I work in an outpatient clinic that treats many teenagers. I'm concerned about the widely reported rise in teen suicides. What is the best way to screen adolescents for suicide risk?—P.T., MD.
Kayliana VanWinkle, Simranjit Kaur, and Bridget Parsh, MSN, EdD, CNS, RN, respond: As you know, suicide in teenagers and young adults has become a serious public health concern. From 2007 to 2017, the number of suicides among young people ages 10 to 24 increased 56%, from 6.8 deaths per 100,000 people to 10.6 deaths per 100,000 people. In the same period, the suicide rate for children and adolescents ages 10 to 14 nearly tripled.1
No specific tests accurately predict suicides, but nurses can identify risk factors during patient assessment (see Risk factors for suicide). Questionnaires with direct questions about suicidal thoughts and plans can help nurses identify at-risk patients and intervene in cases that might otherwise go unnoticed.2,3 Although some nurses worry that raising the issue may “put ideas” into a patient's head, research has shown that discussing suicide does not increase the risk.4-6
Suicide screening with a standardized instrument or protocol can be performed independently or as part of a more comprehensive health or behavioral health screening. Evidence-based screening tools such as the Columbia-Suicide Severity Rating Scale (C-SSRS) and the P4 Suicidality Screener include direct questions about thoughts of suicide and self-harm over the past month.7-11 P4 is shorthand for the four screening questions: past history, plan, probability, and preventive factors.7,11
Available free of charge from the National Institute of Mental Health, the Ask Suicide-Screening Questions (ASQ) Toolkit is designed to help clinicians in EDs, clinics, and other healthcare settings identify at-risk patients by asking four short questions.12 A study involving patients ages 10 to 21 showed that a “yes” response to one or more of the four questions identified 97% of youth at risk for suicide.13
For patients who may be at risk for suicide, a more comprehensive suicide evaluation should be done immediately to gauge the level of severity. This includes exploring suicidal intent, plans for self-harm, and suicidal thoughts and behavior.3,7
Suicide assessment combines close-ended questionnaires with open-ended interviews to build a bigger picture of the patient's thoughts, behaviors, and such risk factors as access to lethal means or a history of suicide attempts. Along with the patient's medical and behavioral health history, the clinician should also assess protective factors (such as family support) and initiate a safety plan.
Based on the patient's risk level, the care team makes decisions on interventions, such as hospital admission with suicide precautions, developing a crisis plan, or outpatient referral.7 The Joint Commission recommends various strategies depending on the healthcare setting and the patient's level of risk (see Resources for patients and nurses).2
Using a screening tool to identify at-risk patients is only the start of the process. Nurses must be prepared to help at-risk patients stay safe, undergo clinical evaluation, and receive the treatment they need.
Risk factors for suicide1,10,14
- family history of suicide
- past suicide attempt(s)
- history of depression, other mental health problems, or incarceration
- exposure to previous suicidal behavior by others
- history of physical or sexual abuse
- easy access to lethal means, such as firearms
- alcohol and/or drug use
- residential mobility that might lessen opportunities for developing social connections and supports
- impaired parent-child relationship
- exposure to social isolation, bullying
- gay, lesbian, bisexual, transgender, or gender nonconforming identity
- difficulties in school or missing school
- stressful life events such as conflicts with a romantic partner.
Resources for patients and nurses
The Columbia Lighthouse Project
The Joint Commission Sentinel Event Alert, Issue 56, February 24, 2016
National Suicide Prevention Hotline
National Suicide Prevention Lifeline
Suicide Prevention Resource Center
1. Curtin SC, Heron M. Death rates due to suicide and homicide among persons aged 10-24: United States, 2000-2017. NCHS Data Brief, no. 352. Hyattsville, MD: National Center for Health Statistics; 2019.
2. The Joint Commission. Detecting and treating suicide ideation in all settings. Sentinel Event Alert
. Issue 56. February 24, 2016.
4. Dazzi T, Gribble R, Wessely S, Fear NT. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence. Psychol Med
5. DeCou CR, Schumann ME. On the iatrogenic risk of assessing suicidality: a meta-analysis. Suicide Life Threat Behav
6. Manton A. Suicide prevention...ask the question! J Emerg Nurs
7. SAMSA/HRSA Center for Integrated Health Resources. Screening tools: suicide risk screening tools. http://www.integration.samhsa.gov/clinical-practice/screening-tools#suicide
9. The Columbia Lighthouse Project. Identify risk. Prevent suicide. http://cssrs.columbia.edu
10. Kennebeck S, Bonin L. Suicidal ideation and behavior in children and adolescents: evaluation and management. UpToDate. 2018. http://www.uptodate.com
11. Dube P, Kurt K, Bair MJ, Theobald D, Williams LS. The p4 screener: evaluation of a brief measure for assessing potential suicide risk in 2 randomized effectiveness trials of primary care and oncology patients. Prim Care Companion J Clin Psychiatry
12. Ask Suicide-Screening Questions Toolkit. National Institutes of Health/National Institute of Mental Health. http://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml
13. Horowitz LM, Bridge JA, Teach SJ, et al Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med
14. Shain BCommittee on adolescence. Suicide and suicide attempts in adolescents. Pediatrics