ASQ Information Sheet

Screening Patients for Suicide Risk in Medical Settings

Background

• “In the U.S., suicide is the 10th leading cause of death across all age groups and is the 2nd leading cause of death for youth ages 10-24.
• In 2018, more than 6,800 American youth killed themselves and over 2 million young people attempt suicide each year in the U.S.”
• Early identification and treatment of patients at elevated risk for suicide is a key suicide prevention strategy, yet high risk patients are often not recognized by healthcare providers.
• Recent studies show that the majority of individuals who die by suicide have had contact with a healthcare provider within three months prior to their death.
• Unfortunately, these patients often present solely with physical complaints and infrequently discuss suicidal thoughts and plans unless asked directly.

Suicide in the Hospital

Suicide in the medical setting is one of the most frequent sentinel events reported to the Joint Commission (JC). In the past 20 years, over 1,300 patient deaths by suicide have been reported to the JC from hospitals nationwide.

• Notably, 14% of these suicides occurred in
  non- behavioral health settings such as general medical units and the emergency department.
• Root cause analyses reveal that the lack of proper “assessment” of suicide risk was the leading cause for these reported suicides.

Screening in Medical Settings

The emergency department, inpatient units, and primary care settings are promising venues for identifying people at risk for suicide.

• Several studies have refuted myths about iatrogenic risk of asking people questions about suicide, such as the worry about “putting ideas into their heads.”
• Screening positive for suicide risk on validated instruments may not only be predictive of future suicidal behavior, but may also be a proxy for other serious mental health concerns that require attention.
• Non-psychiatric clinicians in medical settings require brief validated instruments to help detect medical patients at risk for suicide.

Emergency Department (ED)

• For over 1.5 million youth, the ED is their only point of contact with the healthcare system, creating an opportune time to screen for suicide risk.
• Screening in the ED has been found to be feasible (non-disruptive to workflow and acceptable to patients and their families).

Inpatient Units

• Research reveals that the majority of medical inpatients have never been asked about suicide before; however, opinion data indicate that most individuals support screening in inpatient settings.

Primary Care/Inpatient Units

• Primary Care Physicians (PCPs) are often the de-facto principal mental healthcare providers.
• Patients may be more comfortable discussing risk-taking activities with PCPs than with specialists.

Suicide Risk Screening Recommendations

• 2007 & 2019 – The JC issued National Patient Safety Goal 15A, requiring suicide risk screening for all patients being treated for mental health concerns in all healthcare settings.
• 2010 & 2016 – The JC issued a Sentinel Event Alert, recommending that all medical patients in hospitals also be screened for suicide risk.

asQ Development

• The ASQ was developed in 3 pediatric Emergency Departments (EDs):
• Children’s National Medical Center, Washington, DC
• Boston Children’s Hospital, Boston, Massachusetts
• Nationwide Children’s Hospital, Columbus, Ohio
• Sound psychometric properties for youth and adult medical patients*
• *For description of study: Horowitz LM, Bridge JA, Teach SJ, Ballard E, Klima J, Rosenstein DL, Wharff EA, Ginnis K, Cannon E, Joshi P, Pao M. Ask Suicide-Screening Questions (ASQ): A Brief Instrument for the Pediatric Emergency Department. Arch Pediatr Adolesc Med. 2012;166(12):1170-1176. Horowitz LM, Snyder DJ, Boudreaux ED, He J-P, Harrington CJ, Cai J, Claassen CA, Salhany JE, Dao T, Chaves JF, Jobes DA, Merikangas KR, Bridge JA, Pao M, Validation of the Ask Suicide-Screening Questions (ASQ) for Adult Medical Inpatients: A Brief Tool for All Ages. Psychosomatics. 2020. doi:10.1016/j.psym.2020.04.008.
• For use by non-psychiatric clinicians
• Takes less than 2 minutes to screen
• Positive screen: “yes” to any of the 4 items

Ask Suicide-Screening Questions (ASQ)

Ask the patient:

• In the past few weeks, have you wished you were dead? (Yes/No)
• In the past few weeks, have you felt that you or your family would be better off if you were dead? (Yes/No)
• In the past week, have you been having thoughts about killing yourself? (Yes/No)
• Have you ever tried to kill yourself?
• If yes, how? When?

If the patient answers yes to any of the above, ask the following question:

• Are you having thoughts of killing yourself right now?

After administering the asQ

• If patient answers “No” to all questions 1 through 4, screening is complete (not necessary to ask question #5). No intervention is necessary (*Note: Clinical judgment can always override a negative screen).
• If patient answers “Yes” to any of questions 1 through 4, or refuses to answer, they are considered a positive screen. Ask question #5 to assess acuity:
• “Yes” to question #5 = acute positive screen (imminent risk identified)
• Patient requires a STAT safety/full mental health evaluation. Patient cannot leave until evaluated for safety.
• Keep patient in sight. Remove all dangerous objects from room. Alert physician or clinician responsible for patient’s care.
• “No” to question #5 = non-acute positive screen (potential risk identified)
• Patient requires a brief suicide safety assessment to determine if a full mental health evaluation is needed. Patient cannot leave until evaluated for safety.
• Alert physician or clinician responsible for patient’s care.

For more information contact:

• Lisa M. Horowitz, Ph.D., M.P.H. Email: horowitzl@mail.nih.gov. Intramural Research Program, National Institute of Mental Health, NIH
• Jeffrey A. Bridge, Ph.D. Email: jeff.bridge@nationwidechidlrens.org. Nationwide Children’s Hospital, The Ohio State University College of Medicine
• Elizabeth A. Wharff, Ph.D., M.S.W. Email: elizabeth.wharff@childrens.harvard.edu. Boston Children’s Hospital, Harvard Medical School