Early identification of health risks is crucial in any medical setting. When it comes to mental health, and specifically the risk of suicide, using effective and efficient screening tools can be a matter of life and death. The Ask Suicide-Screening Questions (ASQ) tool stands out as a vital Care Screen Health Tool for medical professionals. This brief, validated method helps identify individuals at risk quickly and accurately, ensuring that those in need receive timely intervention and support. Developed and rigorously tested by the National Institute of Mental Health (NIMH), the ASQ tool is designed for use across various medical environments, from bustling emergency departments to outpatient clinics, for both youth and adults.
This video is provided for general informational purposes only and does not constitute an endorsement by NIMH.
This article delves into the significance of suicide risk screening, the mechanics of the ASQ tool, and how it can be seamlessly integrated into your practice to enhance patient care and safety. We will explore the background of suicide as a public health crisis, the critical role of early detection, and the practical application of the ASQ toolkit in different medical settings.
The Public Health Imperative: Understanding Suicide Risk
Suicide is not just a personal tragedy; it’s a significant global public health problem. It ranks among the leading causes of death worldwide across all age demographics. In the United States, the statistics are particularly alarming, with suicide being the second leading cause of death for young individuals aged 10 to 24. Data from the Centers for Disease Control and Prevention (CDC) reveals that over 47,000 lives were lost to suicide in 2019 alone. These numbers underscore the urgent need for effective suicide prevention strategies, with early detection at the forefront.
The stark reality is that for every completed suicide, there are countless more suicide attempts and individuals grappling with suicidal thoughts. This highlights the broader spectrum of suffering and the immense opportunity for intervention before a crisis point is reached.
Why Early Suicide Risk Screening is Essential
A crucial aspect of suicide prevention is early detection. Studies have shown that a significant majority of individuals who die by suicide had contact with a healthcare provider in the months leading up to their death. This contact represents a vital window of opportunity to identify those at risk and connect them with the necessary mental health resources. However, despite this clear opportunity, routine suicide risk screening is not yet standard practice in many healthcare settings.
Recognizing this gap, The Joint Commission, the leading accreditation organization for healthcare programs in U.S. hospitals, issued a Sentinel Event Alert in February 2016. This alert strongly recommends universal suicide risk screening for all medical patients across all medical settings. This includes inpatient units, outpatient practices, and emergency departments. The recommendation emphasizes the use of validated suicide risk screening tools, proven effective in medical settings and with both youth and adult populations. These tools empower clinicians to accurately identify individuals at risk and determine the appropriate level of intervention needed.
Implementing an evidence-based clinical pathway is crucial for a streamlined and effective screening process. Such a pathway provides a clear framework for identifying at-risk patients and managing those who screen positive. This systematic approach saves valuable time and resources when responding to positive screens, ensuring that patients receive prompt and appropriate care. The ASQ Toolkit offers several suicide risk clinical pathways designed to provide this structured support.
Introducing the ASQ Tool: A Quick and Effective Care Screen
The Ask Suicide-Screening Questions (ASQ) tool was developed through NIMH-led multisite research starting in 2008, initially focusing on youth in medical settings. Further research in 2014 expanded its validation to include adult populations. The ASQ is remarkably brief, consisting of just four yes/no questions that take approximately 20 seconds to administer. This brevity is a key advantage in busy medical environments, making it a practical and efficient care screen health tool. The primary purpose of the ASQ is to identify individuals who require a more comprehensive mental health or suicide safety assessment.
One of the main challenges in implementing suicide risk screening in medical settings is effectively managing patients who screen positive. To address this, settings need a clear management plan in place before initiating screening. The ASQ Toolkit was specifically created to support this crucial aspect, providing resources and guidance for managing patients identified as being at risk. It simplifies the implementation of suicide risk screening and equips healthcare providers with the tools necessary for appropriate patient management.
Leveraging the ASQ Toolkit for Enhanced Patient Safety
The ASQ toolkit is specifically designed for medical patients aged 8 years and older. It is important to note that for children younger than 8 years, validated screening tools are not available. If suicide risk is suspected in this younger age group, a comprehensive mental health evaluation is recommended instead of using a screening tool. The ASQ tool is available free of charge and has been translated into multiple languages to enhance accessibility and broaden its reach.
When screening youth, best practices recommend conducting the screening without a parent or guardian present. The toolkit includes nursing scripts to guide healthcare providers in respectfully requesting parents or guardians to step out of the room during screening. However, if a parent or guardian declines to leave, or if the child insists on their presence, the screening should still be conducted. In all cases, any other visitors in the room should be asked to leave to ensure patient privacy and encourage honest responses.
Responding to Positive Screens: The Brief Suicide Safety Assessment (BSSA)
When a patient screens positive for suicide risk on the ASQ, the next critical step is a brief suicide safety assessment (BSSA). This assessment should be conducted by a trained clinician, such as a social worker, nurse practitioner, physician assistant, physician, or other mental health professional. The BSSA is designed to be brief and focused, guiding the subsequent steps for patient care within the specific medical setting. Regardless of the final disposition after the BSSA, every patient who screens positive should be provided with a Patient Resource List offering immediate support and contact information for mental health services.
The ASQ toolkit is thoughtfully organized by medical setting, providing tailored resources for emergency departments, inpatient medical/surgical units, and outpatient primary care and specialty clinics. For any questions about the toolkit materials or the implementation of suicide risk screening, professionals are encouraged to contact Dr. Lisa Horowitz at [email protected] or Debbie Snyder, MSW at [email protected].
Youth Resources: Emergency Department (ED/ER), Inpatient Medical/Surgical Unit, Outpatient Primary Care/Specialty Clinics
Adult Resources: Emergency Department (ED/ER), Inpatient Medical/Surgical Unit, Outpatient Primary Care/Specialty Clinics
Note: Certain materials within the toolkit are universally applicable across all medical settings. These resources can also be valuable in other environments where youth are served, such as school nursing offices and juvenile detention centers.
Essential Suicide Prevention Resources
For immediate support and further information on suicide prevention, please refer to these vital resources:
National Suicide Prevention Lifeline : 1-800-273-TALK (8255) – Spanish/español: 1-888-628-9454
Crisis Text Line : Text HOME to 741-741
Suicide Prevention Resource Center
National Institute of Mental Health
Substance Abuse and Mental Health Services Administration
By integrating the ASQ care screen health tool into your practice, you are taking a proactive step towards creating a safer and more supportive environment for your patients. Early detection and intervention are key to suicide prevention, and the ASQ toolkit provides the resources and guidance needed to make a significant difference.
References
Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., … & Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department . Archives of Pediatrics & Adolescent Medicine, 166(12), 1170-1176.
Horowitz, L. M., Snyder, D. J., Boudreaux, E. D., He, J. P., Harrington, C. J., Cai, J., Claassen, C. A., Salhany, J. E., Dao, T., Chaves, J. F., Jobes, D. A., Merikangas, K. R., Bridge, J. A., Pao, M. (2020). Validation of the Ask Suicide-Screening Questions (ASQ) for adult medical inpatients: A brief tool for all ages. Psychosomatics, 61(6), 713-722.
Horowitz, L. M., Wharff, E. A., Mournet, A. M., Ross, A. M., McBee-Strayer, S., He, J., Lanzillo, E., White, E., Bergdoll, E., Powell, D. S., Merikangas, K. R., Pao, M., & Bridge, J. A. (2020). Validation and feasibility of the Ask Suicide-Screening Questions (ASQ) among pediatric medical/surgical inpatients. Hospital Pediatrics, 10(9), 750-757
Aguinaldo, L. D., Sullivant, S., Lanzillo, E. C., Ross, A., He, J. P., Bradley-Ewing, A., Bridge, J. A., Horowitz, L. M., & Wharff, E. A. (2021). Validation of the Ask Suicide-Screening Questions (ASQ) with youth in outpatient specialty and primary care clinics . General Hospital Psychiatry, 68, 52–58.
Brahmbhatt, K., Kurtz, B. P., Afzal, K. I., Giles, L. L., Kowal, E. D., Johnson, K. P., … & Workgroup, P. (2019). Suicide risk screening in pediatric hospitals: Clinical pathways to address a global health crisis . Psychosomatics, 60(1), 1-9.
Roaten, K., Horowitz, L. M., Bridge, J. A., Goans, C. R. R., McKintosh, C., Genzel, R., Johnson, C., & North, C. S. (2021). Universal pediatric suicide risk screening in a health care system: 90,000 patient encounters. Journal of the Academy of Consultation-Liaison Psychiatry.
Horowitz, L. M., Mournet, A. M., Lanzillo, E., He, J. P., Powell, D. S., Ross, A. M., Wharff, E. A., Bridge, J. A., & Pao, M. (2021). Screening pediatric medical patients for suicide risk: Is depression screening enough? Journal of Adolescent Health, S1054-139X(21)00060-4.
Mournet, A. M., Smith, J. T., Bridge, J. A., Boudreaux, E. D., Snyder, D. J., Claassen, C. A., Jobes, D. A, Pao, M., & Horowitz, L. M. (2021). Limitations of screening for depression as a proxy for suicide risk in adult medical inpatients. Journal of the Academy of Consultation-Liaison Psychiatry.
Thom, R., Hogan, C., & Hazen, E. (2020). Suicide Risk Screening in the Hospital Setting: A Review of Brief Validated Tools. Psychosomatics, 61(1), 1–7.
Lanzillo, E. C., Horowitz, L. M., Wharff, E. A., Sheftall, A. H., Pao, M., & Bridge, J. A. (2019). The importance of screening preteens for suicide risk in the emergency department. Hospital Pediatrics, 9(4), 305–307.
DeVylder, J. E., Ryan, T. C., Cwik, M., Wilson, M. E., Jay, S., Nestadt, P. S., Goldstein, M., & Wilcox, H. C. (2019). Assessment of selective and universal screening for suicide risk in a pediatric emergency department. JAMA Network Open, 2(10), e1914070.
Ballard, E. D., Cwik, M., Van Eck, K., Goldstein, M., Alfes, C., Wilson, M. E., … & Wilcox, H. C. (2017). Identification of at-risk youth by suicide screening in a pediatric emergency department . Prevention Science, 18(2), 174-182.
Newton, A. S., Soleimani, A., Kirkland, S. W., & Gokiert, R. J. (2017). A systematic review of instruments to identify mental health and substance use problems among children in the emergency department . Academic Emergency Medicine, 24(5), 552-568.
Ross, A. M., White, E., Powell, D., Nelson, S., Horowitz, L., & Wharff, E. (2016). To ask or not to ask? Opinions of pediatric medical inpatients about suicide risk screening in the hospital . The Journal of Pediatrics, 170, 295-300.
Horowitz, L. M., Bridge, J. A., Pao, M., & Boudreaux, E. D. (2014). Screening youth for suicide risk in medical settings: time to ask questions . American Journal of Preventive Medicine, 47(3), S170-S175.
Ballard, E. D., Bosk, A., Pao, M., Snyder, D., Bridge, J. A., Wharff, E. A., Teach, S. J., & Horowitz, L. (2012). Patients’ opinions about suicide screening in a pediatric emergency department . Pediatric Emergency Care, 28(1), 34.
