A Few Simple Questions Can Help Prevent Suicide

Overview

Each year, thousands of people in the United States see a health care professional weeks or days before they take their own lives.¹ Signs and symptoms of suicidal thoughts or behaviors are often subtle and not immediately apparent to health care providers, so many patients experiencing these symptoms are not screened. These interactions are missed opportunities to connect people to life-saving care.

Health care providers should ask all patients, whether they exhibit signs of risk or not, if they are considering suicide. Initial screening takes less than a minute, is covered by public and private insurers, and can effectively help identify individuals experiencing suicidal thoughts or behaviors.

Patients who are at risk for suicide don’t always show it

• Suicide is rarely caused by a single factor. Most current screening practices focus on mental health conditions as a primary indicator of suicide risk, yet more than half of people who die by suicide do not have a prior mental health diagnosis.⁷ A wide range of factors can contribute to suicide risk, many of which are not evident in health records or may not be voluntarily disclosed by patients. These factors may include individual and family history; socioeconomic circumstances; access to lethal means, including firearms and medications; and barriers to accessible and affordable mental health care, including inadequate insurance coverage for services and a lack of mental health care professionals.⁸
• Individuals exhibit suicidality—which includes suicidal thoughts, plans, deliberate self-harm, and suicide attempts—differently. Not all individuals self-disclose that they are experiencing suicidal thoughts or behaviors.⁹ People may also express symptoms of suicidality or mental health conditions differently, depending on their cultural background, gender, or even personality.¹⁰ Understanding the complex constellation of suicide risk factors and warning signs is challenging. Providers can misinterpret symptoms—or lack thereof—and underdiagnose or misdiagnose patients.¹¹

Universal screening is more effective than current practices

• Universal screening identifies more people experiencing suicidality; connecting them to care reduces suicide attempts and deaths. Asking a few direct questions can help ensure that all individuals experiencing suicidal thoughts are identified and connected to care. In fact, a study of universal screening in emergency departments found that health care providers identified nearly twice as many patients for suicide risk than they would have if they did not screen everyone.¹² Another study of emergency departments found 30% fewer total suicide attempts over a year among patients who received universal screening and evidence-based follow-up care than among patients who were not identified through universal screening.¹³
• Talking about suicide does not increase risk. Some health care providers avoid asking about suicide out of a belief that talking about suicide may trigger suicidal thoughts or behavior. However, studies show that suicide risk screening is safe and is not associated with increased suicidality.¹⁴ Further, directly communicating with patients about suicide is critical to identifying individuals experiencing suicide risk and increasing the likelihood that they will receive treatment.¹⁵

Universal screening in practice

Parkland Health & Hospital System in Dallas is one of the country’s largest public hospital systems, treating more than 1 million patients annually.¹⁶ In 2015, Parkland was the first health system in the U.S. to implement a universal suicide screening program in its facilities. Among the adult and pediatric populations screened that year, 96% did not report symptoms that would suggest they were at risk for suicide and 97% warranted no further action from their health care provider.¹⁷ However, the screening protocols did identify elevated suicide risk in about 2.3% of patients seeking nonpsychiatric care who would not have been recognized if universal screening had not been implemented.¹⁸ These findings reinforce other research suggesting that a significant number of people experiencing suicide risk move through our hospitals and health systems undetected.¹⁹

Call to action

Health systems, hospitals, urgent care centers, doctors’ offices, and other providers should implement universal screening as part of routine health exams to quickly and effectively identify more people who are thinking about suicide. Universal screening should be part of broader comprehensive suicide prevention and intervention efforts to ensure that people experiencing suicidality are identified, appropriately assessed, and connected to follow-up care and treatment.

Endnotes 

1. B.K. Ahmedani et al., “Health Care Contacts in the Year Before Suicide Death,” Journal of General Internal Medicine 29, no. 6 (2014): 87077, https://doi.org/10.1007/s11606-014-2767-3.
2. Centers for Disease Control and Prevention, “Facts About Suicide,” accessed June 10, 2022, https://www.cdc.gov/suicide/facts/index.html.
3. Ahmedani et al., “Health Care Contacts.”
4. D.M. Stone et al., “Vital Signs: Trends in State Suicide Rates—United States, 1999-2016 and Circumstances Contributing to Suicide—27 States, 2015,” Morbidity and Mortality Weekly Report 67, no. 22 (2018): 617-24, https://dx.doi.org/10.15585/mmwr.mm6722a1.
5. E.D. Boudreaux et al., “Improving Suicide Risk Screening and Detection in the Emergency Department,” American Journal of Preventive Medicine 50, no. 4 (2016): 445-53, https://doi.org/10.1016/j.amepre.2015.09.029.
6. I.W. Miller et al., “Suicide Prevention in an Emergency Department Population: The ED-SAFE Study,” JAMA Psychiatry 74, no. 6 (2017): 563-70, http://dx.doi.org/10.1001/jamapsychiatry.2017.0678.
7. Stone et al., “Vital Signs: Trends in State Suicide Rates.”
8. Centers for Disease Control and Prevention, “Suicide Rising Across the U.S.,” accessed June 10, 2022, https://www.cdc.gov/vitalsigns/suicide/; Centers for Disease Control and Prevention, “Risk and Protective Factors,” accessed June 10, 2022, https://www.cdc.gov/suicide/factors/index.html.
9. B.A. Ammerman et al., “The Role of Suicide Stigma in Self-Disclosure Among Civilian and Veteran Populations,” Psychiatric Research 309 (2022), https://doi.org/10.1016/j.psychres.2022.114408; A.C. Knorr et al., “Predicting Status Along the Continuum of Suicidal Thoughts and Behavior Among Those With a History of Nonsuicidal Self-Injury,” Psychiatry Research 273 (2019): 514-22, https://doi.org/10.1016/j. psychres.2019.01.067.
10. Emergency Task Force on Black Youth Suicide and Mental Health, “Ring the Alarm: The Crisis of Black Youth Suicide in America” (2020), https://theactionalliance.org/resource/ring-alarm-crisis-black-youth-suicide-america; P. Baiden et al., “Examining the Intersection of Race/Ethnicity and Sexual Orientation on Suicidal Ideation and Suicide Attempt Among Adolescents: Findings From the 2017 Youth Risk Behavior Survey,” Journal of Psychiatric Research 125 (2020): 13-20, https://doi.org/10.1016/j.jpsychires.2020.02.029; W. Lu et al., “Psychometric Properties of the Ces-D Among Black Adolescents in Public Housing,” Journal of the Society for Social Work and Research 8, no. 4 (2017): 595-619, https://doi.org/10.1086/694791.
11. Emergency Task Force on Black Youth Suicide and Mental Health, “Ring the Alarm”; Lu et al., “Psychometric Properties of the Ces-D.”
12. Boudreaux et al., “Improving Suicide Risk Screening.”
13. Miller et al., “Suicide Prevention in an Emergency Department Population.”
14. C.W. Mathias et al., “What’s the Harm in Asking About Suicidal Ideation?” Suicide and Life-Threatening Behavior 42, no. 3 (2012): 341-51, doi:10.1111/j.1943-278X.2012.0095.x.
15. G.E. Simon et al., “Does Response on the PHQ-9 Depression Questionnaire Predict Subsequent Suicide Attempt or Suicide Death?” Psychiatric Services 64, no. 12 (2013): 1195-202, doi:10.1176/appi.ps.201200587; G.E. Simon et al., “Risk of Suicide Attempt and Suicide Death Following Completion of the Patient Health Questionnaire Depression Module in Community Practice,” Journal of Clinical Psychiatry 77, no. 2 (2016): 221-27, doi:10.4088/JCP.15m09776.
16. The Pew Charitable Trusts, “Universal Screening Can Help Identify People at Risk for Suicide,” January 25, 2022, https://www.pewtrusts.org/en/research-and-analysis/articles/2022/01/25/universal-screening-can-help-identify-people-at-risk-for-suicide
17. K. Roaten et al., “Development and Implementation of a Universal Suicide Risk Screening Program in a Safety-Net Hospital System,” The Joint Commission Journal on Quality and Patient Safety 44 (2018): 4-11, https://doi.org/10.1016/j.jcjq.2017.07.006; K. Roaten et al., “Universal Pediatric Suicide Risk Screening in a Health Care System: 90,000 Patient Encounters,” Journal of the Academy of ConsultationLiaison Psychiatry 62, no. 4 (2021): 421-29, https://doi.org/10.1016/j.jaclp.2020.12.002.
18. Roaten et al., “Universal Pediatric Suicide Risk Screening”; The Pew Charitable Trusts, “Universal Screening Can Help.”
19. Miller et al., “Suicide Prevention in an Emergency Department Population”; Boudreaux et al., “Improving Suicide Risk Screening”; M.A. Ilgen et al., “Recent Suicidal Ideation Among Patients in an Inner City Emergency Departmetn,” Suicide and Life-Threatening Behavior 39, no. 5 (2009): 508-17, doi: 10.1521/suli.2009.39.5.508; M.H. Allen et al., “Screening for Suicidal Ideation and Attempts Among Emergency Department Medical Patients: Instrument and Results From the Psychiatric Emergency Research Collaboration,” Suicide and LifeThreatening Behavior 43, no. 3 (2013): 313-23, https://doi.org/10.1111/sltb.12018.