Some simple questions can help prevent suicide

Overview

Every year, thousands of people in the United States see a health professional weeks or days before taking their own life.1 The signs and symptoms of suicidal thoughts or behavior are often subtle and not immediately apparent to health care providers, so many patients experiencing these symptoms are not screened. These interactions are missed opportunities to connect people with life-saving care.

Health care providers should ask all patients, whether they show signs of risk or not, if they are considering suicide. The initial assessment takes less than a minute, is covered by public and private insurers, and can effectively help identify people experiencing suicidal thoughts or behavior.

Suicide in the United States, in numbers

  • In 2020, almost 46,000 people living in the United States committed suicide.two
  • About half of people who die by suicide visit a health care provider within four weeks of their death.3
  • More than half of people who die by suicide do not have a known mental health diagnosis.4
  • A study of eight emergency departments showed that universal screening for suicide risk helped identify twice as many people who were at risk of suicide compared to the usual approach of screening patients with psychiatric symptoms.5 The researchers also found that universal screening followed by evidence-based interventions reduced total suicide attempts by 30% during the year of the study.6

Patients at risk of suicide do not always show it

  • Suicide is rarely caused by a single factor. Most current screening practices focus on mental health conditions as a primary indicator of suicide risk, yet more than half of people who die by suicide do not have a prior mental health diagnosis.7 A wide range of factors can contribute to suicide risk, many of which are not evident in health records or may not be voluntarily disclosed by patients. These factors may include individual and family history; socioeconomic circumstances; access to lethal force, including firearms and medicine; and barriers to accessible and affordable mental health care, including inadequate insurance coverage for services and a lack of mental health care professionals.8
  • People exhibit suicidal tendencies, which include suicidal thoughts and plans, deliberate self-harm, and suicide attempts, differently. Not all people disclose that they are experiencing suicidal thoughts or behaviors.9 People may also express symptoms of suicidality or mental health conditions differently, depending on their cultural background, gender, or even personality.10 Understanding the complex constellation of suicide risk factors and warning signs is challenging. Providers can misinterpret symptoms, or lack of them, and underdiagnose or misdiagnose patients.eleven

Universal screening is more effective than current practices

  • Universal screening identifies more people experiencing suicidality; connecting them with care reduces suicide attempts and deaths. Asking a few direct questions can help ensure that all people experiencing suicidal thoughts are identified and connected to care. In fact, a study of universal screening in emergency departments found that health care providers identified almost twice as many patients as at risk for suicide than they would have if they didn’t screen everyone.12 Another study of emergency departments found 30% fewer total suicide attempts over a year among patients who received universal screening and evidence-based follow-up care than among patients who were not identified through universal screening.13
  • Talking about suicide does not increase the risk. Some health care providers avoid asking about suicide because they believe that talking about suicide can trigger suicidal thoughts or behavior. However, studies show that screening for suicide risk is safe and is not associated with increased suicidality.14 In addition, direct communication with patients about suicide is critical to identifying individuals at risk for suicide and increasing the likelihood that they will receive treatment.fifteen

Universal screening in practice

Parkland Health & Hospital System in Dallas is one of the largest public hospital systems in the country, treating more than 1 million patients a year.sixteen In 2015, Parkland was the first health system in the US to implement a universal suicide screening program in its facilities. Among the adult and pediatric populations examined that year, 96% reported no symptoms suggesting they were at risk for suicide and 97% warranted no further action by their health care provider.17 However, screening protocols identified an elevated risk of suicide in about 2.3% of patients seeking non-psychiatric care who would have gone unrecognized if universal screening had not been implemented.18 These findings reinforce other research that suggests a significant number of people at risk of suicide pass through our hospitals and health systems undetected.19

call to action

Health systems, hospitals, urgent care centers, doctors’ offices and other providers should implement universal screening as part of routine health exams to quickly and effectively identify more people who are thinking about suicide . Universal screening should be part of broader comprehensive suicide prevention and intervention efforts to ensure that people experiencing suicidality are identified, appropriately assessed, and connected to follow-up care and treatment.

If you or someone you know needs help, please dial 988Call to National Lifeline for Suicide Prevention a 800-273-8255or text HOME to 741741 to reach a Crisis Counselor Text Line.

final notes

  1. BK Ahmedani et al., “Health Care Contacts in the Year Before Death by Suicide” Journal of General Internal Medicine 29, no. 6 (2014): 87077, https://doi.org/10.1007/s11606-014-2767-3.
  2. Centers for Disease Control and Prevention, “Facts About Suicide,” accessed June 10, 2022, https://www.cdc.gov/suicide/facts/index.html.
  3. Ahmedani et al., “Health Care Contacts.”
  4. DM Stone et al., “Vital Signs: Trends in State Suicide Rates: United States, 1999-2016 and Circumstances Contributing to Suicide: 27 States, 2015” Weekly Morbidity and Mortality Report 67, no. 22 (2018): 617-24, https://dx.doi.org/10.15585/mmwr.mm6722a1.
  5. ED Boudreaux et al., “Improving Suicide Risk Screening and Screening in the Emergency Department” American Journal of Preventive Medicine 50, no. 4 (2016): 445-53, https://doi.org/10.1016/j.amepre.2015.09.029.
  6. IW Miller et al., “Suicide Prevention in an Emergency Department Population: The ED-SAFE Study” JAMA Psychiatry 74, no. 6 (2017): 563-70, http://dx.doi.org/10.1001/jamapsychiatry.2017.0678.
  7. Stone et al., “Vital Signs: Trends in State Suicide Rates.”
  8. Centers for Disease Control and Prevention, “Suicide Rising Across the US,” accessed June 10, 2022, https://www.cdc.gov/vitalsigns/suicide/; Centers for Disease Control and Prevention, “Risk and Protective Factors,” accessed June 10, 2022, https://www.cdc.gov/suicide/factors/index.html.
  9. BA Ammerman et al., “The Role of Suicide Stigma in Self-Disclosure Among Civilian and Veteran Populations” psychiatric research 309 (2022), https://doi.org/10.1016/j.psychres.2022.114408; A.C. Knorr et al., “Prediction of status along the continuum of suicidal thoughts and behaviors among people with a history of nonsuicidal self-harm” research in psychiatry 273 (2019): 514-22, https://doi.org/10.1016/j. psychres.2019.01.067.
  10. Emergency Task Force on Black Youth Suicide and Mental Health, “Sound the Alarm: America’s Black Youth Suicide Crisis” (2020), https://theactionalliance.org/resource/ring-alarm-crisis-black-youth-suicide-america; P. Baiden et al., “Examining the intersection of race/ethnicity and sexual orientation in suicidal ideation and attempted suicide among adolescents: Findings from the 2017 Youth Risk Behavior Survey” Journal of Psychiatric Research 125 (2020): 13-20, https://doi.org/10.1016/j.jpsychires.2020.02.029; W. Lu et al., “Psychometric Properties of the Ces-D Among Black Adolescents in Public Housing” Journal of the Society for Social Work and Research 8, no. 4 (2017): 595-619, https://doi.org/10.1086/694791.
  11. Emergency Task Force on Black Youth Suicide and Mental Health, “Sound the Alarm”; Lu et al., “Psychometric properties of Ces-D”.
  12. Boudreaux et al., “Improving Screening for Suicide Risk.”
  13. Miller et al., “Suicide Prevention in an Emergency Department Population.”
  14. CW Mathias et al., “What’s the harm in asking about suicidal ideation?” Suicidal and life-threatening behavior 42, no. 3 (2012): 341-51, doi:10.1111/j.1943-278X.2012.0095.x.
  15. GE Simon et al., “Does Response to the PHQ-9 Depression Questionnaire Predict Subsequent Suicide Attempt or Death by Suicide?” psychiatric services 64, no. 12 (2013): 1195-202, doi:10.1176/appi.ps.201200587; GE Simon et al., “Risk of suicide attempt and death by suicide after completion of the depression module of the patient health questionnaire in community practice” Journal of Clinical Psychiatry 77, no. 2 (2016): 221-27, doi:10.4088/JCP.15m09776.
  16. The Pew Charitable Trusts, “Universal Screening May Help Identify People at Risk for Suicide,” January 25, 2022, https://www.pewtrusts.org/en/research-and-analysis/articles/2022/01/25/universal-screening-can-help-identify-people-at-risk-for-suicide
  17. K. Roaten et al., “Development and Implementation of a Universal Suicide Risk Screening Program in a Safety Net Hospital System” Journal of the Joint Commission on Quality and Patient Safety 44 (2018): 4-11, https://doi.org/10.1016/j.jcjq.2017.07.006; K. Roaten et al., “Universal Pediatric Suicide Risk Screening in a Health Care System: 90,000 Patient Encounters” Journal of the Academy of Consultation Liaison Psychiatry 62, no. 4 (2021): 421-29, https://doi.org/10.1016/j.jaclp.2020.12.002.
  18. Roaten et al., “Universal Pediatric Suicide Risk Screening”; The Pew Charitable Trusts, “Universal Screening Can Help.”
  19. Miller et al., “Suicide Prevention in an Emergency Department Population”; Boudreaux et al., “Improving Screening for Suicide Risk”; MA Ilgen et al., “Recent suicidal ideation among patients in an inner-city emergency department,” SSuicidal and life-threatening behavior 39, no. 5 (2009): 508-17, doi: 10.1521/suli.2009.39.5.508; MH Allen et al., “Detection of Suicidal Ideas and Attempts Among Emergency Department Medical Patients: Instrument and Results of the Psychiatric Emergency Research Collaboration” Suicide and Life-Threatening Behavior 43, no. 3 (2013): 313-23, https://doi.org/10.1111/sltb.12018.

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