Suicide Risk Assessment Model Individuals within the healthcare team must understand their role in suicide assessment and prevention within their organization. While each organization will differ, healthcare professionals should consider their role within the organization related to the Suicide Risk Assessment Model. The best practice would be for each role to flow to the following individual in the organization. As part of the routine screening, a behavioral health questionnaire should be given to each patient who presents to their primary healthcare provider to collect data regarding their psychological well- being. A typical clinical protocol involves a healthcare team member deciding whether the Patient Health Questionnaire-9 (PHQ-9) or other behavioral health screening is indicated for a particular patient. Upon receiving the patient into the office, if they are identified as needing this screening, the medical assistant will ensure it is completed and scored. If the suicidality question on the PHQ-9 is positive, then the medical assistant will administer the Columbia-Suicide Severity Rating Scale (C-SSRS) questionnaire. Both assessment documents are then placed in the electronic medical record. The primary healthcare provider will review the results with the patient and discuss the patient’s present symptoms. The provider should contact a behavioral healthcare provider and, in the interim, conduct any needed safety planning and consider restricting access to lethal means. The primary healthcare provider will also engage the patient regarding strategies for managing depression symptoms. It is also vital to always encourage participation and facilitate a warm hand-off to the integrated behavioral health provider. A licensed behavioral health provider needs to be available for urgent consultation of an acutely suicidal patient. The role of the behavioral health provider is to see patients for treatment or to determine if the patient is appropriate for specialty behavioral treatment. An integrated approach to behavioral health is imperative for the successful outcome of the patient who presents with depression symptoms or suicidal ideations. Suicide Screening Tools Screening an individual for suicidal risk involves several equally important factors: 1. Establishing rapport with the individual to determine an honest assessment. 2. Using an evidence-based screening tool that is appropriate for the individual and the situation. 3. Knowing what to do with the information collected. Suicide screening tools are standardized and brief. Screening personnel may administer them and take less than 15 minutes to complete. The screener needs to ask all questions in a screening tool precisely. Should an individual show “at-risk scores or indicators,” they require a full suicide assessment by a behavioral health provider.
ASQ – A Suicide Risk Screening Tool The Ask Suicide-Screening Questions (ASQ) is a free resource for emergency departments, inpatient medical/surgical units, and outpatient clinics or primary care units by the National Institute of Mental Health (NIMH). This four-question tool takes about 20 seconds to administer 39 : 1. In the past few weeks, have you wished you were dead? 2.
Suicide Screening
“Screening” and “assessment” are not synonymous. “Screening” is a method to identify those at increased risk for a specific condition or disorder and who could benefit from further evaluation 5 . “Suicide screening” is often a quick and standard procedure to identify individuals at risk for suicide. The method may be a standard form in a clinic, provider office, or the emergency department triage area. Often, suicide screening takes 15 minutes or less to conduct. On the other hand, “assessment” is more comprehensive than screening and provides a more thorough conceptualization of an individual. 5 Assessments may include screenings, but these screening measures are used with other information to form an assessment or evaluation of the patient. U.S. Preventive Task Force Recommendations The U.S. Preventive Services Task Force (USPTF)’s most current recommendation for suicide screening is from 2014. As of September 2022, the USPTF is updating its current recommendation statement for suicide risk screening in adolescents, adults, and older adults. The existing recommendation states that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in a primary- care setting. It is important to note that this recommendation applies to individuals who do not have an identified psychiatric disorder. 37 Joint Commission Recommendations As of July 2019, the Joint Commission suggests that screening in some select environments for individuals with certain presenting complaints may indicate standard screening. The details of the recommendation are as follows 38 : • Conduct an environmental risk assessment to identify features that could be used to attempt suicide. • Screen all patients for suicide ideation using a brief and standardized screening tool. • Use an evidenced-based process to perform a suicide risk assessment of those who have screened positive for suicidal ideation. • Document an individual’s overall level of risk for suicide and a plan to mitigate the risk. • Follow policies and procedures regarding the care of individuals identified at risk for suicide. At a minimum, these should include: ° Guidelines for reassessment. • Follow policies and procedures for counseling and follow-up care at discharge for patients identified at risk for suicide. • Monitor implementation and effectiveness Training and competence assessment of staff who care for patients at risk for suicide. ° of policies and procedures for screening, assessment, and management of patients at risk for suicide.
In the past few weeks, have you felt that you or your family would be better off if you were dead? In the past week, have you been having thoughts about killing yourself? Have you ever tried to kill yourself? If yes, how?
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In addition to the screening tool, the NIMH designed a script for nursing staff that introduces the screening tool as well as what to say if a risk for suicide is identified. The script is located along with the tool on the following website: https://www.nimh. nih.gov/research/research-conducted-at-nimh/ asq-toolkit-materials The Patient Health Questionnaire 2 The Patient Health Questionnaire 2 (PHQ-2) is designed to screen as a first step approach for depression in the primary healthcare setting. The PHQ-2 is a simple tool containing two questions, enhancing routine inquiry about depression, the most prevalent and treatable mental disorder in the primary care setting. The PHQ-2 questions are the first two questions of the PHQ-9 tool 40 : “ Over the past 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless? ” The patient indicates the frequency in which they experience these prompts on a 4-point scale of 0 (“Not at all”), 1 (“Several days”), 2 (“More than one-half of the days”), and 3 (“Nearly every day”) 40 . One concern about this approach is that a patient may answer ‘no’ to the two questions but still have suicidal thoughts. Organizations should consider adding an additional question to the PHQ- 2 assessing suicide risk, such as “Over the past 2 weeks, have you been bothered by: Thoughts you may want to kill yourself or have you attempted suicide?” Individuals who screen positive on the PHQ-2 need to be further evaluated with the PHQ-9 to determine their risk for a depressive disorder 40 . View the PHQ–2 at https://www.med-iq.com/files/ noncme/material/pdfs/LI042%20IG%20tools.pdf The Patient Health Questionnaire 9 The Patient Health Questionnaire 9 (PHQ-9) is a multipurpose tool for screening, diagnosing, monitoring, and measuring the severity of a patient’s depression in the primary healthcare setting 41 . The tool rates the frequency of symptoms and then factors into the scoring severity index. The survey asks nine questions about depression and suicidal ideation over the past two weeks.
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