Suicide Screening and Assessment

Suicide Prevention
Resource Center

This publication introduces two approaches to evaluating suicide risk and

provides links to resources that offer additional guidance on choosing and
implementing suicide screening and assessment programs.

There is no universal agreement on the definition or utility of either suicide

screening or assessment. Yet most experts agree that a process by which
people at risk for suicide can be identified and referred to treatment is
an essential component of a comprehensive suicide prevention program.
We hope this publication will help you make an informed choice about
integrating such a process into your suicide prevention efforts.

What is the Difference between Suicide Screening and Suicide Assessment?

Suicide prevention experts usually use the term suicide screening to refer to a procedure in which a standardized
instrument or protocol is used to identify individuals who may be at risk for suicide. Suicide screening can be
done independently or as part of a more comprehensive health or behavioral health screening. Screening may
be done orally (with the screener asking questions), with pencil and paper, or using a computer.

Suicide assessment usually refers to a more comprehensive evaluation done by a clinician to confirm suspected
suicide risk, estimate the immediate 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 behavior, 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.

When Are People Screened or Assessed for Suicide Risk?

Screening can be applied either universally or selectively. A universal screening program is applied to everyone
in a population regardless of whether they are thought to be at a higher risk than the average person. For
example, a universal screening program might include every student in a high school or every patient visiting a
primary care office.

Selective programs are used to screen members of a group that research has shown to be at a higher than
average risk for suicide, regardless of whether particular members of that group are displaying any warning signs
of elevated risk. A selective screening program in a school district might target American Indian youth (who have
a much higher suicide rate than their non-Native peers) and LGBT youth (who have a much higher rate of suicide
attempts than heterosexual youth). A selective screening program in a primary care office might target only those
patients being treated for depression or a substance abuse disorder.

Suicide assessment is characteristically used when there is some indication that an individual is at risk for suicide;
for example, when a patient has been identified as such by a suicide screening or a clinician notices some signs
that a patient may be at risk. Suicide assessment is also used to help develop treatment plans and track the
progress of individuals who are receiving mental health treatment because they have been assessed as being at
risk for suicide.

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Are Suicide Screening and Assessment Effective?
Several expert panels have reviewed the research on suicide
screening and assessment.

The Department of Veterans Affairs/Department of Defense

Assessment of Risk for Suicide Working Group (2013) concluded
that “suicide risk assessment remains an imperfect science, and
much of what constitutes best practice is a product of expert
opinion, with a limited evidence base.”

The U.S. Preventive Services Task Force (2013) reported that “limited
evidence suggests that primary care-feasible screening instruments
may be able to identify adults at increased risk of suicide” and that
evidence that screening is effective is “more limited in older adults and adolescents.” Instruments that successfully
identify adults at risk for suicide tend to produce a high rate of false positives—that is, they incorrectly attribute
suicide risk to people who are not at risk. The task force suggested that screening for suicide may be more effective
when embedded in broader mental health or depression screenings, especially in primary care settings.

The American Academy of Pediatrics Committee on Adolescence (2007) reported that “no specific tests are
capable of identifying a suicidal person” and “scales…tend to be oversensitive and underspecific and lack
predictive value.”

The American Psychiatric Association Work Group on Suicidal Behaviors (2003) concluded that “although
suicide assessment scales have been developed for research purposes, they lack the predictive validity
necessary for use in routine clinical practice. Therefore, suicide assessment scales may be used as aids to suicide
assessment but should not be used as predictive instruments or as substitutes for a thorough clinical evaluation.”

What Do Experts Recommend about Suicide Screening and Assessment?

Despite the mixed research findings on the ability of both screening and assessment to accurately predict who
may be at risk of suicide, there is fairly widespread agreement that both instruments can be useful if conducted by
trained practitioners within a more comprehensive effort in which individuals identified as being at risk for suicide
receive further evaluation and appropriate treatment. The following are summaries of some of the conclusions and
recommendations regarding screening and assessment issued by several expert panels and task forces.

The National Strategy for Suicide Prevention (NSSP): Goals and Objectives for Action (2012) reports that
“Clinical preventive services, including suicide assessment and preventive screening by primary care and
other health care providers, are crucial to assessing suicide risk and connecting individuals at risk for suicide to
available clinical services and other sources of care.” Objective 7.2 of the NSSP recommends training for “mental
health and substance abuse providers on the recognition, assessment, and management of at-risk behavior, and
the delivery of effective clinical care for people with suicide risk.”

The SAMHSA-led Lessons Learned Working Group (2012) recommended that school-based suicide screening
should be implemented after a strategic planning effort has determined that such a program is needed and
that “screening efforts should ideally include related training, education or outreach before or concurrently with
screening campaigns in order to improve screening participation rates and to establish a more robust network of
support for youths at elevated risk for suicide.”

The Joint Commission’s National Patient Safety Goal 15.01.01 (2014) recommends that behavioral health care
and psychiatric hospitals, as well as general hospitals treating patients for emotional or behavioral disorders,
“conduct a risk assessment that identifies specific characteristics of the individual served and environmental
features that may increase or decrease the risk for suicide.”

The National Action Alliance Clinical Care & Intervention Task Force (2012) concluded that suicide assessment
“should be completed by a professional with appropriate and specific training in assessing for and evaluating
suicide risk. This professional must have the skills to engage patients in crisis and to elicit candid disclosures of
suicide risk in a non-threatening environment.”

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The American Psychiatry Association Work Group on Suicidal Behaviors (2003) developed Practice Guidelines
and Treatment of Patients with Suicidal Behaviors. Section II of these guidelines includes recommendations for
a psychiatric evaluation that “will provide information about the patient’s history, current circumstances, and
mental state and will include direct questioning about suicidal thinking and behaviors.”

The American Pediatric Association Committee on Adolescence (2007) recommended that “primary care
pediatricians should be comfortable screening for suicide and mood disorders by asking about emotional
difficulties, identifying lack of developmental progress, and estimating level of distress, impairment of
functioning, and level of danger to self and others.” They suggest that “the best way to assess for suicidal
ideation is by directly asking or screening via self-report” and that “self-administered scales can be useful
for screening, because adolescents may disclose information about suicidality in self-report that they deny in
person” and that “adolescents who endorse suicidality on a scale should always be assessed clinically.”

How Should I Choose a Suicide Screening or Assessment Instrument or Program?

You should choose an instrument or approach based on the following:

1. The evidence showing it will be effective with the

population you are planning to screen or assess
2. The resources you have available to devote to this activity

Questions to ask when choosing an instrument or approach

include the following:

»» Has the instrument been evaluated and found effective?

»» Is there a cost associated with using the instrument?
»» For what age group was the instrument developed?
»» How long does it take to screen or assess an individual?
»» Who will conduct the screening or assessment?
Paraprofessionals? Health care professionals? Mental health professionals?
»» Does using the instrument require training? If so, how expensive is this training, and how many people
will you need to train?
»» If you are planning to implement screening, are you planning to screen universally or selectively?

It is also essential to remember the advice of the experts: Identifying a screening or assessment instrument—
and training people to use it—is only part of the process. It is critical to be prepared to help individuals who are
identified as being at risk to stay safe, receive clinical evaluation, and receive treatment. The following resources
can help you make decisions about whether engaging in suicide screening or assessment is appropriate for your
organization and setting and, if so, how to design and implement this process.

Suicide Screening and Assessment: Selected Resources

Assessment of Suicidal Behaviors and Risk among Children and Adolescents
D. Goldston, National Institute of Mental Health (2000).
http://www.sprc.org/sites/sprc.org/files/library/GoldstonAssessmentSuicidalBehaviorsRiskChildrenAdolescents.pdf
This report describes instruments used to screen and assess suicidal behaviors and risk among children and
adolescents.

Behavioral Health Care National Patient Safety Goals

The Joint Commission (2014).
http://www.jointcommission.org/assets/1/6/BHC_NPSG_Chapter_2014.pdf
The Joint Commission creates standards that help health care organizations measure, assess, and improve
performance. Goal 15 is “Identify individuals at risk for suicide.”

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Clinical Practice Guideline: Suicide Risk Assessment: Full Version
Emergency Nursing Resources Development Committee, Emergency Nurses Association (2012).
http://www.ena.org/practice-research/research/CPG/Documents/SuicideRiskAssessmentCPG.pdf
This Clinical Practice Guideline (CPG) “evaluates the scientific and research literature for the initial assessment
and evaluation of patients who present to the emergency setting who have suicidal ideation or after attempted
suicide and/or those patients at high risk for future attempts of suicide.”

Identifying and Assessing Suicide Risk Level

National Action Alliance for Suicide Prevention (2014).
http://zerosuicide.actionallianceforsuicideprevention.org
This Web-based resource features information on suicide screening in health care and behavioral health settings
as well as links to additional resources.

National Strategy for Suicide Prevention: Goals and Objectives for Action
U.S. Surgeon General and the National Action Alliance for Suicide Prevention (2012).
http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full_report-rev.pdf
Objective 7.2 focuses on training mental health providers to recognize, assess, and manage suicide risk. Goal 7
of the National Strategy is to “Provide training to community and clinical service providers on the prevention of
suicide and related behaviors.”

Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System
Committee of Pediatric Emergency Medicine, American Academy of Pediatrics (2011).
http://pediatrics.aappublications.org/content/127/5/e1356.full.html
This technical report includes recommendations for specific instruments to use in assessing suicide risk in
children and adolescents in emergency departments. It supports the recommendations found in Suicide and
Suicide Attempts in Adolescents and A Resource Guide for Implementing the Joint Commissions 2007 Patient
Goals on Suicide.

Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors
American Psychiatric Association Work Group on Suicidal Behaviors (2003).
http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1673332
Part A, Section II of these guidelines “discusses the assessment of the patient, including a consideration of
factors influencing suicide risk.”

Recommendations for School-Based Suicide Prevention Screening

Lessons Learned Working Group, Substance Abuse and Mental Health Services Administration (2012).
http://www.sprc.org/sites/sprc.org/files/library/Recommendations%20for%20School-Based%20Suicide%20
Prevention%20Screening.pdf
These recommendations on implementing suicide risk screening programs in secondary schools are also
applicable to other settings, including primary care.

A Resource Guide for Implementing the Joint Commissions 2007 Patient Goals on Suicide
D. Jacobs, Screening for Mental Health, Inc. (2007).
http://www.sprc.org/sites/sprc.org/files/library/jcsafetygoals.pdf
This guide, developed in collaboration with the Suicide Prevention Resource Center, is designed to help
behavioral health care staff implement the recommendations of the Joint Commission’s National Patient Safety
Goals on patient suicide, which are described elsewhere in this resource list.

A Review of Suicide Assessment Measures for Intervention Research with Adults and Older Adults
G. Brown, National Institute of Mental Health (2003).
http://www.sprc.org/sites/sprc.org/files/library/BrownReviewAssessmentMeasuresAdultsOlderAdults.pdf
This resource presents a systematic examination of assessment instruments for suicidal behaviors and behaviors
closely associated with suicide risk in adults and older adults.

Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care
United States Preventive Services Task Force Recommendations (May 2014).
http://www.uspreventiveservicestaskforce.org/uspstf/uspssuic.htm

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Screening for Suicide Risk in Primary Care: A Systematic Evidence Review for the U.S. Preventive Services
Task Force
E. O’Connor, B. Gaynes, B. U. Burda, C. Williams, & E. P. Whitlock (2013).
http://www.ncbi.nlm.nih.gov/pubmed/23678511

Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S.
Preventive Services Task Force
E. O’Connor, B. N. Gaynes, B. U. Burda, C. Soh, & E. P. Whitlock (2013).
http://annals.org/article.aspx?articleid=1681063
The three reports just above on the accuracy of suicide risk screening instruments and effectiveness of suicide
screening were developed by independent groups of experts that make recommendations about clinical
preventive services.

Suicide and Suicide Attempts in Adolescents

Committee on Adolescence, American Academy of Pediatrics (2007).
http://pediatrics.aappublications.org/content/120/3/669.full.html
This clinical report includes specific advice for pediatricians who are screening adolescents for suicide risk.

Suicide Care in Systems Framework

National Action Alliance for Suicide Prevention Clinical Care & Intervention Task Force (2012).
http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/taskforces/
ClinicalCareInterventionReport.pdf
This report recommends routine universal screening for suicide risk in all primary care, hospital care, behavioral
health care, and crisis response settings.

Suicide Risk Factors and Risk Assessment Tools: A Systematic Review

E. M. Haney, M. E. O’Neil, S. Carson, A. Low, K. Peterson, L. M. Denneson . . . D. Kansagara. Health Services
Research & Development Service, Department of Veterans Affairs (2012).
http://www.ncbi.nlm.nih.gov/books/NBK92671/pdf/TOC.pdf
This report reviews “recent evidence about suicide risk factors and suicide risk assessment tools” to inform
practice guidelines for clinicians serving veterans and military populations. However, much of the information is
also applicable to the general adult population.

VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide
Assessment and Management of Risk for Suicide Working Group, Department of Veterans Affairs/Department
of Defense (2013).
http://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf
This comprehensive guideline outlines a framework for a structured assessment of adults (18 and over) suspected
to be at risk for suicide as well as both the immediate and long-term management and treatment that should
follow if an individual is found to be at risk. It was developed for health care professionals working in both
general and mental health care settings.

September 2014

You may reproduce and distribute these sheets provided you retain SPRC’s copyright information and website address.

Cite as: Suicide Prevention Resource Center. (2014, September). Suicide Screening and Assessment. Waltham, MA: Education
Development Center, Inc.

The people depicted in the photograph in this publication are models and used for illustrative purposes only.

The Suicide Prevention Resource Center is supported by a grant from the U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration (SAMHSA) under Grant No. 5U79SM059945.

Suicide Prevention Resource Center

Web: http://www.sprc.org • E-mail: [email protected] • Phone: 877-GET-SPRC (438-7772)

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