● Significant clinical change (increase in suicidal ideation [SI], suicidal behavior, change in mental status, unstable mood, impulsiveness, trauma victimization). ● Regarding inpatient care settings, a change in privilege level, when there is a deterioration in mental status, and before discharge. Warning signs are verbal expressions, changes in behaviors, or new behaviors that may indicate that a person is suicidal. The more of these warning signs a person displays, the greater the risk of suicide (SAMHSA, 2021). Adult warning signs include (Jacobs & Klein-Benheim, 2021): ● Talking about feeling hopeless or having no purpose. ● Talking about feeling trapped or being in unbearable pain. ● Talking about being a burden to others. ● Talking about wanting to die. ● Looking for a way to kill oneself.
● Experiencing severe mental pain. ● Depression. ● Severe anxiety, panic attacks. ● Displaying extreme mood swings. ● Showing rage or talking about seeking revenge. ● Giving away prized possessions. ● Saying a final goodbye to family and friends. ● Putting affairs in order. ● Lack of interest in future plans. Youth warning signs include (Jacobs & Klein-Benheim, 2021): ● Talking about or making plans for suicide. ● Expressing hopelessness. ● Displaying severe emotional pain or distress. ● Showing worrisome behavioral cues or marked changes in behavior, such as: ○ Withdrawal from or change in social connections, including extracurricular activities and school performance. ○ Changes in sleep. ○ Anger or hostility that is out of character or out of context.
● Talking about great guilt or shame. ● Increasing the use of alcohol or drugs. ● Acting anxious, agitated, or reckless. ● Sleeping too little or too much. ● Withdrawing or feeling isolated. ● Daring or risk-taking behavior.
○ Recent increased agitation or irritability. ○ Risk-taking behavior or alcohol/drug use.
SUICIDE SCREENING
Screening and assessment are not synonymous. “Suicide screening" is often a quick and standard procedure or form to identify individuals at risk for suicide who could benefit from further evaluation (Jacobs & Klein-Benheim, 2021). On the other hand, “assessment” provides a more thorough Suicide screening tools Screening an individual for suicidal risk involves several equally important factors: ● Establishing rapport to determine an honest assessment. ● Using an evidence-based screening tool that is appropriate for the individual and the situation. ● Knowing what to do with the information collected. Suicide screening tools are standardized and brief, taking less than 15 minutes to complete. The screener needs to ask all questions in the tool precisely. Should an individual show “at-risk scores or indicators,” they require a full suicide assessment by a behavioral health provider. 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 depressive symptoms in the primary healthcare setting (American Psychological Association [APA], 2020). The tool rates the frequency of symptoms and then factors in the scoring severity index. A follow-up questionnaire on the PHQ-9 assigns weight to the degree that the depressive problems are affecting the patient’s level of functioning. It can be used repeatedly to determine improvement or worsening of depression in response to treatment (APA, 2020). 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 (Zero Suicide, n.d.). This screening tool may be more useful in an outpatient behavioral health setting.
conceptualization of an individual (Jacobs & Klein-Benheim, 2021). Assessments may include screenings, but these screening measures are used with other information to form an assessment.
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. Columbia-Suicide Severity Rating Scale (C-SSRS) The C-SSRS assists in determining risk for suicide, the severity or imminence of that risk, and what level of support the individual needs (Columbia Lighthouse Project, 2016). Individuals and organizations establish criteria or thresholds that determine what steps need to be taken following the screening. The scale, as well as training on how to use the tool, is available free of charge and is available in 140 languages (Columbia Lighthouse Project, 2016). View the Columbia-Suicide Severity Rating Scale (C-SSRS) tool at https://cssrs.columbia.edu/wp- content/uploads/C-SSRS- Full-Lifetime-Recent-1.doc. 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 (Beck Institute, n.d.). 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 (Beck Institute, n.d.). Any positive responses indicate the need for further detailed questioning. Beck Hopelessness Scale (BHS) The BHS tool is based on pessimism, hopelessness, and suicidal risk (Beck Institute, n.d.). Hopelessness is a strong predictor and is a stronger indicator than the severity of depression. If the screening indicates a risk for
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Book Code: SWPA1525
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