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This article provides an overview of evidence-based suicide risk assessment and intervention methods geared towards practicing mental health professionals working in hospital-based settings (eg, inpatient, emergency departments, intensive outpatient programs and standard outpatient programs). Empirically validated screening questionnaires, more in-depth assessment tools, and prevention interventions that directly address suicidal thoughts and behaviors are briefly described. Guidelines for implementing these methods are outlined, and links to associated resources are provided. Consideration is given to the limitations of existing research.
Working with people who experience suicidal thoughts, suicidal behaviors, or suicide risk is one of the most critical responsibilities of mental health professionals (MHPs). Over 80% of people who die by suicide have a diagnosable mental health disorder,1 one out of three individuals who die by suicide comes into contact with mental health services within one year of death, and one out of five within one month of death.2 MHPs are in an important position to prevent suicide deaths, yet many providers feel ill-equipped to assess and respond to patients at risk. The purpose of this article is to provide an overview of evidence-based suicide risk assessment and intervention methods, along with guidance on how to use these tools in practice. Recommendations are geared towards MHPs (psychiatrists, psychologists, social workers, psychiatric nurses, etc.) working in hospital-based settings.
This practitioner-oriented review focuses on direct assessment and intervention of suicidal thoughts and behaviors (STBs). However, comprehensive risk assessment should include consideration of risk and protective factors beyond STBs (eg, demographics, diagnoses, recent life events, social connectedness, etc.; a comprehensive list is provided in Franklin et al3), and interventions that target interrelated problems should be included in the treatment plan (eg, treatment for comorbid conditions). Additionally, this review is intended to be brief, with the busy practicing MHP in mind. More in-depth descriptions of suicide risk assessment instruments and interventions can be found elsewhere.4,5
Assessment
Importance of Evidence-based Assessment
In practice, many providers do not routinely assess suicide risk using standardized, evidence-based methods, and some avoid asking about suicide altogether. First, it is a common misconception that talking about suicide increases risk. This idea has been thoroughly debunked,6 and asking directly about suicide normalizes disclosure. Second, many providers do not conduct follow-up assessment for patients initially presenting as low risk. However, research using intensive assessment methods demonstrates that STBs fluctuate substantially, even over minutes to hours.7 It is therefore crucial to repeatedly assess risk, regardless of past risk determinations. Third, even providers who frequently ask about suicide may not use standardized measures due to a lack of familiarity with or appreciation for the importance of evidence-based assessment. Evidence-based assessment tools have undergone the rigorous process of validation, which involves testing reliability (the ability of the instrument to provide consistent results), validity (the degree to which the instrument is measuring the condition that it is designed to measure), sensitivity (the ability of the instrument to correctly identify individuals with the condition) and specificity (the ability of the instrument to correctly identify individuals without the condition). Thus, using a validated tool ensures that assessment is consistent, can track changes over time, captures STBs rather than related but distinct constructs (eg, depression), and accurately identifies individuals at risk so that resources can be efficiently directed towards prevention.
Screening Versus Assessment
Suicide risk assessment is generally considered to occur at two levels: 1) screening to identify individuals who may be at risk and require further follow-up, and 2) comprehensive assessment to elucidate the scope of risk and inform treatment decisions. The distinctions are not entirely clear-cut, as the same measure may be considered a screener or assessment instrument depending on the setting, and even among comprehensive tools, there is variability in depth. We will separate our review of measures based on whether they are generally used for screening vs assessment, while acknowledging these categories are imprecise. Measures are listed in Table A.
Table A
Overview of Evidence-based Suicide Risk Screening and Assessment Instruments
| Ask Suicide-Screening Questions (ASQ) | Screening | Self-report | 4 items | All ages | Free | www.nimh.nih.gov/asq |
| Beck Scale for Suicide Ideation (BSS/SSI) | Assessment | Self-report (BSS); Interview (SSI) | 2 items | Adults | Proprietary |
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| Columbia Suicide Severity Rating Scale (C-SSRS) | Screening and Assessment Versions | Interview and self-report versions | Variable | Adults, Adolescents | Free | https://cssrs.columbia.edu |
| Geriatric Suicide Ideation Scale (GSIS) | Assessment | Interview and self-report | 31 items | Older adults | Proprietary | Heisel MJ, Flett GL. The development and initial validation of the geriatric suicide ideation scale. Am J Geriatr Psychiatry. 2006;14(9):742–751. |
| Patient Health Questionnaire-9 (PHQ-9) Depression Scale - Question 9 | Screening | Self-report | 1 item | Adolescents Adults, | Free | https://www.phqscreeners.com/select-screener |
| Patient Safety Screener-3 (PSS-3) | Screening | Interview | 3 items | Adults, Adolescents | Free | https://sprc.org/micro-learning/the-patient-safety-screener-a-brief-tool-to-detect-suicide-risk |
| Suicidal Behaviors Questionnaire–Revised (SBQ-R) | Screening | Self-report | 4 items | adolescents Adults, | Free | https://youthsuicideprevention.nebraska.edu/wp-content/uploads/2019/09/SBQ-R.pdf |
| Self-Injurious Thoughts and Behaviors Interview-Revised (SITBI-R) | Assessment | Interview and self-report versions | Variable | Adults, adolescents | Free | Fox KR, Harris JA, Wang SB, Millner AJ, Deming CA, Nock MK. Self-injurious thoughts and behaviors interview-revised: de-velopment, reliability, and validity. Psychol Assess. 2020;32(7):677–689. |
| Suicidal Ideation Questionnaire-Junior (SIQ-JR) | Assessment | Self-report | 15 items | Adolescents Pre-teens, | Proprietary | Reynolds WM. SIQ, Suicidal Ideation Questionnaire: Professional Manual. Psychological Assessment Resources; 1988. |
| Ultra-Short Suicide Ideation Scale (USSIS) | Screening | Self-report | 4 items | Older adults | Proprietary | Nugent WR, Cummings S. A validity and measurement equivalence study of the ultra-short suicidal ideation scale with older adults. J Soc Social Work Res. 2014;5(4):439–459. |
Note: Instruments are listed alphabetically.
Screening Instruments
Screening tools generally come in two forms: 1) individual questions embedded in a more generalized measure of psychiatric symptoms, and 2) stand-alone, brief suicide-specific measures. Both types of screeners are increasingly used across medical settings as part of routine intake procedures. Screening instruments primarily assess the presence and severity of current suicidal ideation. While suicidal ideation is one of the stronger predictors of suicide risk, it is a weak predictor in an absolute sense, and even the most validated screening instruments produce many false positives.8 Thus, screening alone is insufficient and should be followed by more comprehensive assessment. Screener accuracy is reported when available.
Patient Health Questionnaire (PHQ-9) Depression Scale Item 9. The most popular first type of screener is item 9 of the PHQ-9,9 a freely available self-report questionnaire assessing symptoms of depression. Item 9 probes the intensity of thoughts of “being better off dead, or of hurting yourself ” over the previous 2 weeks. The PHQ-9 is the most widely used universal screening instrument in general medical settings, particularly in primary care. It has the advantage of serving the dual purpose of screening for depression and suicide risk, as well as being the most efficient validated suicide screener with just one question. However, there are concerns about its wording, which combines passive and active thoughts of self-harm, and its limited accuracy in classifying high-risk individuals (sensitivity/specificity = 80%/70%).5
Ask Suicide Screening Questionnaire (ASQ). The ASQ is a 4-item self-report questionnaire developed by the National Institute of Mental Health.10 Items assess the presence of passive and active suicidal ideation in the past few weeks, and lifetime history of suicide attempts. If any items are positive, a fifth item probes current suicidal thoughts. The ASQ has been validated in adult and adolescent samples (sensitivity/specificity = 96.9%–100%/87.6%–89%),11,12 and the Joint Commission (JC) recommends the ASQ for all ages. The ASQ is part of a resource toolkit that includes instructions on how to respond to a positive screen, including guidance on additional assessment and intervention options.
Patient Safety Screener-3 (PSS-3). The PSS-3 consists of three items assessing suicide attempt history and the presence of suicidal ideation and depressed mood or hopelessness in the previous 2 weeks. The PSS-3 was developed as part of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study to screen for suicide risk in acute settings.13 It has primarily been studied in emergency departments (EDs) with adults but has been used across acute settings with patients 12 and older. Like the ASQ, the PSS-3 includes a tip sheet with recommendations for responding to a positive screen, including a secondary screener to help stratify patients based on risk.
Suicidal Behaviors Questionnaire Revised (SBQ-R). The SBQ-R is a four-item self-report measure of STBs,14 reduced from the original 34-item scale developed by Dr. Marsha Linehan. (M. M. Linehan, M. E. Addis; unpublished manuscript; 1983.) Like other screeners, the SBQ-R assesses the frequency of suicidal thoughts and history of attempts. However, it also assesses communication of intent to die by suicide, as well as perception of the likelihood of a future attempt. The SBQ-R has been validated for use with adults and adolescents. Cut-off scores have been established for both the total score (sensitivity/specificity = 80%–93%/91%–95%) and the first item (sensitivity/specificity = 80%–100%/97%–100%) in clinical and non-clinical samples. The first item (history of ideation and attempts) can be used as a brief one-item screener with decent accuracy.15
Ultra-Short Suicide Ideation Scale (USSIS). The USSIS contains four self-report items assessing the frequency of suicidal thoughts, including methods, intent, and plans. The USSIS has undergone less validation testing than the above screeners; however, it is included here because it is one of the only screeners designed specifically for older adults. Older adults are a particularly high-risk group, exhibiting important differences in suicide risk (eg, different risk factors and methods), so a tailored approach to risk assessment is needed.16 The USSIS demonstrates good scale properties; however, its ability to predict suicidal behavior has not yet been examined.17
Assessment Instruments
The ultimate goal of comprehensive risk assessment is to inform intervention decisions. It is common practice to use these measures to stratify patients based on levels of risk (low, medium, high), with prescriptive follow-up interventions assigned to each level. This approach is practically desirable for busy health care systems that rely on MHPs of varying disciplines and training levels to appropriately manage risk; however, research increasingly highlights the inaccuracy of risk stratification.18 Instead, it is recommended that risk assessment and treatment planning take an idio-graphic approach, integrating information from evidence-based assessment tools with consideration of individual patient factors (eg, barriers to treatment, social support) and clinical judgement.
Beck Scale for Suicide Ideation (BSS/SSI). The BSS19 is one of the oldest standardized assessments of suicide ideation and is commonly used across acute and nonacute medical settings. The BSS was developed as a self-report version of the Scale for Suicide Ideation (SSI).20 The SSI is a semistructured interview completed by a trained clinician, whereas the BSS is a 21-item self-report measure completed by the patient. The BSS remains a widely used instrument with individuals 17 years of age and older; however, some have expressed concern that the language has become outdated.
Columbia Suicide Severity Rating Scale (C-SSRS). The C-SSRS21 is a set of measures (the Columbia Protocol) that includes a six-item screener (sensitivity/specificity = 53.9%/75.6%)22 and a longer, detailed assessment of current and prior suicidal thoughts and behaviors. It has been tested in adolescent and adult populations. Both the screener and the full version probe the presence of passive and active suicidal thoughts, plans, and preparation for a suicide attempt. The full C-SSRS adds further detail to capture nuances in suicidal thinking (eg, with or without a plan) and behaviors (eg, interrupted vs. aborted attempts), as well as intensity of ideation and lethality of behaviors. It can be adapted for a variety of time scales (eg, lifetime, past month, since last visit).
Geriatric Suicide Ideation Scale (GSIS). The GSIS23 is a 31-item measure designed to assess suicidal ideation specifically in older adults. The GSIS can be used to produce a total score and subscale scores, including suicide ideation, perceived meaning of life, loss of personal self-worth, and death ideation. The GSIS has been validated in clinical, community, and residential samples. Two abbreviated versions exist, including the 10-item Brief Geriatric Suicide Ideation Scale (BGSIS) and the five-item Geriatric Suicide Ideation Scale– Screen (GSIS–Screen).24
Self-Injurious Thoughts and Behaviors Interview–Revised (SITBI-R). The SITBI25 and its more recent revised version (SITBI-R)26 assess the frequency of suicidal and nonsuicidal thoughts and behaviors, as well as their characteristics (eg, frequency of thoughts, methods of suicide attempts). Although initially conceptualized as an interview, it has often been used as a self-report. The items do not create a sum score, and thus, which specific items are used can be customized to fit the different settings' needs. Like the C-SSRS, the reference timeframe can also be easily modified.
Suicidal Ideation Questionnaire (SIQ) and Suicidal Ideation Questionnaire Junior (SIQ-JR). The SIQ and SIQ-JR are two self-report measures designed to assess frequency of suicidal thoughts within the previous month in youth.27 The SIQ-JR contains a subset of 15 items from the longer 30-item SIQ. Items are rated on a seven-point Likert scale ranging from “I never had this thought” to “Almost every day.” Both measures were originally designed to be administered in younger adolescents (grade 7 through 9); however, the SIQ-JR has been used as an assessment tool in multiple randomized controlled trials with a broad range of adolescents (12 to 18 years).
Intervention
Like evidence-based assessment measures, evidence-based interventions have undergone a rigorous process of empirical evaluation to ensure they produce the desired outcome (reduction/prevention of STBs) better than chance and compared to standard practice. The following interventions are those with the strongest support. The Collaborative Assessment and Management of Suicidality (CAMS)28 is excluded from this list because it is covered in another article in this special issue (Jobes et al 29). All interventions are listed in Table B.
Table B
Overview of Evidence-based Suicide Prevention Interventions
| Caring Contacts | Caring Contacts interventions target the high-risk period following discharge from hospitalization or the ED. They have been implemented through multiple mediums (postcards, emails, phone calls, text messages, etc.), though they all share similar qualities:
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Skopp NA, Smolenski DJ, Bush NE, et al. Caring contacts for suicide prevention: a systematic review and meta-analysis. Psychol Serv. 2023;20(1):74–83. |
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| Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) | CBT-SP involves 10–12 sessions of outpatient individual therapy unfolding over 3 phases:
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| Two versions of CBT-SP were developed by separate research groups, though they share many similarities and demonstrate comparable reductions in risk. | ||
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| Collaborative Assessment and Management of Suicidality (CAMS) | CAMS is an evidence-based framework for addressing suicide risk that is, as the name implies, highly collaborative between the patient and clinician. It involves thorough and ongoingassessment of risk, development of a treatment plan (the ‘Stabilization Plan’) targeting twopatient-identified “drivers” of risk, and implementation/continued monitoring of the plan.Clinicians can use any interventions they deem appropriate to address the drivers, includingCBT. | Jobes, D. A. (2023). Managing suicidal risk: A collaborative approach (3rd ed.). Guilford Publications. |
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| Dialectical Behavioral Therapy (DBT) | DBT was developed by Marsha Linehan to treat clients with chronically elevated suicide risk. DBT is an evolution of traditional CBT that integrates acceptance and change-focused methods, which are typically implemented over 6–12 months of treatment involving individual therapy, phone coaching, group therapy, and a consultation team for therapists. DBT is perhaps best known for its numerous coping skills across the domains of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. | Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press. |
| Linehan, M. (2014). DBT skills training manual. Guilford Publications. | ||
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| Lethal Means Counseling | Counseling patients to reduce access to lethal means involves:
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Free Online Course in Counseling on Access to Lethal Means for Providers: https://zerosuicidetraining.edc.org/enrol/index.php?id=20 |
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| Safety Planning Intervention | A Safety Plan is a personalized list of coping strategies and sources of support to promote safety during a suicidal crisis. The Stanley-Brown Safety Plan has six sections:
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Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256–264. https://suicidesafetyplan.com/wp-content/uploads/2024/12/Stanley-Brown-Safety-Plan-05-02-2024.pdf |
Note: Interventions are listed alphabetically.
Lethal Means Counseling. Lethal means counseling involves assessing access to lethal means, working with patients and families to develop a plan to eliminate or restrict access, and following up to ensure that the plan has been enacted and maintained. For example, reducing access to lethal medications may involve prescribing safe quantities or less-lethal alternatives, providing education on safe medication disposal, and working with families to develop a safe storage plan. Notably, reducing access to specific methods does not lead to increases in suicide deaths involving other methods.30
Safety Planning. A safety plan is a personalized list of coping strategies and sources of support to promote safety during a suicidal crisis. The most ubiquitous safety plan template, developed by Stanley and Brown,31 involves six steps that the patient can execute in succession, escalating from lower to higher levels of support. A safety plan should be developed collaboratively with a patient at the first sign of elevated risk and is more effective when highly personalized and regularly reviewed and updated throughout treatment.
Caring Contacts. Caring Contacts target the elevated risk period following discharge from hospitalization.32 They involve reaching out to recently discharged patients through a variety of modalities (eg, phone call, text message, postcard) to express caring and concern about their well-being without placing a burden on them to respond. Research suggests that Caring Contacts are effective for up to one year following discharge, and the appropriate number appears to be eight contacts.
Psychotherapy Interventions. Among psychotherapy interventions, cognitive-behavioral therapies (CBTs) demonstrate the most consistent efficacy in reducing suicide risk.33 Two types of CBT were designed specifically to target STBs: CBT for suicide prevention (CBT-SP)34,35 and dialectical behavioral therapy (DBT).36,37 Both CBT-SP and DBT have demonstrated superiority to treatment as usual and have been found to reduce the risk of suicide attempts by at least 50%.38
What Are MHPS Required Versus Recommended to Do?
The JC, which sets and enforces standards for hospital accreditation, does not mandate universal suicide risk screening across all patient populations and clinical settings. However, the JC does require screening for individuals who are primarily being evaluated or treated for behavioral health conditions, and screening is encouraged for those presenting with behavioral health as a secondary concern. A comprehensive assessment of risk is required for patients who screen positive. Beyond these minimum requirements, it is critical that providers conduct screenings in a manner that fosters a safe and open environment, one in which patients feel comfortable disclosing suicidal thoughts or behaviors. Unfortunately, research indicates that providers may unintentionally assess suicide risk in ways that discourage disclosure, such as framing questions in a manner that subtly signals a preference for a “no” response rather than inviting honest conversation about suicidal thoughts.39
The JC's requirements for interventions are less prescriptive, emphasizing that MHPs follow individual hospital policies and procedures. However, safety planning and lethal means counseling are implicit in requirements to create and document a risk mitigation plan and discharge counseling. The use of evidence-based interventions, including the Stanley-Brown Safety Plan, Caring Contacts, and CBTs like CBT-SP and DBT, is strongly recommended.
Conclusion
In this article, we have highlighted suicide risk screening, assessment, and intervention tools with the strongest empirical support. Many of these tools are freely accessible, efficient, and easy to use. Given the high rate of patient interaction with the health care system before death by suicide, broadly applied screening measures are critical for identifying at-risk individuals. However, screening alone is insufficient to provide a comprehensive understanding of risk, so screening should always be paired with more in-depth assessment to guide intervention. Lastly, multiple levels of intervention can be employed in tandem, balancing the needs, availability, and benefits for health care systems and patients. Brief interventions that require only limited expertise and resources, like counseling on access to lethal means, safety planning, and Caring Contacts, can be applied liberally. Psychotherapy interventions like CBT-SP and DBT are resource intensive and require highly trained clinicians; however, they have demonstrated strong efficacy and remain important options for high-risk patients. We encourage MHPs to use this article as a springboard for integrating evidence-based screening, assessment, and interventions tailored to each patient's individual presentation.
From Rutgers University Behavioral Health Care (MTHS, SM, MM, EMK); Department of Psychology, Rutgers University (MTH, EAE), Piscataway, New Jersey; and American Foundation for Suicide Prevention, New York, New, York (CYM, JMH-F).
Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Mariah T. Hawes-Sousa, PhD, Department of Psychology, Rutgers, The State University of New Jersey, Tillett Hall, 53 Avenue E, Piscataway, NJ 08854; email: [email protected].
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