Suicide Screening and Safety Planning

Risk Factors

• Previous history of suicidal ideation and NSSI (intensity is predictive of suicide attempts)
• Females and those identifying as LGBTQ more at risk for suicidal ideation
• Family history of suicide (2.6 times more likely)
• History of physical and sexual abuse
• Depression and hopelessness
• Agitation, poor impulse control, and substance use 
• Sleep disturbance
• Low social and school connectedness 
• Interpersonal conflict, financial, legal, and disciplinary problems

Protective Factors

• Connectedness to family and friends
• Sense of responsibility to others
• Religious faith
• Strong relationships with medical/mental health professional
• Reality testing ability

Screening is essential to prevention

• The majority of youth who die by suicide have had recent contact with a health care provider (Luoma, et al. 2002).
• Adolescents rarely spontaneously disclose but will when asked directly by a trusted adult.
• Screening may double detection of adolescents at risk (DeVylder et al., 2019).

Limitations of screeners for suicide

• Low overall prevalence of suicide attempts
• Balancing Sensitivity/Specificity: Need for high sensitivity to limit false positives
• Many studies are completed in emergent or high-risk populations, making application to primary care settings difficult.
• Many screeners initially validated with adults.

Screening Instruments:

PHQ-9, Item 9 “Thoughts you would be better off dead or of hurting yourself”

• PHQ-9 designed to measure depression severity, not suicidal risk
• Simon et al. 2013 (n= 84,418) adolescents who responded “nearly every day” to question 9 had a 4% risk of suicide attempt over the following year.
• PHQ-9 missed 1/3 of suicide risk (Kemper et al, 2021).

Columbia- Suicide Screening for Primary Care

• 2- and 5-item version for primary care, with triage points
• No validation studies of the 2-item screener with adolescents

Ask Suicide-Screening Questions (ASQ) 

• Preferred measure for adolescents
• Age 10 and up in primary care (targeted use age 8 and up)
• Any “yes” response requires further questions

Responding to a patient after a positive screen

“I want to follow-up on your responses to the suicide risk screening questions. These can be hard things to talk about. I need to ask you a few more questions.”

Two ways to screen positive on the ASQ:

Acute: “Yes” to #5: “Are you having thoughts of killing yourself right now?”

• Emergent assessment is needed.
• Patient shouldn’t be left alone.

Non-Acute: answers “yes” on #1-4 or refuses to answer

• • Risk assessment to determine if more extensive psychiatric evaluation is needed.
  • “Thank you for speaking up. It’s important that we have a plan with your parents and medical team to keep you safe”

Suicide Risk Assessment

• Occurs if screen is positive
• Involves clinical evaluation
• Identifies risk and protective factors
• Estimates imminent risk of danger to patient

To increase the likelihood of getting a truthful response when inquiring about suicidal thoughts, behaviors, and plans, be:

• Non-Judgmental
  
  • Appreciate your patient’s openness and honesty
  • Validate that this may feel uncomfortable to talk about with a caregiver, while also stressing importance of caregiver involvement
  • Discussion of confidentiality is to be integrated throughout
• Matter of fact language
  
  • Being upfront and not tip toeing around words like “suicide.” Direct discussion leads to a better intervention in the office
• Self-awareness and body language
  
  • Remaining present in that moment

Ask about suicidality as you would any other symptom: frequency, duration, intensity, circumstances, what makes it better, what makes it worse. Two validated tools that can be considered for risk assessment are the Columbia Suicide Severity Rating Scale (CSSRS) and the Brief Suicide Safety Assessment. 

The questions listed here help you to evaluate the thoughts and behaviors around a suicidal plan. You want to know explicitly what steps a patient has taken in a plan, such as looking up videos on suicidal methods, or hoarding medications. You want to know what the child predicts will be the outcome of the plan, both to the child themselves or to others around them.

One caveat here: some children, especially younger children, may have intense suicidal thoughts and intent to harm themselves but describe a non-lethal method, such as holding their breath, because of their limited understanding of physiology. These high-intent, low lethality suicidal plans should be taken seriously, because a child with high intention may stumble on a more lethal method.

A useful question: “Do you want to die, or do you want this painful stuff to go away?”

Often, kids want the painful things in their lives to go away, or just to rest and be left alone for a while. When this seems impossible, death becomes an option.

On the other end of the spectrum are kids who express specific plans which they have researched and practiced. They clearly state their intention and can override any suggestion of mitigating circumstances. These young people are clearly at very high risk for suicide.

As with any other condition, a methodical, targeted assessment is the key to decision-making around suicidal risk.

This includes:

• An assessment of risk and protective factors
• A suicidal risk inquiry into thoughts, plans, intent and access to means
• The application of clinical judgement
• Documentation of the assessment

Protective factors can mitigate risk in a person with moderate to low suicide risk. A person who is strongly connected to others and has a hopeful future may be able to draw on those factors in assessing their own suicidal thoughts. A person with higher suicide risk, however, may still attempt or commit suicide despite an apparently "good life”.

Suicidality is a spectrum of risk, and we have been addressing it so far in the context of rational weighing of risks and protective factors. Irrationality or impaired judgement increase risk across the spectrum. This can include intoxication, psychosis, brain injury, and impulsivity.

Any of these factors can impair judgment:

• Intoxication
• Psychosis (including command auditory hallucinations)
• Traumatic brain injury
• Impulsivity

Once a level of risk is assigned, you can make a triage plan. High risk patients require emergent further assessment, usually in an emergency department setting.

For moderate and lower risk patients, you can arrange follow-up and make a safety plan.

A safety plan, such as the Stanley Brown, is a brief, collaborative intervention that engages the patient in identifying protective factors and various supports. If viewed as an intervention versus a strategy to mitigate liability, safety planning can help youth and caregivers tap into internal and external resources and reduce suicide risk.

Safety planning engages the patient and caregiver in five areas:

• Environmental safety (reducing access)
• Identify risk factors/warning signs
• Use of internal coping strategies
• External supports
• Resource phone numbers

Safety Planning Steps:

1. Warning signs of developing crisis
2. Personal coping mechanisms
3. People that provide support and distraction
4. Contact people and numbers for support
5. Professionals/agencies where help can be sought
6. Environmental safety 
7. One thing worth living for

Step 6: Elements of environmental safety

• Patient and parent/guardian will go through the house together to identify and remove all sharps, weapons and medications
• Any firearms will be secured or removed from the home
• Patient will be supervised at all times
• Monitor safety while at school. Parent/guardian will inform School Social Worker of this plan.
• Parent/guardian will bring Patient to the nearest ER, contact 811 or CARES at 800-345-9049, if Patient is experiencing a psychiatric emergency.

Involvement of the caregiver is key: The safety plan is a “map” of ways to cope when it becomes difficult.

Safety plans work best when they are creative and personalized to the child

• What are the patient’s interests?
• Social media (in moderation and with monitoring); phones (have them enter crisis lines into their phones in the office)
• Resources to meet the patient’s specific and unique needs (i.e., LGBTQ)

Documentation is evidence that serves as a record of your safety evaluation

• Helps provide support and justification for your plans
• Informs other providers of the plan
• Highlights what you did to help increase safety
• Provide details of the questions you asked and information you obtained
• Discuss where the safety plan will live in the home

Zero Suicide 

NIMH Tool Kit

Columbia Light House Project