Conducting a Brief Suicide Safety Assessment

There are several publicly available, evidence-based assessment tools that can be used to assess risk of suicidal ideation or behaviors in individual patients. Each tool will have different methods of scoring for suicide risk. The purpose of the assessment is to determine next steps.

Commonly used tools include:

• Columbia Suicide Severity Rating Scale (C-SSRS)—Full Version
• Ask Suicide-Screening Questions Brief Suicide Safety Assessment (ASQ BSSA)
• Suicide Assessment Five-Step Evaluation and Triage (SAFE-T)

Integrating brief suicide safety assessments into clinical practice

• The brief suicide safety assessment (BSSA) is the middle step of the 3-tiered clinical pathway
• The BSSA helps the pediatric health clinician decide whether it is safe to send the patient home, or whether there is a need for immediate intervention
  • The BSSA is different from the screening tool, which simply identifies risk
  • The BSSA is a brief conversation with the patient that assists in further triage by evaluating their personal risk and protective factors (eg, frequency of suicidal thoughts, plans, psychiatric symptoms, suicide attempt history, reasons to live, social support)
• Brief suicide safety assessment/risk assessment tools can be integrated into the clinical workflow or electronic health record (EHR) systems to ease implementation
• The brief suicide safety assessment can be performed by anyone with advanced training (e.g., physician, nurse practitioner, physician assistant, or mental health professional) and has been trained in how to administer the specific assessment tool
• Some tools have trainings available online (eg, see ASQ BSSA and C-SSRS)
• The brief suicide safety assessment should be conducted during one-on-one time between the youth and the pediatric health clinician. When a child screens positive for suicide risk, parents should be carefully and thoughtfully notified:
• Explain to the patient that you will need to talk with their parents/caregivers and talk with the patient about how they would like to be involved in that conversation (See “Further Considerations for Caring for all Patients at Risk for Suicide,” below)
• Ask the parent/caregiver if they know about the child’s suicidal ideation/behavior in a way that does not come across as blaming or judgmental. For example, you can say, “Your child spoke about suicidal ideation. Is this something they have shared with you?”
  • Be aware that youth are often private about their suicidal thoughts, and it is common for parents/caregivers to be unaware of suicidal ideation or behaviors
• The ASQ Toolkit provides language to use with parents/caregivers here
  • Ask the parent/caregiver if there is anything they want to tell you in private
    • Parents/caregivers may have information about family history that they do not want to speak about in front of the child
    • A private conversation with the parent/caregiver provides an opportunity to speak privately to gather relevant health information

See NIMH ASQ toolkit for more details on administering the brief suicide safety assessment.

It is not always an emergency if a patient discloses thoughts of suicide 

• While many young people think about suicide, and detection is necessary to ensure safety and assess risk, suicidal behavior is a relatively rare event. Most youth who have suicidal thoughts will not require emergency care. However, youth who have thoughts of suicide need compassion, attention, and further evaluation
• Only the patients who are assessed to be at imminent or acute risk of suicide need full safety precautions (eg, a 1:1 observer and searched belongings)
• Patients who are not at imminent risk of suicide but require further evaluation, do not require safety precautions
• The majority of young people who screen positive for suicide risk are non-acute cases
• Regardless of level of risk, all patients and their parents/caregivers should be given the 988 Suicide and Crisis Lifeline and Crisis Text Line

Why is it important to determine level of risk?

• Pediatric health care settings should work to provide a level of care that appropriately matches the level of risk for each patient
• Sometimes, pediatric health clinicians over-respond to reports of thoughts of suicide:
  • For example, sometimes when a patient reveals suicidal ideation, they are treated in what may be perceived as a punitive way. They are sent to the ED where their clothes are taken and they are put in a paper gown, their belongings and cell phone are taken, and they are given a 1:1 observer or automatically sent to a psychiatric unit
  • These extreme measures are considered full safety precautions. They are only meant to keep people safe who are at imminent risk of harming themselves
• Utilizing full safety precautions for patients who are not at imminent risk comes with several disadvantages:
  • Youth value informed treatment options, with involvement in decision-making processes. Forced safety precautions or hospitalizations without patient input removes patient agency and can decrease the perception that care is a collaborative process between a patient and their clinician
  • Over-response to previous suicidal behavior can be traumatizing for patients, or can be such a negative experience that they may feel reluctant to return for care or disclose suicidal ideation in the future
  • Taking unnecessary safety precautions, like finding a hospital bed or using a 1:1 observer, can disrupt workflow systems and overtax already-strapped mental health resources within the health system
• However, while rare, there are some patients who will require immediate intervention and comprehensive safety precautions. Importantly, hospitalization is only recommended when the patient presents an immediate plan to attempt suicide, which cannot wait for non-urgent assessment

Since suicide risk is stratified, pediatric health clinicians can provide care that is appropriate for the level of risk.

After the brief suicide safety assessment, determine next steps

• Patient is at imminent risk and needs emergent mental health evaluation
• Patient requires further evaluation but is not at imminent risk
• Patient is deemed low risk, and receives resources and possible mental health referral for the future

See corresponding sections for full details on caring for a patient in each category:

• Caring for Patients at Low Risk of Suicide
• Caring for Patients Who Need Further Medical Mental Health Evaluation
• Caring for Patients and Imminent Risk of Suicide