youth at risk for suicide. The ASQ is a set of four screening questions that takes 20 seconds to administer. In a NIMH study, a “yes” response to one or more of the four questions identified 97 percent of youth (aged 10 to 21 years) at risk for suicide. By enabling early identification and assessment of young patients at high risk for suicide, the ASQ toolkit can play a key role in suicide prevention (NIMH, 2018, p. x). The NIMH research revealed that early screening of youth for suicide by medical and mental health professionals is critical and it is therefore advised that all health professionals screen for suicidal ideation. Important points supporting this advice include: ● In 90% of youth, suicide attempts are unknown to parents. ● 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 health-care providers. ● Recent studies show that the majority of individuals who die by suicide have had contact with a healthcare provider within 3 months prior to their death. ● Unfortunately, these patients often present solely with physical complaints and infrequently discuss suicidal thoughts and plans unless asked directly. The NIMH provides the following information on research findings on suicide in varying medical settings (NIMH, 2018): ● Suicide in the hospital : Suicide in a 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, 25% of these suicides occurred in non-behavioral health settings such as general The Ask Suicide Screening Questions (ASQ) The NIMH has developed different scripts, forms, and guidelines geared to the staff in various healthcare settings to assist in screening for at-risk patients. The following is a sample list of screening questions; further questions can be viewed on the NIMH (2018) website (see the Resource section at the end of this course): ● 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? Yes/No ○ If yes, how? When? ● If the patient answers “Yes” to any of the above, ask the following question: Are you having thoughts of killing Patients who screen positive for suicide risk on the ASQ should receive a brief suicide safety assessment (BSSA) conducted by a trained clinician (e.g., social worker, nurse practitioner, physician assistant, physician, or other mental health clinician) to determine if a more comprehensive mental health evaluation is needed. The BSSA is used with youth 10 to 24 years old who screen positive on the ASQ. It should be brief and guides what happens next in each setting, including emergency department, inpatient medical/surgical unit, and outpatient primary care and specialty clinics. A sample of the BSSA follows: ● Praise patient for discussing their thoughts : “I’m here to follow up on your responses to the suicide risk screening questions. These are hard things to talk about. Thank you for telling us. I need to ask you a few more questions.” ● Assess the patient : If possible, assess patient alone (depending on developmental considerations and parent willingness). Review patient’s responses from the ASQ considerations. yourself right now? Yes/No ○ If yes , please describe.
medical units and the emergency department. Root-cause analyses reveal that the lack of proper suicide-risk assessment 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 young people at risk for suicide. Several studies have refuted myths about iatrogenic risk of asking youth questions about suicide, such as the worry of “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 health-care 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 adolescents support screening in inpatient settings. ● Primary care/inpatient clinics : Primary care physicians (PCPs) are often the de-facto principal mental healthcare providers for children and adolescents. Adolescents may be more comfortable discussing risk-taking activities with PCPs than with specialists. After administering the ASQ If patient answers “No” to questions 1 through 4, screening is complete (not necessary to ask question 5). No intervention is necessary, though it is important to note that 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. A response of “Yes” to question 5 indicates an acute positive screen (imminent risk identified). The patient requires a STAT safety/full mental health evaluation and cannot leave until evaluated for safety. The patient should be kept in sight and all dangerous objects should be removed from the room. Alert physician or clinician responsible for patient’s care. A response of “No” to question #5 indicates a non-acute positive screen (potential risk identified). The patient requires a brief suicide-safety assessment to determine if a full mental health evaluation is needed and cannot leave until evaluated for safety. Alert physician or clinician responsible for patient’s care. ● Determine the frequency of suicidal thoughts, i.e., if and how often they occur : Ask the patient: “In the past few weeks, have you been thinking about killing yourself?” If yes, ask: “How often?” (once or twice a day, several times a day, a couple times a week, etc.) “Are you having thoughts of killing yourself right now?” If “yes,” patient requires an urgent/STAT mental health evaluation and cannot be left alone. A positive response indicates imminent risk. ● Suicide plan : Assess if the patient has a suicide plan, regardless of how they responded to any other questions. Ask about method and access to means. Ask the patient, “Do you have a plan to kill yourself? Please describe.” If they have no plan, ask, “If you were going to kill yourself, how would you do it?” If the patient has a very detailed plan, this is more concerning than if they haven’t thought it through in great detail. If the plan is feasible (e.g., if they are planning to use pills and have access to pills), this is a reason for greater concern and removing or securing dangerous items (medications, guns, ropes, etc.) is necessary.
What to do when a pediatric patient screens positive for suicide risk Brief Suicide-Safety Assessment (BSSA; NIMH, 2018)
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