission placed growing emphasis on the importance of screening for suicide risk in health care settings, say the researchers.

Moreover, the general hospital trend towards programs of universal suicide screening has been likely furthered following The Joint Commission’s patient safety goals, effective July 2019, recommending suicide screening of all patients being evaluated or treated primarily for a behavioral health complaint.

Yet, while the National Patient Safety Goal does not differentiate between adults and youth, there is no ‘one size fits all’ for screening both young people and adults, say the researchers—and hospital health care systems seeking a program of universal suicide screening “will need to identify a tool that will work best with their practice patterns and patient populations to effectively identify patients at risk for suicide while minimizing the impact on clinician workflow.”

Since The Joint Commission’s report does not define behavioral health patients, “how best to identify such patients remains a challenge for health care systems,” say the researchers.

Included in their paper is reference to the feasibility of implementing a universal suicide-screening program in a safety-net hospital system, including outpatient clinics, emergency departments (EDs), and inpatient units. Parkland Health and Hospital Systems, Dallas, found that universal screening was not overly burdensome. The rate of positive screens was 6.3% in the ED, 1.6% in inpatient settings, and 2.1% in outpatient settings.

“Universal screening, where all patients irrespective of chief complaint are screened, is one systematic way to avoid under-detection,” agree the researchers.

But “these are two distinct populations…for screening both youth and adults,” they say. Screening young people should be with tools developed specifically for their age group.


“Screening for suicide risk without an appropriate response plan would be irresponsible and problematic clinically, ethically, and legally.”


Validated screening tools

Validated screening tools vary in ease of use, the age range of their target population, as well as the quality of supportive data.

“Screening should be systematic, the tool used must be empirically validated in the population and site [in which] it is being used, and a plan for how to further assess those who screen positive is necessary,” say the researchers.

“It is important to note that all screening scales have limitations in their potential to identify those at risk and generally are validated by comparison to other instruments and assessments of risk, rather than with data regarding actual suicidal behavior.

“One recent prospective study of patients presenting to an ED demonstrated that clinical impression and suicide risk-screening tools showed poor predictive value for psychiatric admission.

“For patients with a positive screen or who otherwise raise clinical concern, a screening tool is not a substitute for a thorough suicide risk assessment by a trained clinician, and even under the best of circumstances, our ability to predict which patients will attempt or complete suicide remains limited.”

Examples of screening tools provided by The Joint Commission include the Patient Health Questionnaire (PHQ)-2, the Patient Safety Screener, the Tool for Assessment of Suicide Risk Adolescent Screener, and the ASQ tool. The Joint Commission also noted that the Columbia-Suicide Severity Rating Scale (C-SSRS) can be used for both screening and more in-depth assessment.

A summary of the screening tools that met the researchers’ inclusion criteria is tabulated in their paper:

  • The Columbia-Suicide Severity Rating Scale was developed to create a single tool that could be used to assess the severity of, and to track, changes in both suicidal ideation and behavior as two separate constructs.
  • The Ask Suicide-Screening Questions tool was developed as a brief validated screening tool to assess for suicide risk in children and young adults evaluated in EDs for medical or surgical reasons.
  •  The Suicide Affect-Behavior-Cognition Scale was based on the tripartite model which postulated that attitudes toward suicide were comprised of suicide-related affects, behaviors, and cognitions.
  •  The Patient Safety Screener study assessed a three-question (PSS-3) and a two-question (PSS-2) screener, comparing the likelihood of agreement of a positive screen in PSS with a positive screen on the Beck Scale for Suicidal Ideation.
  •  The Patient Health Questionnaire-9 tool is used to screen for the presence and severity of depression. A recent study quoted in the paper sought to determine the validity of using item 9 of the PHQ-9 for suicide screening.

“In choosing a suicide risk-screening tool for universal implementation in a health care setting, it is important to consider ideal features,” say the researchers. “In general, a high degree of sensitivity is more important than specificity when the goal is to identify possible at-risk cases. Without also having reasonably high specificity, however, too many cases may be identified than is either necessary or feasible for reasonable follow-up assessment. For example, screening that includes positive results for passive suicidal thoughts or self-injurious urges may have less utility because of high false-positive rates.

“For the purposes of screening in a general medical setting, to ensure its use, any screening tool must also be both easy to access (available in the public domain) and easy to administer (self-explanatory and without specific training required for administration or interpretation).

“Perhaps the most important requirement given the service demands for clinicians is that the tool must be easy to administer.

“Finally, considering the variety of patients seen in a general medical setting, the tool should ideally be validated across the full lifespan and specifically within medical settings. Tools that are validated in individuals with intellectual disabilities, neurodevelopmental disorders, and in various cultural contexts are also needed.”

Limitations of screening tools

The PSS and the ASQ are the only two suicide risk-screening tools that were designed and validated specifically for patients presenting to a general medical setting, say the researchers. Data regarding both their accuracy and their predictive validity is, however, limited.

The only available validation studies for these screening tools are based on comparison to pre-existing screening tools or risk-assessment tools, rather than on prospective data.

“It is also interesting to note that there is considerable variability in the approaches used to validate the various screening tools,” say the researchers. “While some, such as the PHQ- 9 and the ASQ, report sensitivity and specificity data, others report only measures of internal consistency or reliability.”

The ASQ—with its high sensitivity and specificity, and ease of administration—nevertheless has been validated only in the specific population of children and young adults in the ED and for chief non-behavioral health complaints. “It would be premature to generalize this tool to other populations,” say the authors.

Critical follow-up

The researchers also point out: “The purpose of a suicide risk-screening tool is to identify patients at elevated risk for suicide. Identifying risk does not alone decrease risk for suicide.

“It should also be noted that brief screening tools are meant to identify patients in need of further revaluation, rather than to predict suicide.

“It will be critically important for hospital systems to determine next steps to evaluate each patient who screens positive.”

Before implementation, “there must be plans and resources in place for an appropriate response to a positive screen.

“These should include a timely suicide assessment by a trained professional and development of a management plan to reduce risk.”

In one clinical pathway (by Brahmbhatt and others, quoted in the paper), a tiered screening process was implemented, whereby the ASQ was used for initial screening, followed by a brief suicide safety assessment. The researchers recommend using either the ASQ Brief Suicide Safety Assessment or the C-SSRS for this step to determine whether a full suicide safety assessment is required.

“Screening for suicide risk without an appropriate response plan would be irresponsible and problematic clinically, ethically, and legally,” say the researchers.


Psychosomatics journal cover

The full paper, Suicide Risk Screening in the Hospital Setting: A Review of Brief Validated Tools, by Robyn Thom, MD, Charlotte Hogan, MD, Eric Hazen, MD, is here.

See: “ASQ Toolkit “Can Play a Key Role” in Suicide Prevention among Young Patients,” this issue.


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