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Suicide Risk Screening Training: How to Manage Patients at Risk for Suicide

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>> LISA HOROWITZ: Hello. My name is Lisa Horowitz. I'm a clinical psychologist and staff scientist at the National Institute of Mental Health. And today we're going to be talking about suicide risk screening and how to manage patients that screen positive for suicide risk. Before I start I just wanted to put this disclaimer disclosure slide on that says, "The views expressed in this presentation do not necessarily represent the views of the government," and I have no financial conflicts to disclose. Okay. Today's focus is really going to be in what to do when a patient screens positive for suicide risk and how to proceed on to the next steps. So the first thing we're going to do is discuss what happens when a patient screens positive on a suicide risk screening tool like the Ask Suicide-Screening Questions tool. And then I'm going to describe the Ask Brief Suicide Safety Assessment, which from now on I'm going to call the BSSA, and how to use the BSSA to manage patients that are found to be at risk for suicide. So I always like to start with my take-home message. And so I'm going to be advocating for universal suicide risk screening for patients in medical settings and that we ask directly about suicide. Now some of you will be screening only mental health patients and some of you will be doing universal screening. And so I will talk about both sides of those. But either way, it's important that if you're worried about someone at risk for suicide that you ask directly. And clinicians really require population-specific and site-specific validated screening instruments and we're going to talk a lot about that today.

And we're proposing a clinical pathway which is a three-tiered system that starts with a brief suicide screening. That should take about 20 seconds. And then the most critical part of this pathway is what we're going to focus on today, is the Brief Suicide Safety Assessment. And that should take about 10 or 15 minutes. And that is a critical step because that helps you decide on how to manage this patient in the medical setting you're in. And sometimes that will result in a full psychiatric safety evaluation and sometimes it won't. And it's also important to remember that all patients who screen positive should be discharged with a safety plan, resources like the national suicide lifeline and the crisis text line which are 24/7 helplines, and means restriction and safe storage education. So let's just go through some background about suicide. So suicide is an international public health problem. Upwards of 800,000 people die by suicide every year worldwide. It is the second leading cause of death for young people not only in the United States but worldwide. And in 2008 the World Health Organization did a study that showed that the number of deaths from suicide exceeded the number of deaths by homicide and war combined. So more people killing themselves than are killed throughout the world. If we look in the United States, suicide's the 10th leading cause of death among all ages and the most recent data we have is 2017. Nearly 47,000 Americans kill themselves every year.

And this is the graph of the suicide rate over time and we really have not been able to make a dent in it in over 60 years. For youth, suicide's the second leading cause of the death for  10 to 24-year-olds in United States. And, in 2017, the CDC statistics show that of all the deaths in this age group, 25% of them died by suicide. So here is a very similar graph, where it just keeps creeping up. And, in fact, for youth, there are more deaths from suicide than the seven other leading causes combined. So, while suicide is still relatively rare event, what's more common is suicidal behavior. And what's even more common than suicidal behavior is suicidal ideation. So, for adults, ages 26 and older, about 739,000 adults attempted suicide in 2017. And you can see for thinking about suicide, it's even more. Little over 7 million adults have serious thoughts of suicide and almost 2 million adults went as far as making a suicide plan. For young people, it's estimated that there is about 2 million adolescents that attempt suicide every year. And, if we look at the Youth Risk Behavior Survey, which is a survey conducted by the CDC, they go into high schools around the country and ask your average high school student, tens of thousands of them, "In the past year, have you tried to kill yourself?" And so 7.4% of high school students in the US self-reported that they had tried to kill themselves one or more times in the past year. And 3% made an attempt resulting in medical treatment. Now I put the range up there because this varies from state to state. As far as ideation, 17.3% of your average high school students reported that they have seriously considered killing themselves in the past year and 13.6% made a plan.

So this is a critical public health crisis right now. Now there is a myth that younger children don't think about suicide, but the truth is that children under 12 years old plan, attempt, and die by suicide. And it is actually the fourth leading cause of death for 8 to 12-year-olds. Right now, the 10 to 14-year-old age group is actually-- deaths in that age group have exceeded deaths by traffic accidents, which used to be the number one killer. And this age group is the fastest-growing age group. We had a study published recently that looked at the pre-teens in our Ask Study sample, and we found that almost 30% of 10 to 12-year-olds in our sample screen positive for suicide risk. And 17% of them reported a past suicide attempt. Now if a 10 to 12-year-old is reporting a past suicide attempt, that means they're trying to kill themselves when they are very young. So this is very disquieting statistic. I was also fortunate enough to be part of a study with Dr. Jeffrey Bridge from Nationwide Children's Hospital, and he was looking at the rate for children under 12. And, if you look at it over time, from 1993 to 2012, you find that it looks pretty stable. But then if you parse it out by race, you find a significant racial disparity with the rate for black children increasing and the rate for white children decreasing. So that is currently being investigated. The other important part to come out these data that 30% of these young people had disclosed their suicidal thoughts to an adult. And so that represents a tremendous opportunity for capture. Okay. Let's talk about the high-risk factors for suicide. So I'm not going to go through every one of these but I bolded the most potent, which is previous attempt. So there is a saying in psychology, "A best predictor of future behavior is past behavior." And this is true for suicide. Anyone who has tried to kill themselves in the past is more likely to try to kill themselves again in the future. Mental illness is also an important risk factor, and 90% of people who die by suicide have a diagnosable mental illness. I wanted to highlight medical illness because this is a risk factor that is often overlooked. Now, most people who have these risk factors are not going to die by suicide, and that is because they are risk factors, and that goes for any medical condition. But picture yourself as a triage nurse in an emergency department. If someone came in for risk factors for heart attack, let's say they were a smoker and obese and had hypertension and high cholesterol, they had those risk factors, and they walked up to you triage desk, you would not think they were having a heart attack, but they came in with the warning signs of a heart attack and were clutching their chest in pain and sweating profusely, then you might think, "Oh, they're having a heart attack." So the same thing goes for suicide. There is warning signs that we have to pay attention to. So talking about wanting to die or kill oneself-- now that seems like an obvious one, but sometimes, that kind of talk is not taken seriously, looking for a way to kill oneself, searching for weapons to buy or acquire, talking about feeling hopeless or like a burden or trapped, increasing use of alcohol or drugs, acting anxious or agitated or behaving recklessly and then some signs of depression, sleeping too little or too much, withdrawing or feeling isolated, showing rage or talking about seeking revenge, or displaying extreme mood swings, these are all warning signs as someone might be at imminent risk for suicide.

So our research group has asked the question, "Can we save lives by screening for suicide risk in the medical setting?" And we think the answer to this is Yes. So before we talk about screening, let's just talk about the difference between screening and assessment. So these two things are very distinct, and it's really important that you understand the difference. So screening is just meant to be a very quick way to identify someone who needs further assessment. So it just flags someone at greater risk. And then the assessment is meant to be more of a comprehensive evaluation that confirms the risk and estimates the risk and then guides the next step. So let's talk about what valid questions there are for nurses and physicians to use to screen patients for suicide risk in a medical setting. Now because this training is focused on the brief suicide safety assessment, I'm going to go over-- we ask very briefly. There was a study that created the Ask in the medical setting, and it was created in the pediatric emergency department. The Ask is being studied in adults as well and being tested, and we had preliminary data from about 200 patients, and we found that the Ask was had really strong psychometrics, had good sensitivity and good specificity. So we feel comfortable now with the Ask being used with adults as well, but more information on that will be [kind?]. So let's talk about the questions on the Ask. There are four questions. In the past few weeks, have you wished you were dead? In the past few weeks, have you felt that you or your family would be better off if you were dead? In the past week, have you been having thoughts about killing yourself? And have you ever tried to kill yourself? If the patient answers Yes to any one of those four questions the person administering is asked to give a fifth acuity question, are you having thoughts of killing yourself right now? So the ask is meant to be administered by nurses, medical technicians, medical assistance, and really can be administered by anybody in the beginning of a process of screening for suicide risk. We have created an app tool kit that accompanies the ask, and it has materials on it that are important for implementation. The tool kit, which is available online is that website is divided into three different venues; the emergency department, the inpatient medical-surgical unit, and the outpatient primary care specialty clinic. And it has things like scripts, and flyers and videos and resources. And you're welcome to take a look at that. So the main point of this training is what happens when a patient screens positive for suicide risk? So what is considered a positive screen on the ask? So there's two ways to screen positive. The first and the most common is to screen positive in what we call a non-acute way. And that means someone answered yes to any one of the one to four questions. Now, for young people, if they refuse to answer the question, they are considered a positive screen. And that's because we have data showing that 85% of the kids who refuse to answer had a significant mental health history. So anyone who refuses to answer is treated as a non-acute positive for adults, if they refuse to answer they are allowed to deny as they are allowed to refuse any medical test so they are not considered a non-issue positive. So, anyone who screens positive on one of the first four, we need to conduct a Brief Suicide Safety Assessment or BSSA to determine if more extensive psychiatric evaluation is necessary. A patient is-- may not leave until this further evaluation is completed. The second way described positive is the acute positive. And that's a yes to the fifth question, are you having thoughts of killing yourself right now? If a patient answers yes, to that fifth question, they are seen as being an imminent risk for suicide. It's very rare for a non-behavioral health patient. So a patient presenting with medical chief complaint it is extremely rare for them to have an acute positive. It is more common for a patient presenting with a behavioral health chief complaint to scream positive on that question. But anyone who says yes to that question should not be left alone. For inpatient medical-surgical unit, they should be placed on safety precautions as per standard of care for your institution. For the outpatient setting same, but emergency services will need to be contacted. And the Brief Suicide Safety Assessment is not necessary in this case because the patient is automatically deemed an imminent risk. Study data on ask implementations have revealed that screening does not overburden or overwhelmed systems and in fact, it may result in one extra positive screen for suicide risk per week. Okay, so this is the universal youth suicide risk screening clinical pathway, which is a published pathway. You can see the citation on the bottom left. But it also applies for adults. So we start with a brief screen that should take about 20 seconds, and then the Brief Suicide Safety Assessment and that determines whether or not a full manHelp evaluation is necessary. This is the pathway. I'm not going to go through every single step of it. But I wanted to show you that you get to screen with the ASSK. And then the part we're going to focus today is the Brief Suicide Safety Assessment. So when you administer Brief Suicide Safety Assessment you can do a couple of different things. You can use the Colombia Suicide Severity Rating Scale, the CSSRS, or you can use the ASSK Brief Suicide Safety Assessment which we created for this purpose, or you can use another kind of tool you're comfortable with, but the idea of the second step here, of the BSSA, is to be able to figure out how to manage the patient with next steps. It's not necessarily, "Is this person going to kill themselves right now?" But it's, "What do we do now, in our setting, with this patient who just screened positive?" And so that's where you come in as a clinician. The Colombia allows for risk stratification and that puts people into low, moderate, or high risk, which is good. However, what we found were that people were having problems with the middle category especially. The low and the high seemed to be easier than the middle. So what we were finding was that people at the low end of moderate versus the high end of moderate were different people. And so what we did was we created the ASSK Brief Suicide Safety Assessment because we wanted to help operationalize the next step for the clinician. So I'm going to focus on the Brief Suicide Safety Assessment for this training, and what that's going to do is put people into either a low risk, a high risk, or an imminent risk category. So who can use the Brief Suicide Safety Assessment? Well, ideally, it would be used by mental health clinicians. But it could also be used by nurse practitioners or physicians or physician assistants or other people who are clinically trained professionals who administer the BSSA. It should take about 10 minutes in the emergency department. It might take a little bit longer in the in patient and out patient setting. So the purpose of the BSSA is to help the clinician make the next step, and there's three choices. The first one is imminent risk. Is this patient in need of an emergency psychiatric evaluation? So that's a person who you feel is at risk right now to hurt themselves. And then you would initiate suicide safety precautions and request emergency mental health evaluation. Now, while this is an incredibly difficult clinical situation, usually this is a more obvious presentation and you'll know when someone is at imminent risk and so this one becomes a little bit more obvious. I think the trickiest category is the middle one, which is the high risk, which further evaluation of risk is necessary. So this is the patient that shows up either for a mental health sheet complaint or a medical sheet complaint, and you decide that their suicide screening, and when you administer this BSSA-- it is also the business of the day that they need a mental health evaluation and a full safety assessment. On the in patient medical surgical unit, patients will require a further mental health evaluation from a mental health clinician before discharge. In some hospitals that will be calling psychiatry, sometimes that will be social workers but a mental health clinician will need to do the further evaluation. In the outpatient medical setting, this may mean that you review the safety plan and send them home with a mental health referral as soon as the patient can get an appointment, preferably within three days. But we know, sometimes, that's tricky. Sometimes they may have to come back to the outpatient medical setting just to check in before their appointment. But, again, this is not the imminent risk, so patient needs a full evaluation. But it's not a stat-emergent situation.

And then there's low risk, that it's not the business of the day. So this is the patient that comes into the emergency department for a broken ankle and they screened positive on the ask. And then when you did the brief suicide safety assessment, you found that they were really stressed about a situational factor and they weren't really at imminent risk or high risk. Or maybe they have mental health care outside and they have a plan for seeking help. And so it's not the business of the day, and it does not require the mental health evaluation in the medical setting that you're in. Or you may decide that no further intervention is necessary at that time. So those are pretty much the three choices of the BSSA. So after the patient screens positive on the ask-- so the nurse or the medical technician or the medical assistant had just screened them and then you come in and you say, "I want to follow up on your responses to the suicide risk screening questions. Thank you so much for letting us know you're having these thoughts, and these can be hard things to talk about. I need to ask you a few more questions." Okay, so we're going to start with the emergency department. Now, at first look, it may look a little daunting. But what we're trying to do is take you through this step-by-step, and you should think of this as a guide. This is not a have-to. You do not have to ask every question on this. This is meant to be a guide to remind you of the important parts of a safety evaluation, or I should say a brief safety evaluation.

So, again, I just mentioned this. You're going to praise the patient because they were honest and they spoke up and, again, this is a sensitive topic and a hard topic to talk about with someone that you don't know. And then you're going to assess them for frequency of suicidal thoughts. So you're going to determine, how often are they thinking about suicide?

So, again, anyone who's thinking about this every single day and, for kids, they can't do their math homework because they have so much thoughts about hurting themselves in their head, that's going to be an imminent risk. I'm going to remind you that any time during this evaluation that you have the disposition set in your mind, you can stop. So, for example, if I say to the patient, "In the past few weeks, have you been thinking about killing yourself," and they say, "Yes." And I say, "How often?" And they tell me they're thinking about this every single day and they actually can't think about anything else, then I'm done with the BSSA. Because this patient is at imminent risk and needs a further mental health evaluation.

So I'm just going to go back for a second. Sometimes, people look at this and say, "How am I going to do this in 10 minutes?" And the answer is, this is your guide until you reach the decision of number four, which is the disposition. Okay, so you ask about [plans?]. And what we have in the BSSA are some prompts so for example, do you have a plan to kill yourself. Now, if you have a way that you like to say it better, you are welcome to use that. These are just prompts to remind you in case it's not on the tip of your tongue. And then you can ask them, "If you were going to kill yourself, how would you do it?" Now if the patient has a very detailed plan, that is more concerning than if they're really stretching to think of something they would do. And then you ask about past behavior. And again, that's the strongest predictor of future behavior. So you can ask them about-- and if they have had past behavior. And you can say, "Did you want to die? Did you receive medical attention?" That will give you an idea of how serious the past behavior was. And it's important to remember the difference between intent and attempt. So there are-- intent in [inaudible], I should say. So there are kids that will think taking three Tylenol can kill them. So they took three Tylenol and in their head, they were going to die. Now we know you're not going to die from taking three Tylenol but sometimes people don't know that. So it's important to assess what they did and how they were thinking about it. And then we ask about symptoms and we listed symptoms here and we, again, provided a prompt in case you weren't sure how to assess for this. So we ask about depression and anxiety and impulsivity, hopelessness, substance and alcohol use, and other concerns. And then it's important to assess support and safety. So who do they talk about this with? This particular BSSA I'm showing you is for the emergency department and it's for young people. There's a different one for adults and there's a different one for each setting. So this one happens to be for young people so we ask is there a trusted adult you can talk to and who is that and have you talked to them.

And then the safety question, do you think you need help to keep your self safe? So the important thing about this question is if they say no, that doesn't necessarily mean they're safe. But if they say yes, then that's highly indicative that this is someone at imminent risk. And then a lot of times people forget to ask about reasons for living. So we ask a lot about reasons for dying, wanting to die but we don't ask a lot about reasons for living. So it's important to say, "What are some of the reasons you would not kill yourself?" And this is something that helps you decide-- there's some adults that will say, "I would never do it because I would never leave my children alone." And they say it with conviction and that's helpful when you're assessing their risk. Again, this is the child's version so then this is interview that's done where you bring the parent back in. And the patient is 18 or older and they're there with a parent then you have to ask permission. And you can say to the parent, "After speaking with your child, I have some concerns about his or her safety. We are glad your child spoke up about this as it can be a difficult topic to talk about and we now want to get your perspective." And then you tell them-- and this is in front of the child and of course, you tell the child before you do this that you're going to bring their parent in. And now as we all know, there's no confidentiality when it comes to the topic of suicide and it's important to after the child screens positive to tell them that this is something you have to share with their parents. And actually for kids under 18, by law you have to. But there's a way to finesse that conversation. So you see that this is not to get them in trouble. This is not to be blaming. This is all about getting them help. And sometimes some groundwork has to be done with parents around this too. The child should not be punished for talking about this. This is a good thing that they're speaking up about it. "So your child said they were having thoughts about killing themselves. Is this something that they have shared with you?"

Now we worded it in this way so that it doesn't sound blaming to the parent. Like, "Did you know about this?" And so that they feel foolish if they didn't or humiliated. We want them to know that kids talking about suicide is very secretive. Kids can be very secretive about this topic so it's not their fault if they don't know. But it's important to know if it's something they know about. And then, "Does your child have a history of suicidal thoughts or behaviors that you're aware of?" Again, being very sensitive to they may not be. And then we ask some symptom assessment from the parents. And then we ask, "Are you comfortable keeping your child safe at home?" Now if they say yes, again, that doesn't mean that the child is safe at home. But if they say no, then that's important to pay attention to. And then we talk about means restriction with them and safe storage. And then it's important to say, "Is there anything you would like to tell me in private?" Because sometimes the parent has information that they don't want to share in front of the patient and it's important to give them that opportunity. Oftentimes when you ask this question, you'll hear about a relative that killed themselves that a lot of the time the child knows about anyway, but the parents wants to keep that private. Okay, so this box, number four, is why we do the Brief Suicide Safety Assessment, because we want to determine the disposition. Now, for the emergency department, we divided it into three different categories. And for the in patient and out patient, we gave it four categories, but they're really the same. We just condensed it. But I just want to talk about each category and give an example. So if you determine during the Brief Suicide Safety Assessment that the patient is at imminent risk for suicide, then it's box number one. They need an emergency psychiatric evaluation. And this is a stat page to psychiatry or your mental health crisis team, and you need to keep the patient safe in the emergency department. This would be someone who said, yes, that they're having thoughts of killing themselves right now. That they have a plan. That you just are really concerned about their safety imminently. The second category is further evaluation of risk is necessary during this visit. So this varies from mental health patients versus medical patients, right? So for mental health patients coming to an emergency department, they most likely will need a full mental health evaluation. They're most likely coming in for that reason. But sometimes that's not the case. So this is where your BSSA, after you give it, you decide that the patient does require a full mental health evaluation. For a medical patient, this might be someone who came in for belly pain and you find out that they're thinking of suicide, and even though the belly pain is the business of the day, so to speak, you also found that they're at risk for suicide and you're going to need to do both things. So they're also going to have to be evaluated. I will tell you that what's really important with this category is that it's not an overreaction and not treated as an imminent risk. So, for example, this patient that I just gave an example of, the belly pain, this is not someone that you want to put a sitter on. a one to one observer. There have been some hospitals that have done this. They've overreacted to positive screens and they've put the one to one observer on, taken away the patient's clothing and personal items, put them in a safe room, and given them a 60 minute psychiatric evaluation. That is the reason why we do the Brief Suicide Safety Assessment. Because sometimes, most of the time, that is not necessary. What's necessary is that they're further evaluated, but it;s not an emergency, and it's very important that it's not treated like an emergency. I will tell you that when you screen patients that come in with medical chief complaints, over half of them screen positive to the behavior question which is question number four, are you having thoughts-- have you tried to kill yourself in the past? Now, a lot of times, and especially with kids, this is something that the parent already knows about, that the patient has a mental health clinician on the outside and is working with someone. And so it is not the business of the day, and they do not need further evaluation, and that is why you did the BSSA. Because you found out two years ago, they tried to kill themselves, or 20 years ago, they tried to kill themselves. And they've been in therapy and that is not what they're here in the emergency department for. So you spare resources with this BSSA. And this is probably the most important category. Then the third category is no further evaluation is necessary in the ED. And that is because you decided that it's not the business of the day, that they came in for-- if they're a behavioral health patient, they came in for anxiety. They maybe checked the box that said they wish they were dead but they seem a very low risk for suicide. That is not what they're here for. They have reasons for living. This is something they will not do. This is may be a false-positive even.

And then you're going to send the patient home with mental health referral. Or if it is a true false-positive, then no further intervention is necessary. We once had a patient who came into the emergency department and screened positive on the first question, "Have you wished you were dead?" And it was a child who was being overly reactive because they had done really poorly on an academic test. But when further evaluation was done, it was found that they were very stressed but they were not having thoughts about killing themselves. And so they were sent home with a mental health referral should that ever occur in the future with the facts and example of that. And then there's the resources to provide. Now we're going to talk about the brief suicide safety assessment in the in-patient medical-surgical unit. There are some hospitals that are screening universally. So this happens in the in-patient unit.

Again, this is one for kids. What makes this different than the ED one is you have a little bit more time. So we get a little bit more comprehensive with the interview with the patient and the parent together. And the dispositions are now, instead of three categories, we just-- it's very similar but we've divided it into four categories. So there's the emergency psych evaluation that's needed while the patient is in-patient and need safety precautions. Further evaluation of risk is necessary. So you can request the mental health safety evaluation prior to discharge. But this, again, is not a situation where there needs to be a sitter or a one-to-one observer. That only happens on the first category. And patient might benefit from a non-urgent mental health follow-up post-discharge. It's not the business of the day in the hospital and it's not going to happen while they're an in-patient in your hospital but after they go home, or no further intervention is necessary.

So I just want to give an example of when no further evaluation or I want to give an example of three and four categories. So this might be a patient who screened positive for suicide risk on the ask because they had a past attempt. Now, I will tell you that our data shows that over half of the positive-screens are a single yes to question four which is, "Have you ever tried to kill yourself in the past?" Most of the time, this past attempt will have been already attended to. So the patient might be in mental healthcare. The parent knows about it. If that is the case, we consider through that, not the business of the day. It has already been taken care of. It is not the chief complaint that they're coming into the hospital for. And the patient can be sent home with resources, and no further evaluation is necessary in your hospital. Okay. Then I want to talk about the brief suicide safety assessment in the outpatient setting. Again, what is different is, here is the disposition because you're not in the hospital, so you might not have embedded mental health in your outpatient clinic. So an imminent risk patient is going to have to be sent to the emergency department. And sometimes that means calling 911 even and making sure they're safe until they can get to the hospital. And category number two is further evaluation of risk is necessary. And that will mean, that you're going to send them home, but with a mental health referral. And someone will need to evaluate them, preferably within 72 hours, you review a safety plan or you make a safety plan with them and send them home.

Again, the third category is, they might benefit from a non-urgent mental health follow up. And they still go home with a safety plan because they screened positive or no, or this was a part of a false positive and no further intervention is necessary at this time. And a false positive might look like someone who says, "I wish I were dead because I got a C on my English test." And I've seen this actually, before, in the emergency department. Someone just did really bad on an exam and they were really stressed. And they didn't really mean it, but at the time they meant it and then-- but no further intervention was necessary.
Education was necessary about how serious we take this talk, and how serious it is to say something like that, and-- but nothing more. Okay, so these are what's available. The BASA have been made into a worksheet, which means we left spaces and checkboxes, and so you can literally write on the paper itself. And there's also some hospital systems that have put the BSSA into Epic, and Cerner, and so those things are available as well in electronic health records. As part of the toolkit, we also give mental health resources to patients, and there's links too in videos that can be helpful both to staff and patients. So I encourage you to look at those when you have time.

Okay, let's talk about some additional considerations. What if a patient screens positive on a suicide risk screening tool, and then refuses the BSSA?
If you are concerned that someone is at risk for suicide and they won't talk to you about it, then you're going to have to do an emergency petition. Because as mandated reporters, as we all are working in a health care system, it is our duty to make sure someone's safe. And if they won't talk more about it, and they screened positive, then we have to assume that they're positive. And that, unfortunately, is going to have to fall under your standard of care for what you do, when a patient is at risk for suicide. So while they may refuse to be screened, because they are allowed to-- an adult is allowed to refuse a medical test. They are not allowed, to refuse being assessed, when you're concerned about something. And this would be akin to, if they had a fever of 105 or blood pressure that was really, really, high and you said, "Oh, we need to bring the cardiologist down to check out your blood pressure," and they said, "Nope, I'm going home." You would make them sign out, [inaudible]  against medical advice, they would-- so this would proceed in that similar way. What if a patient refuses to answer the questions? So again, they're allowed to refuse to ask, they're not allowed to refuse the follow-up. And we've had hospitals have situations very rare that a patient refuses or a parent refuses. And then we always get the attending physician involved, as they're the one that has to make the final determination of the AMA and what to do. What if the parent or child won't cooperate with the disposition plan? And again, this is akin to any medical situation where you have medical advice that the patient or the parents are refusing. And the one example I can give is a patient screens positive to every question on the ask, and then the mental health clinician came into social work came in to do the BSA, and the father refused and he said no, "I will not allow my child. My child came in for a head injury, I'm not having them assessed further for suicide risk." And the attending physician was called and luckily the attending physician after some time was able to convince the father that this patient required this and the patient actually really was in need of mental health care. So it was good that it worked out that way. But had the parent not, then it wouldn't have been treated in accordance in accordance with the law of your states and your policies in the hospital. Okay, is the BSSA really going to take me 10 or 15 minutes? So in the beginning, it might take a little bit longer until you get used to it. But again, the BSSA is a guide and should be used until you come up with one of those four disposition boxes. If you're halfway through the BSSA, and you know what you're going to do, then you're done. And so that's why we recommend you trying to do it in 10 or 15 minutes. The other important thing to remember about the BSSA, it is not a full psychiatric evaluation. And that is really critical to remember, it should not take you 30 minutes because then you're doing a full safety evaluation. You have to remember that this is only the step that determines the next step, whether or not you want the patient to have a full evaluation. And I hope I'm making that part clear because that is the time-saving part. I'm going to go through this quickly and briefly just to get enough information to decide if they need more information. So there's a million more questions you can ask with the BSSA, but you're trying to just get to the heart of your planning. Do I contract for safety? So a lot of people make safety contracts with patients where the patient promises not to harm themselves. So I will tell you that this is no longer a valid practice. We do not recommend anybody contracts for safety? This was something that made providers feel better, patient sign that they would not harm themselves and then the provider could go sleep at night. We don't think this is valid anymore, we-- instead we do safety plans. So we don't contracts. We don't do safety contracts, we do safety plans. What are you going to do with 2:00 o'clock in the morning and no one's around and you're having thoughts of suicide, and this is because suicide occurs-- thoughts of suicide occur in states. People have states of mind where they're more at risk for suicide than other times, and it's important to plan and build coping strategies for those times. I can ask him questions about suicide make the patient suicidal, asking questions about suicide does not put thoughts into anybody's head. There's at least four research studies that refute this. In fact, the best way to stop someone from killing themselves is to ask directly, "Are you thinking of killing yourself?" A word about means restriction and safe storage? Okay, so so let's just talk a little bit about firearms and means restriction, and these slides are courtesy of Dr. Matt Miller who does a lot of research in this area. In the United States, over 50% of suicides are firearm suicides. This sets us apart from the rest of the world. And why is means restriction and safe storage so important? And that is because what I just said about states, so if somebody is in a state where they want to kill themselves, and there's a gun around, they may use that gun, where as if the gun is not around-- popular thinking is, "Well, they would just use something else." And actually, that is not true. And that's why nets under bridges works, and that's why safe storage and means restriction work. So one other important statistic is less than 10% of people who survive these near lethal suicide attempts-- less than 10% try it again. So somebody who tried to kill themselves with a gun-- and not that many people survive when-- using a gun usually results in death. But the people who do survive talk about how if the gun wasn't around, then they wouldn't have done this. So it's important to remove the gun from the house or make sure it's locked up. Now, talking to parents about safe storage. There are studies on this because parents believe many times that their pills and their guns are hidden or out of awareness of kids, and there have been studies done that show this is not true. And in fact, a quarter of the kids handle guns when the parents say they don't even have access to them. So this is an important conversation to have with a parent, and we all have medicine in our medicine cabinets. If you have a child who's vulnerable and at risk for suicide, you have to take care to lock those pills up. Okay, safety planning. So the citation on the bottom is really important. Barbara Stanley and Greg Brown are safety planning researchers who've been doing this for years and have some really good safety plan templates. So what safety plans do, and so we could do a whole webinar on safety planning. I'm just going to very briefly talk about this, is this is where you talk with the patient about the warning signs and the triggers for the patient. What triggers you? Well, maybe talking with their ex-girlfriend or boyfriend triggers suicidal thoughts in them. You need to know. They need to write down what are the warning signs. What are their coping strategies? How are they going to cope? Who are their contacts for support and who are their emergency contacts? And then how do you reduce the access to lethal means, whatever it is that they could be? All right, lessons learned. Patients presenting with behavioral health sheets complaints will be more likely to screen positive for suicide risk, and they'll be more likely to have an acute positive screen, especially in a place like an emergency department. If they're showing up for a mental health emergency, they are more likely at acute risk for suicide. If you're doing universal screening, it is rare for patients who come in for medical sheet complaints to screen positive, but it does happen, and that's why we do it. So 90 to 98% of patients who present with medical sheets complaint, and we have data on millions of patients now. The rate is coming up about 3%. 90 to 98% will be negative screens, so most of your patients will screen negative, but those patients you catch will be important ones to capture. And 98 I have up there, because it's under 3%. It will be incredibly rare to have an acute positive screen with a patient presenting with medical medical chief complaints. But because this is the most acute of all scenarios staff should have a plan in place and be prepared for what happens if a medical patient does screen positive. Positive screen rates are manageable with clinical pathways. Now I want to pause here to just say, there are hospitals that respond to any positive screen with what I'm going to call an over-response or an over-reaction. So anyone who screen positive automatically gets a one to one sitter, observer, gets their clothes removed, get put in a safe room, gets a 60 psychiatric evaluation. There is nothing that shuts a screening program down faster than an overreaction to positive screens and that's why the BSSA is so critical. Because every patient who screens positive cannot be treated like an emergency and that's what we have to get more comfortable with. Now we don't want to under-react either but if a patient says, I wish I were dead and you put a one to one observer on them and take away their clothes and their phone and everything then that's not going to be helpful to the patient and it's certainly going to waste your mental health resources in the hospital. So that is why your role is so important and the brief suicide safety assessment is a part that goes in and evaluates these really critical decisions about next steps and that's why we need the pathway in place before you start to screen. Okay, so for the BSSA that can be the social workers or any mental health clinician or the physicians or the nurse practitioners, the PA's or any other clinical staff who can be trained on the BSSA. It should be done in 10 or 15 minutes. That should really be your goal. If you're going over, in the beginning, it's okay but if it's a few weeks and you've done several of them and you're still taking 30 minutes to do a BSSA then there's people you can reach out to. You can reach out to me and we can talk about how to condense the BSSA. Again, as soon as the disposition is understood, that's when you stop. Safety planning including [means?] restriction and safe storage discussion should be conducted by either the person conducting the BSSA or the clinician completing the full mental health evaluation. The BSSA needs to occur before the patient is discharged. If somebody screens positive on the ask or any suicide screening tool and you let them go then the hospital is liable for that happens after they leave and so it's important and also, more importantly, you want to make sure they're safe. We have data from hospitals that are using these clinical pathways, that are using the ask, that are screening for suicide risk and what we're finding is that screening is not overburdening the hospital and there's a learning curve in the beginning but when you get into the-- when you implement it in these ways that are evidence-informed, it is a manageable part of care to screen for suicide risk. Okay. So to wrap up here. We do not have a crystal ball. It's safety first as best you can. There is nothing simple about this and I'll take myself who's been trained to asses someone for suicide and work with people who are at risk for suicide and every case is hard. So and I'm humbled by every single case because every time I leave that assessment I don't know if I did the right thing. I'm doing the best I can. That's all we can ask is remembering that there are limits in our ability to predict but we have to err on the side of caution and if you're not sure, grab a colleague that you can run it by as well because peer consultation is always good too okay, in summary, the medical setting is such an important place to screen patients for suicide risks and to identify people who need further mental healthcare. But you have to have clinical practice guidelines in place for managing patients who scream positive. This three-tiered clinical pathway has been used and makes the implementation of suicide risk screening manageable. You start with the brief 20-second screen with the ask. You do the BSSA for 10 or 15 minutes and that helps you determine whether or not the full mental health or safety evaluation is necessary. Positive screens are manageable with BSSA in place. Clinicians should use, again, what they're comfortable-- the tools they're comfortable with, but BSSA is available to help you operationalize your next steps. And that's what's the next important thing to remember about the BSSA. You're not fully evaluating someone. You're determining what the next steps are in this pathway. And all patients should be discharged with a safety plan that includes suggestions for coping strategies and safe storage or removal of lethal needs.

I'm going to end with an example. There was an outpatient clinic where a pediatrician started screening for suicide risk. And I always advise that people start with a pilot in this quality improvement way, you do a plan-do-study-act. So this pediatrician started his screening with well visits. Any patient that came in for a well visit was screened for suicide risk where they ask. And then one day, a mother brought a patient and he was an 18-year old male presenting with fatigue for a sick visit. And the mother thought maybe he had mono. He was laying around all the time. He was on the couch. He just wasn't acting like himself. This was a very socially well-connected scholar athlete kid who was going to college on an athletic scholarship and [inaudible] with acting with logic. So she brought him in for a sick visit. And the nurse who was screening him had a bad feeling about this. And I can't tell you how many lives have been saved by a nurse having a bad feeling about something. And so this nurse just thought something wasn't right and she administered the ask. And this is how the patient scored. The first question was asked, yes. Second, yes. Third question, yes. Have you ever to kill yourself in the past? No. This was someone who had never thought about suicide before. Are you having thoughts of killing yourself right now? Yes. So this was actually the only acute positive screen this practice had in two years I think. But this was a patient who had been caught at a party for underage drinking and was in jeopardy of losing his scholarship. And the pediatrician went in and evaluated him with the BSSA. And again, this pediatrician didn't feel that comfortable with suicide risk screening assessment, but he went through the BSSA. And at the end, he said to the patient, "I'm debating what to do here because I'm worried about you." And the patient said to him, "You know what, before I came in here, I had no hope." And the patient was actually planning on killing himself. And now I have hope. And so because this nurse-- and it shouldn't have to be a nurse relying on intuition. And that's why we should have universal screening. But because this nurse made the right move and screen this patient and because this pediatrician asked him further questions with the BSSA, the pediatrician did not send him to the emergency department, did send him home with a mental health referral. And I'm happy to report, this was a couple of years ago, this kid has got mental healthcare and is thriving in college right now. The pediatrician is convinced this would have been someone you read about in the newspaper and they killed themselves had this nurse not intervened. So this could be a very powerful intervention and save somebody's life.

Okay, I want to put up my thank you slide because there were huge teams of people who contributed to creating the ask, testing the ask, and creating a brief suicide safety assessment. So thank you to everyone, and part of our research is supported by the American Foundation for suicide prevention and a special thank you to nurses and the physicians and social workers and mental health clinicians who have done this work, and a special thank you to patients and their families .for participating in our studies. If you have any questions, you're welcome to email me directly and thank you for your attention. I hope every single one of you will use this information because every single one of you can save a life. Thank you.