Skip to main content

Transforming the understanding
and treatment of mental illnesses.

Celebrating 75 Years! Learn More >>

 Archived Content

The National Institute of Mental Health archives materials that are over 4 years old and no longer being updated. The content on this page is provided for historical reference purposes only and may not reflect current knowledge or information.

Suicide Risk Screening Training: How to Use the ASQ to Detect Patients at Risk for Suicide


>> LISA HOROWITZ: Hi, my name is Lisa Horowitz, and I'm a pediatric psychologist and staff scientist in the Intramural Program at the National Institute of Mental Health at the National Institutes of Health. I'm here to talk to you today about how to use the ASQ to detect patients at risk for suicide. I want to put this slide up just to tell you that I have no financial conflicts to disclose.

Objectives today will be to describe suicide into suicide behavior as a national and global public health crisis. And we also want to train medical providers to appropriately administer the ASQ (Ask Suicide Risk Screening Tool) to young patients.

The take home message is going to be that we should universally screen all patients in the medical setting for suicide risk. And the best way to do this is to ask directly.

And that clinicians require population, site specific, validated screening instruments. And I'm going propose a three-tiered system where you start with a brief screen like the ASQ, which takes about twenty seconds. And then you follow up positive screens with the brief suicide safety assessment that should take about ten minutes. And that's that intermediate step will help determine whether, or not, you go on to the third step, which is a full psychiatric or safety evaluation.

And I just want to remind people that anyone who screens positive should be discharged with the safety plan with resources like the National Suicide Prevention Lifeline and the crisis text line and they should have means restriction education.

Just to give you a brief background to suicide is an international public health crisis right now but nationally it is the second leading cause of death for youth aged ten to twenty-four in the United States. In fact, in two thousand and seventeen, over six thousand young people died of suicide and a quarter of all young death in this country occur by suicide. This is the graph you have in front of you is the suicide rate overtime and as you can see it just keeps creeping up.

And in fact, there are more deaths from suicide for young people, then these seven others leading medical causes combined. So, it's just an enormous public health crisis right now.

So, our research team looked into, can we save lives by screening for suicide risk and detecting early by finding kids that risk in the medical setting and we think the answer to this is yes. Why is the medical settings such an important place to identify suicide risk? Well, when you look at death registry studies, it turns out that the majority of patients who die by suicide, both kids and adults, have had contact with medical professional within three months of killing themselves. And sometimes even within weeks of killing themselves.

I want to talk about the difference between a suicide screening tool and a suicide risk assessment. A screening tool is meant to be very brief and just identify someone who needs further evaluation.

A suicide risk assessment is a more comprehensive evaluation that confirms the risk and guides the next steps. So, the ASQ is a suicide risk screening tool and it's not an assessment tool.

What are the valid questions nurses and physicians can use to screen patients for suicide risk in the medical setting?

So we did a research study, and we created the ASQ, which is a suicide risk screening tool. And the questions are:  In the past few weeks, have you wish you were dead? Have you felt that 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 you ask the fifth question -  Are you having thoughts of killing yourself right now? That's the acuity question.

The ASQ was found to have good sensitivity, which is true positive rate and good specificity, which is the true negative rate and that limits false positives and it has a strong negative predictive value.

So, the ASQ was developed for the pediatric emergency department, but it has been validated and is being used now on inpatient medical surgical units and outpatient primary care specialty units, clinics in schools and child abuse clinics, and detention facilities. It's being rolled out in the Indian Health Service, and it's being tested right now in young people with autism spectrum disorder and neurodevelopmental disorders. It is also been translated into these sixteen languages and is available for free for anybody to use in the public domain.

So, one of the most common myths and concerns that parents have about asking young people about suicide is can asking questions about suicidal thought put ideas into their head. At least four research studies have refuted that you will implant suicidal thoughts, it is very safe to ask kids about to suicide. In fact, the best way to keep a young person from killing themselves is to ask directly - Are you thinking of killing yourself?

So, let's talk about how to administer the ASQ.

There is a tool kit that we created, and the web address is above. And here's the summary of what is in the tool kit, and we've divided it by venue.

So, there's a section for the emergency department, the inpatient medical surgical unit, and the outpatient primary care clinic.

We have provided a script for nurses and medical assistants who are the most common providers that screen using the ASQ.

And so, here's the script and so we you start by saying to the parent or guardian if there is one of the rooms “National safety guidelines, recommend that we screen all kids for suicide risk. We asked these questions in private. So, I'm going to ask you to step out of the room for a few minutes. If we have any concerns about your child safety, we will let, you know.” So, it's important when you're doing this, to tell the parent to step out and to not turn to the child and ask permission - don't say what, would you prefer your mother to stay or to go, because that puts too much a burden on the child to make a decision. So you just tell the parent in a very casual, normal kind of way. We're just going ask you step out for a minute or two. So, this is not go get a cup of coffee from the cafeteria because the ASQ only takes twenty seconds.
This is just step outside the room for a minute or two.  And then once the parent leaves, you say, now I'm going to the patient now, I'm going ask you a few more questions and you minister we ask at that time, you could also administer any other questions that you need to do in private, for example, a domestic violence screening question this would be a good time to ask.

It's the parent refuses to leave the room, it is OK to administer the ASQ in front of the parent we prefer, and we believe that kids will give more frank answers if you have the parent out of the room but if the parents in the room is actually a good way to model how to ask a child about suicide risk. If the patient screens positive, you can say to them – “I'm so glad you spoke up about this. I'm going to talk to your parents and your medical team. Someone who is trained to talk with kids about suicide is going to come speak with you.” It's important, not to turn to the kid and say your suicidal or anything like that. Because this is a screen and remember the screen just identify someone who needs further evaluation. And then the same thing goes for the parent, we don't want to walk outside and say your child is suicidal. We are going say “we have some concerns about your child safety that we would like to further evaluate. It's really important that he or she spoke up about this. I'm going to talk to your medical team and someone who's trying to talk with kids about suicide is going come speak with you and your child.”

So, this is a template for a script and of course, people can adapt to how they feel comfortable introducing the ASQ. It's important though that you do not change the questions for the ASQ that they're asked verbatim, because each question, each item, and the ASQ was empirically develop and validated. So, it's important that you stay true to the test and ask every question verbatim.

Okay, so what happens when a patient screens positive.

So, what is considered a positive screen on the ASQ? Any yes to questions one through four is considered a positive screen. In addition, any young person that refuses to answer is also considered a positive screen. And that's because we have data showing that young people that refused to answer the questions on the ASQ had significant psychiatric histories and were at greater risk. So, we can, we will further evaluate.

Once someone has said, yes to questions one through four, they're administered question five. Are you having thoughts of killing yourself right now?

So, there's two ways to screen positive -  the first way and the more common way is the non-acute that is a yes to any one of the four questions and a no to question five.

Those patients will need further evaluations via a brief suicide safety assessment to determine if more extensive psychiatric evaluation is necessary. These patients do not need full safety precautions. They do not need a one to one observer. They are considered a non- acute positive. The joint commission has deemed this valid and they need a further brief safety assessment to determine whether or not they are imminent risk or whether or not what else they need and that is in another training. The patient shouldn't leave until they have the brief suicide safety assessment. However, if they refused to stay, then they should sign out against medical advice.  Just like someone who had high blood pressure and wanted to leave before cardiologist showed up with sign out against medical advice.

The more rare way to screen positive is a acute positive which is a yes the question five. Are you having thoughts of killing yourself? Right now? This is considered urgent and an emergency, and it's very rare for non-behavioral health patients presenting with medical chief complaints to screen acutely positive and that happens less than one percent of the time. But these patients should not be left alone and you cannot leave these patients and they will require a one to one observer and full on safety precautions.

The brief suicide safety assessment is not necessary for these patients, because they are automatically deemed at imminent risk and will need a full psychiatric evaluation and safety evaluation.

However, if you want to do a brief suicide safety assessment, as part of the way your implementation program goes, that is also understandable.

Studies reveals that screening does not overburden the system and that universal screening is it's feasible.

So, this is just the pathway and again three tier system with a brief screen with the brief screen, the suicide safety assessment that is conducted by a mental health clinician, or an MD, NP, or PA. And that determines whether or not the patient needs full mental health evaluation.

Brief suicide safety assessments are available in these different versions and in worksheets on the website.

There are also resources to give to patients and links to videos for staff, if you have further interest in this.

Every single one of you can save a life and make a difference. There are things any individual can do right now to prepare to save a life. Everyone should save these numbers in their phone, the National Suicide Prevention Lifeline and the Crisis Text Line. These are twenty-four, seven resources available and there's also some action steps that one can look at AQS suicide prevention web page.

We don't have a crystal ball, so we say safety first is best. You can there's nothing easy about this. It's not simple to figure out if someone's going to try to kill themselves or not. But we believe this screening can be a very feasible way to identify kids that need further evaluation.

The best predictor of future behaviors past behavior. So, anyone who's tried to kill themselves in the past is at greater risk. Let's all remember that there's limits are in our ability to predict, but we all need to err on the side of caution and just do the best we can. So, I'm going to end with a patient example.

This was during our inpatient validation study, there was sixteen-year-old medical surgical patient who had cystic fibrosis, who screened negative on the depression screen. And then one of the data collectors Dr Abby Ross administered the ASQ, and this is how the patient screen. They said no, to the first, no to the second and no to the third. But have you ever tried to kill yourself? They said, yes. They were not an acute risk, but they had suicide behavior in the past that they never told anyone about. And when Dr Ross said to her why did you tell me today? The patient said because you asked the right questions. This was important, because this initiated a way for the patient to talk about her suicidal behavior and to get some mental healthcare, which was important to the patient.

There are a lot of teams to thank, and a lot of people that went into making the ASQ and testing the ASQ and implementing the ASQ. So, thank you for your attention.