Improving Suicide Screenings

• Nurses should be concerned about suicide because it is one of the leading causes of death in the United States. 
• In fact, according to the Centers for Disease Control and Prevention, in 2020 1.2 million people attempted suicide and 46,000 deaths were attributed to suicide. 
• Nurses must actively listen to their patients to detect warning signs of suicide. Suicide screenings tools exist to identify risk factors. 

Nurses should be concerned about suicide because it is one of the leading causes of death in the United States. In fact, according to the Centers for Disease Control and Prevention, in 2020 1.2 million people attempted suicide and 46,000 deaths were attributed to suicide. Therefore, The Joint Commission continues to mandate a national Patient Safety Goal to reduce the risk for suicide. 

I understand the importance of this goal because I witnessed the aftermath of a suicide at a medical facility when I was an LPN.  

She was 22 and when she was found, CPR could not save her.  

Within hours, she went from our care to the medical examiner’s care.  

Patients were interrogated by police, multiple incident reports were filed, the blame game was played, and emotions ran high.  

What to Look For During Suicide Screenings

Like many people who attempt suicide, our 22-year-old had several risk factors.  

Understanding risk factors, some of which are listed below, is crucial to identifying at-risk patients: 

• History of suicide attempt 
• History of depression or other mental illness 
• Chronic pain 
• Legal troubles 
• Financial difficulties 
• Substance abuse 
• Social isolation 
• Bullying 
• History of adverse childhood experiences 
• Relationship problems 
• Community violence 

Nurses must actively listen to their patients to detect warning signs of suicide.  

Is the patient experiencing feelings of hopelessness and negativity? Is he or she giving away important possessions? Has the patient researched ways to die or prepared for suicide, i.e., bought a firearm or stockpiled medications?  

When you recognize warning signs, be an advocate and follow through.

Different Types of Suicide Screenings

Many healthcare facilities utilize suicide screening tools, such as the Columbia-Suicide Severity Rating Scale (C-SSRS), a short questionnaire suitable for all ages.  

Another tool is the Patient Health Questionnaire, (PHQ-9) which is more focused on depression but does include one direct question, item 9, regarding suicide ideation. A modified version of the PHQ-9, the PHQ-A, is tailored for adolescents.  

The Suicide Cognitions Scale (SCS), another tool, contains 16 items and it taps into emotional experiences, core beliefs, and life problems.  

Although these tools are widely used, we can do a better job of identifying high-risk patients who require immediate attention. We should be eager to bridge the gap between new research and clinical practice.  

Analyzing Current Suicide Screenings

In a 2021 study of more than 2,700 adult patients, the authors mainly focused on the PHQ-9 and the SCS. They aimed to determine whether suicide screenings could be improved to better identify high-risk patients who screen positive on the PHQ-9. After all, many patients seek help before attempting suicide. Another study reports, 30% of patients visited a healthcare provider within one week of dying by suicide, more 50% visited a provider within 30 days of killing themselves, and more than 90% visited a provider within one year of suicide.  

The Annals of Family Medicine study chose several U.S. military primary clinics as the setting for their study because military suicides have been on the rise and suicidal individuals who seek help often visit a primary care or family practice clinic. This means that they will likely encounter you, the nurse, and at this vulnerable time, they will need an advocate more than ever. 

Therefore, nurses should be aware that a positive screen on item 9 on the PHQ-9 in addition to a positive screen on SCS items 8, 13, or 16 (listed below) should raise a red flag because these are associated with increased probability of suicidal behavior. 

• PHQ-9 item 9 question: Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead, or thoughts of hurting yourself in some way? 

(On the SCS, patients rate the degree to whether they agree or disagree with the statements.) 

• SCS item 8: “It is unbearable when I get this upset.” 
• SCS item 13: “I can’t imagine anyone being able to withstand this kind of pain.” 
• SCS item 16: “I don’t deserve to live another moment.” 

The study concludes that item 9 on the PHQ-9 can be improved by pairing it with one of the above items from the SCS, especially items 8 or 13.

The Bottom Line

So, as a patient advocate, what can you do? You can bring this study to the attention of your administrators and, possibly, effect change. If the SCS is used as a secondary screening tool to the PHQ-9, perhaps more lives could be saved. 

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