Question 9 on the tool screens for the presence and duration of suicide ideation. A follow-up questionnaire on the PHQ-9 assigns weight to the degree that the depressive problems are affecting the patient’s level of function. The PHQ-9 is easily completed by the patient and quickly scored by the healthcare provider. It can be used repeatedly to determine improvement or worsening of depression in response to treatment. 41 View the PHQ -9 at https://www.apa.org/depression-guideline/patient- health-questionnaire.pdf. Suicide Assessment Five-Step Evaluation and Triage The Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) interview contains more extensive items that may yield more detailed information about a patient’s suicide risk. 40 This screening tool may be more useful in an outpatient behavioral health setting. It consists of the following five steps 42 : 1. Identify risk factors (suicidal behavior, current/ past psychiatric disorders, key symptoms, family history of suicide, stressors, change in treatment, access to firearms) 2. Identify protective factors (both internal and external factors) 3. Conduct suicide inquiry • Ideation: frequency, intensity, duration in the last 48 hours, past month, and worst ever • Plan: timing, location, lethality, availability, preparatory acts • Behaviors: past attempts, aborted attempts, rehearsals, non-suicidal self-injurious actions • Intent: extent to which the patient expects to carry out the plan and believes the plan to be lethal versus self-injurious. Explore ambivalence of reasons to die versus reasons to live. 4. Determine the risk level of suicide with the appropriate intervention 5. Document the risk level, rationale, treatment plan, and a follow-up plan. View the SAFE-T Pocket Card at https://store. samhsa.gov/product/SAFE-T-Pocket-Card-Suicide- Assessment-Five-Step-Evaluation-and-Triage-for- Clinicians/sma09-4432 Patient Safety Screener 3 The Patient Safety Screener 3 (PSS-3) is a three-item screening tool used in acute care settings where patients remain under constant care (Table 4). 43 It has been validated for use in the emergency department for patients 18 years and older and can be administered to all patients, not only those with a risk of suicide. The PSS-3 is interpreted as follows 43 : • Yes to question 1. This indicates depressed mood. • Yes to question 2. This indicates active suicidal ideation. • Yes to question 3. This indicates a suicide attempt.
Table 4. Patient Safety Screener Over the past two weeks,
…have you felt down, depressed, or hopeless? — Yes. — No.
— Patient unable to complete. — Patient refused. — Yes. — No. — Patient unable to complete. — Patient refused.
…have you had thoughts of killing yourself?
In your lifetime,
…have you ever attempted to kill yourself?
— Yes. — No. — Patient unable to complete. — Patient refused. — If yes, when did this happen? — Within the past 24 hours (including today). — Within the last month (but not today).
— Between one and six months. — More than six months ago. — Patient unable to complete. — Patient refused.
Beck Hopelessness Scale (BHS) The BHS tool takes about five minutes to complete and is based on pessimism, hopelessness, and suicidal risk. 45 Hopelessness is a strong predictor and is a stronger indicator than the severity of depression. If the screening indicates a risk for hopelessness, the provider should conduct a more detailed suicide assessment. Unlike a screening, a full suicide assessment requires a skilled professional who has additional training for assessing at-risk individuals. Using a tool is only half the assessment process. The evaluator must use the information from the screening and assessment tools, as well as the words, gestures, and non-verbal behavioral information from the individual, to evaluate the information and determine the individual’s level of risk for carrying out the suicide action. Suicide Assessment A suicide assessment is a more comprehensive evaluation than screening and is performed by a clinician to confirm suspected suicide risk, estimate the imminent danger to the patient, and decide on a course of treatment. Although assessments can involve structured questionnaires, they also can include a more open-ended conversation with a patient and/or friends and family to gain insight into the patient’s thoughts and behaviors (e.g., related to depression, suicide), risk factors (e.g., access to lethal means or a history of suicide attempts), protective factors (e.g., immediate family support), and medical and mental health history.
View the Patient Safety Screener 3 (PSS-3) at https://sprc.org/micro-learning/the-patient-safety- screener-a-brief-tool-to-detect-suicide-risk
Columbia-Suicide Severity Rating Scale (C-SSRS)
The C-SSRS is one of the most used screening tools. This tool assists the screener in determining whether someone is at risk for suicide, the severity or imminence of that risk, and what level of support the individual needs. The screener will ask the individual if and when they have thought about suicide; which actions they had taken to prepare for suicide and when; and if and when they attempted suicide (whether it was interrupted or if they stopped on their own). Individuals and organizations establish criteria or thresholds that determine what steps need to be taken following the screening. A crisis plan and referral options are a part of the follow-up. The scale, as well as training on how to use the tool, is available free of charge for use in the community and healthcare settings and is available in 140 languages. 44 View the Columbia-Suicide Severity Rating Scale (C-SSRS) tool at https://cssrs.columbia.edu/the-columbia- scale-c-ssrs/about-the-scale/ Beck Depression Inventory-II (BDI-II) The BDI-II depression screening evaluates the individual’s characteristic attitudes and symptoms of depression over the previous two-week period. 45 The tool is widely used and has been validated for use with both adults and adolescents. Beck Scale for Suicidal Ideation (SSI) The SSI tool measures active and passive suicide desires and preparation steps that may have been taken. 45 Any positive responses indicate the need for further detailed questioning.
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