Suicide Risk Screening in Healthcare Settings: Identifying Males and Females at Risk
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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.
KeywordsSuicide risk Suicide risk screening Zero suicide initiative Adolescent suicide risk Safety planning
Work on this manuscript was partially supported by a grant from the National Institute of Mental Health (U01 MH104311). We thank Taylor McGuire for her administrative assistance with the manuscript.
Compliance with Ethical Standards
Conflict of interest
Dr. Cheryl King receives royalties from Guilford Press for the publication, Teen Suicide Risk: A practitioner guide to screening, assessment and care management. Mr. Horwitz, Dr. Czyz, and Ms. Lindsay have no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human participants performed by any of the authors.
- Anestis, M. D., Joiner, T., Hanson, J. E., & Gutierrez, P. M. (2014). The modal suicide decedent did not consume alcohol just prior to the time of death: An analysis with implications for understanding suicidal behavior. Journal of Abnormal Psychology, 123, 835–840. doi: 10.1037/a0037480.CrossRefPubMedGoogle Scholar
- Beautrais, A., Fergusson, D., Coggan, C., Collings, C., Doughty, C., Ellis, P., … Surgenor, L. (2007). Effective strategies for suicide prevention in New Zealand: a review of the evidence. New Zealand Medical Journal, 120, U2459.Google Scholar
- Betz, M. E., Arias, S. A., Miller, M., Barber, C., Espinola, J. A., Sullivan, A. F., …Boudreaux, E. D. (2015). Change in emergency department providers’ beliefs and practices after use of new protocols for suicidal patients. Psychiatric Services, 66, 625–631. doi: 10.1176/appi.ps.201400244.CrossRefPubMedPubMedCentralGoogle Scholar
- Betz, M. E., Wintersteen, M., Boudreaux, E. D., Brown, G., Capoccia, L., Currier, G.,… Harkavy-Friedman, J. (2016b). Reducing suicide risk: Challenges and opportunities in the emergency department. Annals of Emergency Medicine, 68, 758–765. doi: 10.1016/j.annemergmed.2016.05.030.CrossRefPubMedGoogle Scholar
- Boudreaux, E. D., Camargo, C. A., Arias, S. A., Sullivan, A. F., Allen, M. H., Goldstein, A. B.,…& Miller, I. W. (2016). Improving suicide risk screening and detection in the emergency department. American Journal of Preventive Medicine, 50, 445–453. doi: 10.1016/j.amepre.2015.09.029.CrossRefPubMedGoogle Scholar
- Boudreaux, E. D., Miller, I., Goldstein, A. B., Sullivan, A. F., Allen, M. H., Manton, A. P.,…& Camargo, C. A. (2013). The emergency department safety assessment and follow-up evaluation (ED-SAFE): Method and design considerations. Contemporary Clinical Trials, 36, 14–24.CrossRefPubMedPubMedCentralGoogle Scholar
- Brent, D. A., Poling, K. D., & Goldstein, T. R. (2011). Treating depressed and suicidal adolescents: A clinician’s guide. New York: Guilford Press.Google Scholar
- Capoccia, L., Labre, M. (2015). Caring for adult patients with suicide risk: A consensus-based guide for emergency departments. Waltham: Education Development Center, Inc., Suicide Resource Prevention Center.Google Scholar
- Centers for Disease Control and Prevention [CDC]. (2015). Web-based injury statistics query and reporting system (WISQARS). http://www.cdc.gov/ncipc/wisqars.
- Centers for Disease Control and Prevention [CDC]. (2016). Youth Risk Behavior Surveillance: United States, 2015. Morbidity and Mortality Weekly Report, 65, 1–174.Google Scholar
- Chang, H. J., Lai, Y. L., Chang, C. M., Kao, C. C., Shyu, M. L., & Lee, M. B. (2012). Gender and age differences among youth, in utilization of mental health services in the year preceding suicide in Taiwan. Community Mental Health Journal, 48, 771–780. doi: 10.1007/s10597-011-9470-1.CrossRefPubMedGoogle Scholar
- Chapman, C., Mullin, K., Ryan, C., Kuffel, A., Nielssen, O., & Large, M. (2015). Meta-analysis of the association between suicidal ideation and later suicide among patients with either a schizophrenia spectrum psychosis or a mood disorder. Acta Psychiatrica Scandinavica, 131, 162–173. doi: 10.1111/acps.12359.CrossRefPubMedGoogle Scholar
- Currier, G. W., Brown, G. K., Brenner, L. A., Chesin, M., Knox, K. L., Ghahramanlou-Holloway, M., & Stanley, B. (2015). Rationale and study protocol for a two-part intervention: Safety planning and structured follow-up among veterans at risk for suicide and discharged from the emergency department. Contemporary Clinical Trials, 43, 179–184.CrossRefPubMedGoogle Scholar
- Denney, J. T., Rogers, R. G., Krueger, P. M., & Wadsworth, T. (2009). Adult suicide mortality in the United States: Marital status, family size, socioeconomic status, and differences by sex. Social Science Quarterly, 90, 1167–1185. doi: 10.1111/j.1540-6237.2009.00652.x.CrossRefPubMedPubMedCentralGoogle Scholar
- Education Development Center. (2015). Legal and liability issues in suicide care. Zero suicide in health and behavioral health care. http://zerosuicide.sprc.org/sites/zerosuicide.actionallianceforsuicideprevention.org/files/Legal%20and%20Liability%20Issues%20in%20Suicide%20Care%205-27-16_0.pdf.
- Emergency Medicine Network. (2016). Patient safety screener. http://emnet-usa.org/ED-SAFE/materials/K_PtSafetyScreen.pdf.
- Gibbons, R. D., Weiss, D. J., Pilkonis, P. A., Frank, E., Moore, T., Kim, J. B., & Kupfer, D. J. (2012). Development of a computerized adaptive test for depression. JAMA Psychiatry, 69, 1104–1112.Google Scholar
- Gipson, P. Y., Agarwala, P., Opperman, K. J., Horwitz, A. G., & King, C. A. (2015). Columbia-Suicide Severity Rating Scale (C-SSRS): Predictive validity with adolescent psychiatric emergency patients. Pediatric Emergency Care, 31, 88–94. doi: 10.1097/PEC.0000000000000225.PubMedPubMedCentralGoogle Scholar
- Gould, M. S., Lake, A. M., Munfakh, J. L., Galfalvy, H., Kleinman, M., Williams, C.,… McKeon, R (2016). Helping callers to the the National Suicide Prevention Lifeline who are at imminent risk of suicide: Evaluation of caller risk profiles and interventions implemented. Suicide and Life-Threatening Behavior, 46, 172–190. doi: 10.1111/sltb.12182.CrossRefPubMedGoogle Scholar
- Gould, M. S., Munfakh, J. L., Kleinman, M., & Lake, A. M. (2012). National suicide prevention lifeline: enhancing mental health care for suicidal individuals and other people in crisis. Suicide and Life-Threatening Behavior, 42, 22–35. doi: 10.1111/j.1943-278X.2011.00068.x.CrossRefPubMedGoogle Scholar
- Harvard Injury Control Research Center. (2016). Means Matter: Suicide, guns, and public health. http://www.hsph.harvard.edu/means-matter/means-matter/saves-lives/.
- Horowitz, L., Ballard, E., Teach, S. J., Bosk, A., Robensteing, D. L., Paramjit, J., … & Pao, M. (2010). Feasibility of screening patients with nonpyshchiatric complaints for suicide risk in pedicatric emergency department. Pediatric Emergency Care, 26, 787–792.CrossRefPubMedPubMedCentralGoogle Scholar
- Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., … & Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): A brief instrument for the pediatric emergency department. Archives of Pediatrics and Adolescent Medicine, 166, 1170–1176. doi: 10.1001/archpediatrics.2012.1276.CrossRefPubMedGoogle Scholar
- Hubers, A. A., Moaddine, S., Peersmann, S. H., Stijnen, T., van Duijn, E., Van der Mast, R. C., … Giltay, E. J. (2016). Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: A meta-analysis [Abstract]. Epidemiology and Psychiatric Sciences, 1–13. doi: 10.1017/S2045796016001049.
- Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York: Guilford Press.Google Scholar
- Joiner, T. E. (2005). Why people die by suicide. Cambridge: Harvard University Press.Google Scholar
- King, C. A., Berona, J., Czyz, E., Horwitz, A. G., & Gipson, P. Y. (2015). Identifying adolescents at highly elevated risk for suicidal behavior in the emergency department. Journal of Child Adolescent Psychopharmacology, 25, 100–108. doi: 10.1089/cap.2014.0049.CrossRefPubMedPubMedCentralGoogle Scholar
- King, C. A., Ewell Foster, C., & Rogalski, K. M. (2013). Teen suicide risk: A practitioner guide to screening, assessment, and management. New York: Guilford Press.Google Scholar
- King, C. A., Jiang, Q., Czyz, E. K., & Kerr, D. C. (2014). Suicidal ideation of psychiatrically hospitalized adolescents has one-year predictive validity for suicide attempts in girls only. Journal of Abnormal Child Psychology, 42, 467–477. doi: 10.1007/s10802-013-9794-0.CrossRefPubMedPubMedCentralGoogle Scholar
- McManus, B. L., Kruesi, M. J., Dontes, A. E., Defazio, C. R., Piotrowski, J. T., & Woodward, P. J. (1997). Child and adolescent suicide attempts: An opportunity for emergency departments to provide injury prevention education. The American Journal of Emergency Medicine, 15, 357–360. doi: 10.1016/S0735-6757(97)90124-8.CrossRefPubMedGoogle Scholar
- Monnin, J., Thiemard, E., Vandel, P., Nicolier, M., Tio, G., Courtet, P., … & Haffen, E. (2012). Sociodemographic and psychopathological risk factors in repeated suicide attempts: gender differences in a prospective study. Journal of Affective Disorders, 136, 35–43. doi: 10.1016/j.jad.2011.09.001.CrossRefPubMedGoogle Scholar
- National Institute for Mental Health. (2014). Personalized screen to ID suicidal teens in 14 ERs: Aimed to help front-line clinicians save lives. http://www.nimh.nih.gov/news/science-news/2014/personalized-screen-to-id-suicidal-teens-in-14-ers.shtml.
- Nock, M. K., Green, J. G., Hwang, I., McLaughlin, K. A., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry, 70, 300–310. doi: 10.1001/2013.jamapsychiatry.55.CrossRefPubMedGoogle Scholar
- O’Mara, R. M., Hill, R. M., Cunningham, R. M., & King, C. A. (2012). Adolescent and parent attitudes toward screening for suicide risk and mental health problems in the pediatric emergency department. Pediatric Emergency Care, 28, 626–632. doi: 10.1097/PEC.0b013e31825cfb10.CrossRefPubMedPubMedCentralGoogle Scholar
- Oquendo, M. A., Bongiovi-Garcia, M. E., GaIfaIvy, H., Goldberg, P. H., Grunebaum, M. F., Burke, A. K., & Mann, J. J. (2007). Sex differences in clinical predictors of suicidal acts after major depression: A prospective study. American Journal of Psychiatry, 164, 134–141. doi: 10.1176/appi.ajp.164.1.134.CrossRefPubMedPubMedCentralGoogle Scholar
- Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., … & Shen, S. (2011). The Columbia–Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168, 1266–1277.CrossRefPubMedPubMedCentralGoogle Scholar
- Posner, K. (n.d.). Columbia-Suicide Severity Rating Scale (C-SSRS). Retrieved from http://cssrs.columbia.edu/scales_practice_cssrs.html.
- U.S. Department of Health and Human Services, Office of the Surgeon General, & National Action Alliance for Suicide Prevention. (2012). 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Retrieved from Washington D.C.Google Scholar
- Reynolds, W. M. (1988). Suicidal Ideation Questionnaire: Professional manual. Odessa: Psychological Assessment Resources.Google Scholar
- Reynolds, W. M. (2008). Reynolds Adolescent Depression Scale-2nd Edition: Short Form (RADS-2:SF). Lutz: Psychological Assessment Resources, Inc.Google Scholar
- Ribeiro, J. D., Witte, T. K., Van Orden, K. A., Selby, E. A., Gordon, K. H., Bender, T. W., & Joiner, T. E. Jr. (2014). Fearlessness about death: The psychometric properties and construct validity of the revision to the acquired capability for suicide scale. Psychological Assessment, 26, 115–126. doi: 10.1037/a0034858.CrossRefPubMedGoogle Scholar
- Rudd, M. D., Joiner, T., & Rajab, M. H. (2001). Treating suicidal behavior: An effective, time-limited approach. New York: Guilford Press.Google Scholar
- Runyan, C. W., Becker, A., Brandspigel, S., Barber, C., Trudeau, A., & Novins, D. (2016). Lethal means counseling for parents of youth seeking emergency care for suicidality. Western Journal of Emergency Medicine, 17, 8–14. doi: 10.5811/westjem.2015.11.28590.CrossRefPubMedPubMedCentralGoogle Scholar
- Saunders, J. B., Aasland, O. G., Babor, T. F., De La Fuente, J. R., Grant, M (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption–II. Addiction (Abingdon, England), 88, 791–804.CrossRefGoogle Scholar
- Shneidman, E. S. (1993). Suicide as psychache: A clinical approach to self-destructive behavior: Jason Aronson, Inc.Google Scholar
- Stanley, B., Brown, G., Brent, D. A., Wells, K., Poling, K., Curry, J., … & Hughes, J. (2009). Cognitive-behavioral therapy for suicide prevention (CBT-SP): Treatment model, feasibility, and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 1005–1013. doi: 10.1097/CHI.0b013e3181b5dbfe.CrossRefPubMedPubMedCentralGoogle Scholar
- Stanley, B., & Brown, G. K. (2008). Safety plan treatment manual to reduce suicide risk: Veteran’s version. Washington, D.C.: United States Department of Veterans Affairs.Google Scholar
- Substance Abuse and Mental Health Services Administration (2014). Results from the 2013 National Survey on Drug Use and Health: Mental health findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration.Google Scholar
- Suicide Prevention Resource Center. (2008). Assessing and managing suicide risk: Core competencies for mental health professionals. Newton, MA: Education Development Center, Inc.Google Scholar
- Suicide Prevention Resource Center. (2015). Caring for adult patients with suicide risk: A consensus guide for emergency departments. Retrieved from http://www.sprc.org/ed-guide.
- Suicide Prevention Resource Center, & National Action Alliance for Suicide Prevention. (2015a). Identify and assess patients for suicide. Retrieved from http://zerosuicide.sprc.org/toolkit/identify.
- Suicide Prevention Resource Center, & National Action Alliance for Suicide Prevention. (2015b). Zero Suicide in health and behavioral health care. Retrieved from http://zerosuicide.sprc.org.
- The Joint Commission. (2016a). 2016 National Patient Safety Goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx.
- The Joint Commission. (2016b). Sentinel event alert: Detecting and treating suicide ideation in all settings. https://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf.
- The Joint Commission. (2016c). Sentinel event data: General information 1995–2015 https://www.jointcommission.org/assets/1/18/General_Information_1995-2015.pdf.
- Uebelacker, L. A., German, N. M., Gaudiano, B. A., Miller, I. W. (2011). Patient Health Questionnaire Depression Scale as a suicide screening instrument in depressed primary care patients: A Cross-sectional study. The Primary Care Companion to CNS Disorders, 13, doi: 10.4088/PCC.10m01027.
- U.S. Preventive Services Task Force, (2014). Suicide risk in adolescents, adults and older adults: Screening, May 2014. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/suicide-risk-in-adolescents-adults-and-older-adults-screening.