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One ongoing controversy in the field concerns universal screening for suicide risk, especially within health care settings.
“The majority of adults and kids who have died by suicide have visited a health care provider in the months, sometimes even weeks, before they die,” said Horowitz, senior associate scientist in the National Institute of Mental Health Intramural Research Program. “What that presents is an incredible opportunity—you might even argue responsibility—to detect people at risk and be the bridge to getting them help.”
Not everyone agrees. In May 2020, the U.S. Preventive Services Task Force issued a draft recommendation statement noting insufficient evidence to recommend for or against suicide risk screening in asymptomatic children and adolescents, for example. In September, the task force issued a similar draft statement about screening in adults. But kids—and adults—can’t wait for that research, said Horowitz. “We can’t wait five more years for those studies to come out, because kids are dying from suicide right now,” she said. “We have to screen young people so that we can identify those at risk who may not be discussing their suicidal thoughts with anyone else.”
A screening tool Horowitz and her team developed called the Ask Suicide-Screening Questions takes just 20 seconds (JAMA Pediatrics, Vol. 166, No. 12, 2012). Critics of universal screening often conflate screening and assessment, Horowitz explained, but the screening instead represents a rapid way to flag someone who needs further attention and is the first step in a clinical pathway (Academic Pediatrics, Vol. 22, No. 2, 2022). “Screening is the way you start the conversation,” said Horowitz. “It’s an opportunity to reach out before it’s too late.”
Behind the resistance to universal screening lies the fear that such screening means opening Pandora’s box, said Edwin Boudreaux, PhD, a professor of emergency medicine, psychiatry, and quantitative health sciences at the University of Massachusetts Chan Medical School. “They argue that if they don’t have the capacity to intervene, that screening is not really going to help,” said Boudreaux.
What Boudreaux has found is that universal screening catches many who would otherwise be missed. In a large multisite study, he and colleagues found that universal screening of adult emergency department patients almost doubled risk detection, going from just under 3% to almost 6% (Contemporary Clinical Trials, Vol. 95, 2020). That number is still low enough that hospitals do not have to worry about being inundated with at-risk patients, he said, especially if hospitals put in place protocols that are sensitive to patients’ severity of risk. Some patients with lower levels of acute risk, for example, may not need a full psychiatric workup or safety precautions such as searching their belongings for potentially lethal items or assigning someone to watch them constantly.
Plus, said Boudreaux, there are things health care systems can do to make the most of existing resources instead of the traditional—and costly—response of sending patients who mention suicide to the emergency room.
The UMass Memorial Health system, for instance, made changes based on the tenets of Zero Suicide—the now predominant model, which calls for overhauling entire systems to address suicide instead of merely training individual practitioners. The UMass system now does universal screening of patients ages 12 and older, then stratifies them by risk level, with high-risk patients receiving evidence-based interventions. Safety planning, for example, is an easy intervention in which the patient and clinician work together to identify risk factors and warning signs plus ways of coping with them. A revamped electronic health record system helps ensure patients do not fall through the cracks as they transition to the appropriate level of care.
Even something as simple as calling patients after emergency room discharge can reduce suicide, Boudreaux has found. In a multicenter study that focused on adults with recent suicidal ideation or attempts, the researchers found that patients who received follow-up phone calls and discharge resources had 30% fewer suicide attempts than patients who received treatment as usual (JAMA Psychiatry, Vol. 74, No. 6, 2017).
Limiting access to lethal means—especially firearms—is also key, said Michael Anestis, PhD, executive director of the New Jersey Gun Violence Research Center at Rutgers University. Firearms accounted for 53% of suicides in 2020, according to the CDC (Kegler, S. R., et al., Morbidity and Mortality Weekly Report, Vol. 71, No. 19, 2022).
The demographics are changing, however. “There has been an unprecedented surge in firearm sales—not just in deep red states,” said Anestis. That means psychologists must broaden their idea of who is at risk beyond veterans and other traditional high-risk groups. People who bought firearms during the Covid-19 pandemic, Anestis has found, are more likely to report past-month, past-year, and lifetime suicidal ideation than people who have never purchased firearms or purchased them before the pandemic (JAMA Network Open, Vol. 4, No. 10, 2021).
The next frontier is to train people outside of health care, such as military unit leaders and bartenders, to do lethal means counseling—assessing whether someone who is suicidal has access to firearms, prescription medicine, or other potentially lethal items and working with the person and family members to limit access to those items during a crisis. “Folks who die by firearm are less likely to engage with health care,” said Anestis. “Training others to have these conversations is a way to move upstream and shift societal norms.”
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