Does It Make Sense to Screen for Suicide Risk?
by Brian Ahmedani, Ph.D., LMSW, MI Mind Program Co-director
There has been much conversation about the benefit of screening for suicide risk. On one hand, the US Preventive Services Task Force suggests there is not enough evidence to support universal suicide risk screening in primary care. The primary rationale for this determination was that there hasn’t been enough clinical trials data to support screening. However, the Joint Commission National Patient Safety Goal 15.01.01 does require accredited facilities to screening for suicide risk among patients with behavioral health conditions. In addition, their Sentinel Event Alert #56 recommends suicide risk screening for all patients in all settings.
The Joint Commission cites data demonstrating the effectiveness of screening to identify suicide risk among patients in health systems with a more expanded view to include a wider range of studies (not limited to clinical trials). Furthermore, the 2024 US National Strategy for Suicide Prevention takes the same approach, specifically highlighting the importance of screening for suicide risk as the first minimum required step to a comprehensive suicide prevention care pathway in health systems, and the accompanying 2024 US Federal Action Plan for Suicide Prevention outlines requirements for universal screening to support identification and stimulate prevention and intervention in a range of health system settings.
In the MI Mind program, we promote universal suicide risk screening for all patients in primary care and behavioral health settings. Why? Our research indicates that screening is pragmatic (as little as one question) and strongly supported by evidence (from multiple replicated studies). In 2014, our team published a paper showing that >83% of individuals make healthcare visits in the weeks and months leading up to a suicide death. Most of those visits occur in primary care and only half of people have a mental health diagnosis prior to death (PubMed source). Our data also show that when patients do have a mental health condition there is a significant increased risk for suicide (PubMed source). We conclude that the vast majority of people are right in front of us in clinical settings before they die by suicide and that universal screening will help us reach those with and without a mental health diagnosis.
But what about the tools used to screen – do they even work? In 2013, our close colleague, Dr. Greg Simon, published an important paper showing that the 9th question on the PHQ-9 identified individuals in outpatient care who had an increased risk for suicide attempt and death over the following 90 days, one year, and two years into the future (PubMed source). At each level of increased severity of response on that question, the suicide risk doubles – such that at the highest level of response individuals have about an eight times higher risk of suicide in the near-term future.
Subsequently, additional research (including research by our team) has replicated these findings with millions of completed PHQ-9 screeners. While this isn’t clinical trial data, it is clear evidence that screening helps to identify risk. In addition, several other screening tools, such as the ASQ and C-SSRS, have also shown to identify increased risk for suicide in other studies. Similar to a cholesterol or Framingham score and risk of a heart attack, there is limited information about increased risk on the same day as the completed screen, but there is clear evidence of increased risk over time. This means that if someone screens positive for suicide risk, we have the opportunity to initiate risk assessment and brief intervention while establishing a care plan. This protocol is the foundation of our MI Mind suicide risk screening and treatment program, such that we promote pragmatic and evidence-based approaches to identify, prevent, and treat suicide risk.
September is National Suicide Prevention Month. As we remember people we love and people we have lost, we must also consider opportunities to save others who might be at risk in the future. We can envision a future world with comprehensive suicide risk screening leading to targeted prevention and intervention to prevent suicide. MI Mind is the first-ever partnership between physician organizations across an entire state to realize this opportunity. If you have questions about our screening protocols, email MIMind@hfhs.org.