Screening for Suicide Risk in Clinical Practice

Screening is a quick way to identify someone that needs further evaluation. Anyone who screens positive on a suicide risk screening tool should be followed up with a brief suicide safety assessment. The 2022 American Academy of Pediatrics/Bright Futures Recommendations for Preventive Pediatric Care (Periodicity Schedule) recommends screening for suicide risk for all youth ages 12 and above.

Youth ages 12 and older: Universal screening

All patients ages 12 and older who are medically and developmentally able to answer questions should be screened for suicide risk. This practice is called “universal screening,” and is used in a developmentally and medically appropriate manner with pediatric patients.

Why universal screening?

• Most young people keep suicidal thoughts to themselves and may not bring up the topic on their own if they aren’t asked a direct question
• Universal screening is a more comprehensive strategy than “targeted screening,” wherein a setting chooses to screen only behavioral health patients for suicide risk
• While patients who present with a behavioral health concern are at a significantly higher risk for suicide, patients presenting with other health concerns or even those simply engaging with the medical system for preventive care can have pressing mental health concerns that they are not talking about with anyone
• Universal screening is an important way to help all patients feel less alone with suicidal thoughts. Otherwise, they may pass through healthcare settings undetected
  • Research shows that most people who die by suicide have visited a healthcare provider in the weeks or months before to their death. Asking about suicide risk can be a way to recognize someone at risk and get them help
• Universal screening helps to promote equity and address bias in care delivery, by ensuring that all youth are screened for suicide risk across demographic groups, communities, and care settings

Youth ages 8-11: Screen when clinically indicated

Patients ages 8-11 should be screened for suicide risk when they are presenting with behavioral health chief complaints, if the patient or parent raises a concern, if there is a reported history of suicidal ideation or behavior, or if the patient displays warning signs of suicide.

Note: there are also medical settings that have had success with universal screening for youth as young as 10 years old, as some screening tools have been validated down to age 10.

Youth under age 8: Screening not indicated. Assess for suicidal thoughts and behaviors if warning signs or parent report of suicidal behaviors are present

Warning signs of suicide risk that requires further evaluation in children under age 8 include (but not limited to):

• Talking about wanting to die or wanting to kill oneself
• Actions such as grabbing their throat in a “choking” motion, or placing their hands in the shape of a gun pointed toward their head
• Engaging in self-harming behaviors
• Acting with impulsive aggression
• Giving away treasured toys or possessions

Death by suicide is rare for children under 8 years old. However, upstream factors such as depression, anxiety, or suicidal ideation are sometimes present even in young children. Importantly, research has shown racial disparities in suicide rates among children under 12, with young Black children being twice as likely to die by suicide than young white children.

For children under 8 years old that present suicide risk, the clinician should privately meet with the parent to discuss these concerns and conduct lethal means safety counseling.

Screening Tools

Evidence-based, publicly available, validated tools for suicide risk screening in medical settings that can be used to detect suicidal ideation or behaviors:

• Ask Suicide-Screening Questions (ASQ)
• Suicide Behavior Questionnaire-Revised (SBQ-R)

Other publicly available tools that are commonly used in primary care settings:

• Columbia Suicide Severity Rating Scale (C-SSRS) – Triage Version
• Patient Health Questionnaire – 9 Adolescent Version (PHQ-9A)
• Patient Safety Screener – 3 (PSS-3)

When selecting the tools that are right for your clinical practice, be sure to choose ones that have been validated via scientific research. Unvalidated tools may over- or under-detect suicide risk. The tools listed above are commonly used for youth ages 10 and older.

Integrating screening into clinical practice

• Screening tools can be integrated into the clinical workflow or electronic health record (EHR) systems to ease implementation
• Any member of the clinical team who is trained in administering a screening tool can screen a patient. In many cases, a nurse or medical assistant will administer the screening early in the visit, when taking the health history
• Screening tools can be administered verbally, via paper-and-pencil, or on an electronic tablet
• Screening tools can be administered along with other preventive service screeners and questionnaires
• When utilizing screening tools with patients or parents/caregivers with limited English proficiency, it is critical to use a properly trained interpreter. Failure to do so can result in misdiagnosis or development of inappropriate treatment strategies. Some of the tools are available in languages other than English
• It is best to screen patients without a parent/caregiver in the room, to encourage open and honest discussion
  • If the parent refuses to leave the room, it is still okay to proceed with screening. While the patient may be less open with their responses, this conversation will model for the parent how to ask young people about suicide risk

Frequency of Screening

Young people need to be screened more frequently than adults because adolescence and young adulthood are times of rapid developmental change. As such, circumstances can shift frequently.

Screening frequency will depend upon practice preference:

• Screening patients who have no history of suicide risk is recommended no more than once a month and no less than once a year
• It is important to remember that screening is used to detect suicide risk. Therefore, if you know a patient is at risk for suicide, you do not have to screen them repeatedly; you need to assess safety at subsequent visits. Consider phrases like, “Last time you were here, you told me you had some thoughts about suicide. I wanted to check in with you about that.”
  
  

Is it safe to ask youth if they are having thoughts of suicide?

Yes! It is safe to ask youth if they are having thoughts of suicide. One of the most common myths about asking youth about suicide is that it will “put the idea into their heads.”

Multiple research studies have established that it is safe to ask young people about suicide:

• Among a sample of people ages 13+, asking about suicide did not significantly impact distress levels immediately or two days later
• Other studies have found no longitudinal changes in suicidal ideation that are associated with assessing for suicide risk

The best way to identify suicide risk in clinical settings is to ask the patient directly and listen to their answer.

• When asking about suicide, use a validated screening tool
• Ask your patient direct questions such as, “Have you been having thoughts about killing yourself?”
  • Ensure this question is asked in a non-judgmental way and follow it with questions that help build a personal connection (See Further Considerations for Caring for all Patients at Risk for Suicide.)
  • Of note, this question alone should not be used as a screening tool, as research has found that using one question to screen for suicide risk under-detects
• Allowing a young person to discuss their thoughts of suicide makes it safe to talk and may bring them relief