Section 1
Chapter
Identification and screening of suicide risk
3 Kelly Posner, Jacqueline Buchanan, Leora Amira, Kseniya Yershova,
Adam Lesser, and Erica Goldstein
Introduction
Suicide remains one of the world’s greatest public
health crises; however, the magnitude of its public
health impact and global disease burden is under-
recognized (Insel, 2010). Suicide recently became the
number one cause of injury mortality in the USA
(Rockett et al., 2012), surpassing motor vehicle
crashes. Every 15 minutes an adult dies by suicide
(Centers for Disease Control and Prevention, 2010),
and seemingly no population is spared. Suicide has
been shown to be a leading cause of death among law
enforcement officers (Clark et al., 2012) and in correc-
tional facilities (Hayes, 2010). Within an average cor-
poration of 100 000 employees, every 7 days one
employee or family member will die by suicide, and
each day there will be three suicide attempts. (Paul,
2005). Approximately 8% of high school students
report having attempted suicide in the past year
(Eaton et al., 2012). Most often suicide occurs with
no clear warning signs and its economic burden is
staggering. The annual global disease burden of sui-
cide is nearly $141 billion (John & Ross, 2010). In the
USA alone, non-fatal suicide attempts cost $6 billion a
year. (Centers for Disease Control and Prevention,
2010).
Identification is the first necessary element of
any prevention effort – ability to treat is contingent
upon the ability to find at risk individuals or those
suffering in silence. However, a large proportion of
individuals who later die by suicide go undetected
due to lack of querying and inadequate methods to
do so, especially in non-mental health settings.
Forty-five percent of suicides across all age groups
have contact with their primary care providers
within 1 month prior to their death; 77% across all
age groups will see their primary care provider
A Concise Guide to Understanding Suicide, ed. Stephen H. Koslow, Pedro Ruiz, and Charles B. Nemeroff. Published by
Cambridge University Press. © Cambridge University Press 2014.
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within 1 year of their death (Luoma et al., 2002).
Nearly 90% of suicidal youth were also seen for a
medical appointment within a 12-month period
(McCarty et al., 2011). Yet, less than 3% of primary
care patient appointment records prior to suicide
reflect a comment about suicide risk (Appleby
et al., 1996). Among approximately 1500 individuals
admitted to Walter Reed Army Medical Center
between 2001 and 2006, 11% were admitted for
serious suicidal ideation and 12% with suicide
attempt, yet no documentation of past suicidal
behaviors was noted. There was no suicide screening
or assessment measure administered in a single case.
It was later strongly recommended that military
providers be trained in the use of screening or
assessment tools (Posner et al., 2013). One in five
adolescents who screened positive for suicidal idea-
tion and/or attempts in an emergency department
presented for non-psychiatric reasons (King et al.,
2009); thus, without general screening, suicidal indi-
viduals will be missed. 20–25% of adolescents who
die by suicide have had contact with mental health
professionals within a year of their death (Gould et
al., 2003). Only 19% of primary care providers rel-
ative to 59% of psychiatric practitioners knew about
the suicidal intentions of their patients who died by
suicide (Isometsa et al., 1994). Individuals at high-
risk for suicide will not be adequately detected if
screening is not done routinely and relies on those
who self-identify. All of this is to suggest that
screening should be a first-line prevention strategy
and that screening for suicide should be as common
as monitoring for blood pressure.
Screening for suicide has been shown to be effective
in identifying at risk individuals and connecting them
with treatment. Local depression screening programs
17
 Section 1: Understanding Suicide
are known to increase the number of individuals treated
for depression and to decrease suicide rates (Mann
et al., 2005) and administering screening instruments
for depression, suicidal ideation, or suicidal acts to high
school students more than doubled the proportion of
identified at risk individuals relative to those identified
by school professionals (Scott et al., 2009). Studies show
that use of a standardized screening tool can result in a
600% increase in detection of suicidal ideation (Bryan
et al., 2008). Screening programs such as The College
Screening Project of the American Foundation for
Suicide Prevention encouraged high-risk students to
enter treatment for the first time and resulted in a
67% reduction in suicides during the 4-year screening
program relative to the previous 4 years (Haas et al.,
2008). In addition, continuous monitoring for suicide,
especially in high-risk populations, can be an interven-
tion in and of itself with a strong impact on reducing
suicide attempts. Research has shown that monitoring
suicidal symptoms alone for 1 year reduced attempts
from the previous year by 80% (Stanley, 2006).
While identification of high-risk individuals is crit-
ical to prevention, inquiry about suicide has been
complicated by the historical lack of clear definitions
for suicidal ideation and behavior, concern over
whether asking about suicide can be iatrogenic or
harmful, and confusion about how to ask such ques-
tions. Research has shown that inquiring about
suicide-related phenomena does not, in fact, cause
suicidal thinking or distress in youth (Gould et al.,
2005). On the contrary, asking questions about suicidal
ideation and behavior improves risk identification
(Posner et al., 2011).
Gaps in suicide risk management and physician
training are responsible for some of these misconcep-
tions (Sudak et al., 2007; Goldman et al., 1999; Milton
et al., 1999; Smith & Scoullar, 2001). The implementa-
tion of training programs such as the Skills Training
on Risk Management (STORM) project significantly
improve physician suicide assessment practices
(Appleby et al., 2000; Nutting et al., 2005).
Traditional methods of relying upon open-ended
questions in assessing suicide risk have been problem-
atic. Clinicians who perform routine intakes identify
only 25% of patients with history of suicide attempt
compared to structured instruments (Hawton, 1987).
When clinicians were trained to ask two open-ended
questions about suicide they over-detected suicidal
ideation and under-detected suicidal behavior in ado-
lescent patients (Holi et al., 2008). Structured or semi-
18
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structured tools improve detection in routine clinical
assessments. Use of a structured questionnaire
detected 29.7% of patients with suicidal ideation and
18.7% of patients with a history of a suicide attempt
that went undetected by an open-ended clinician inter-
view (Bongiovi-Garcia et al., 2009). In medical emer-
gency department screening, a phone-administered
suicide questionnaire (Columbia-Suicide Severity
Rating Scale (C-SSRS)) increased suicide attempt
detection by more than 40% compared to chart
reviews (Arias et al., 2014).
Furthermore, utilizing research-supported instru-
ments facilitates clinical decision-making and fosters
confidence in the determination of next steps for indi-
viduals identified with various levels of suicide risk.
Using a scale with stratified thresholds in conjunction
with triage protocols may enable the reduction of
burden on limited mental health services and the sub-
sequent redirection of scarce resources (Peñta &
Caine, 2006).
Assessment of suicidal ideation
and behavior
The prevailing diathesis-stress model of suicidal
behavior suggests that such behavior occurs when an
individual with a pre-existing vulnerability such as a
family history of suicide or impulsivity experiences a
precipitating stressor (Mann et al., 1999; Oquendo
et al., 2003). Having any psychiatric diagnoses is also
a well-documented risk factor for suicidal ideation and
behavior (Petronis et al., 1990; Shaffer et al., 1996;
Gould et al., 1998; Vijayakumar & Rajkumar, 1999;
Kessler et al., 1999; Borges et al., 2010); more than 90%
of those who die by suicide meet criteria for at least
one psychiatric disorder (American Psychiatric
Association, 2003). Specifically, major depressive dis-
order is a strong risk factor for suicide (Harris &
Barraclough, 1997; Kessler et al., 1999), and alcohol
disorders are also known to raise risk (Harris &
Barraclough, 1997). Screening for depression is rec-
ommended in primary care settings and can lead to
improved identification of high-risk individuals
(Mann et al., 2005). Referral and subsequent treatment
of individuals with these disorders may be helpful in
diminishing suicide rates (Mann et al., 2005).
Suicidal ideation and a history of suicidal behav-
ior are among the most salient short- and long-term
risk factors for suicide (Nordström et al., 1995; Beck
et al., 1999; Brown et al., 2000; Kuo et al., 2001).
 Chapter 3: Identification and screening of suicide risk

The clinical concern associated with a suicide The full range of suicidal behaviors
attempt also necessitates its status as an outcome
Traditionally, suicide screening instruments and
along with suicide. For these reasons, and because
other assessment tools queried about suicide
many individuals die from their first suicide attempt
attempts only. Consequently, behaviors in which
(Isomets, 1998), it is important to identify suicidal
steps are taken imminently before a suicide attempt
ideation and behavior risk factors. Identification of
or suicide would have otherwise occurred (e.g., put-
short-term risk necessarily requires identification
ting a noose around one’s neck and changing one’s
and differentiation of symptoms of suicidal ideation
mind, being rescued by another before jumping from
and behavior.
the roof of a building) and behaviors in preparation
The identification of suicidal ideation and behavior
of suicide (e.g., buying a gun, collecting pills, writing
is challenged by inadequate standardization of defini-
a suicide note) have been left undetected. In the effort
tions. The US Institute of Medicine concluded that
to establish a meaningful common language for sui-
absence of consistent definitions for suicidal phenom-
cidal behavior, the CDC has adopted terminology
ena is one of the major impediments to suicide preven-
that distinguishes between the following suicidal
tion: “research on suicide is plagued by many
behaviors: (1) suicide, (2) suicide attempt, (3) inter-
methodological problems. . .definitions lack uni-
rupted attempt, (4) self-interrupted/aborted attempt,
formity. . .[and] reporting of suicide is inaccurate”
and (5) preparatory acts or behavior (Crosby &
(Goldsmith et al., 2002). Inconsistent or ambiguous
Melanson, 2011) (See Figure 3.1 for definitions).
terminology for identical suicidal phenomena
A suicide assessment instrument should ideally assess
(O’Carroll et al., 1996; Posner et al., 2007) has contrib-
for the full range of behavior and have distinct defi-
uted to confusion about how to label discrete instances
nitions with corresponding probes.
of suicidal ideation or behavior, with a multitude of
In addition to an abundance of extant research
terms often referring to the same occurrence. Terms
demonstrating the potent risk of a suicide attempt
that carry value judgments such as “failed attempt,”
for future suicide attempts or death by suicide (Steer
“suicide gesture,” “manipulative act,” and “suicide
et al., 1988; Fawcett et al., 1990; Malone et al., 1995;
threat” (Crosby & Melanson, 2011) further inhibit iden-
Harris & Barraclough, 1997; Brown et al., 2000), recent
tification. Historically, the ambiguity in definitions has
data support the predictive properties of other suicidal
resulted in over- (e.g., a clinician labeled a slap in the
behaviors for high risk of future suicidal behavior.
face a suicide attempt) and under-identification (e.g., a
These other suicidal behaviors – interrupted attempt,
patient hung himself after a fight with his father, which
self-interrupted/aborted attempt, or preparatory acts
was incorrectly attributed to his schizophrenia) of high-
or behavior – also confer significant risk, with odds
risk individuals, increasing both false positive and false
ratios similar to that of suicide attempts (Posner,
negative cases. Numerous international agencies,
Greist et al., 2013). Moreover, the very behaviors that
including the US Centers for Disease and Control
have historically been overlooked constitute the
(CDC), the World Health Organization (WHO), and
majority of suicidal behaviors that individuals engage
the US Food and Drug Administration (FDA), have
in (Mundt et al., 2011). Extant research suggests that
undertaken initiatives to standardize definitions and
interrupted attempts are predictive of suicide (Steer,
classification of suicidal ideation and behavior.
1988), aborted attempts increase risk for suicide
Suicide screening instruments should strive to
attempts (Marzuk et al., 1997; Barber et al., 1998),
make multiple distinctions within suicide ideation
and individuals who engage in preparatory behavior
and behavior risk factors for more precise determina-
are more likely to die by suicide than those who do not
tion of suicide risk. There are several elements that are
report such behavior (Steer et al., 1988; Marzuk et al.,
critical to the identification of high-risk individuals,
1997; Beck et al., 1999). While suicidal behavior is a
including the assessment of: (1) the full range of sui-
rare occurrence, more precise identification of high-
cidal behaviors, (2) intent to die, a necessary compo-
risk individuals is paramount to prevention efforts.
nent of suicidal behavior that distinguishes it from
non-suicidal self-injurious behavior, (3) suicidal idea-
tion and suicidal behavior as separate entities, and (4) Intent to die
the wish to die and intent to act as components of Research supports the use of an intent-based defini-
suicidal ideation. tion of suicidal behavior (Brent et al., 1993;

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 Section 1: Understanding Suicide

Definitions
Self-directed violence (analogous to self-injurious behavior)

Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.
This does not include behaviors such as parachuting, gambling, substance abuse, tobacco use or other risk
taking activities, such as excessive speeding in motor vehicles. These are complex behaviors some of which
are risk factors for SDV but are defined as behavior that while likely to be life-threatening is not recognized by
the individual as behavior intended to destroy or injure the self. (Farberow, N. L. (Ed.) (1980). The Many Faces
of Suicide. New York: McGraw-Hill Book Company). These behaviors may have a high probability of injury
or death as an outcome but the injury or death is usually considered unintentional. Hanzlick R, Hunsaker
JC, Davis GJ. Guide for Manner of Death Classification. National Association of Medical Examiners. Available at:
http//www.charlydmiller.com/LIB03/2002NAMEmannerofdeath.pdf. Accessed 1 Sept 2009.

Self-directed violence is categorized into the following:

Non-suicidal (as defined below)
Suicidal (as defined below).

Non-suicidal self-directed violence

Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.
There is no evidence, whether implicit or explicit, of suicidal intent. Please see appendix for definition of
implicit and explicit.

Suicidal self-directed violence

Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.
There is evidence, whether implicit or explicit, of suicidal intent.

Suicide attempt
A non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior.
A suicide attempt may or may not result in injury.

Interrupted self-directed violence - by self or by other

By other-A person takes steps to injure self but is stopped by another person prior to fataI injury. The
interruption can occur at any point during the act such as after the initial thought or after onset of behavior.
By self (in other documents may be termed "aborted*suicidal behavior) - A person takes steps to injure
self but is stopped by self prior to fatal injury.
Source: Posner K, Oquendo MA, Gould M, Stanley B, Davies M. Columbia Classification Algorithm of Suicide
Assessment (C-CASA): Classification of Suicidal Events in the FDA's Pediatric Suicidal Risk Analysis of
Antidepressants. Am J Psychiatry. 2007; 164:1035-1043.
http://cssrs.columbia.edu/

Other suicidal behavior including preparatory acts

Acts or preparation towards making a suicide attempt, but before potential for harm has begun. This can
include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun,
collecting pills) or preparing for one's death by suicide (e.g., writing a suicide note, giving things away).
Posner et al, 2007.
Suicide
Death caused by self-directed injurious behavior with any intent to die as a result of the behavior.

Figure 3.1. CDC definitions of self-directed violence. Reproduced with permission.)

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Fergusson et al., 2005; Clark et al., 2012), yet suicide
screening instruments often do not adequately assess
for the intent of the self-injurious behavior.
Individuals engaging in suicidal behavior frequently
have mixed motives (Andriessen, 2006). The degree
of intent to die is often difficult to discern and there is
rarely a single intent or a desire for a single outcome
accompanying a suicidal act (Marzuk et al., 1997;
Silverman, 2006). Thus, it is recommended that
screening instruments assess for any or “non-zero”
intent to die (Posner et al., 2011). The behavior is
considered suicidal unless one engages in the act
entirely for reasons other than to end one’s life.
Additionally, intent to die must be causally linked to
the suicidal behavior such that the behavior is exe-
cuted partially or wholly to fulfill this intent.
Historically, suicide scales have asked whether a per-
son tried to kill themselves; however this omission of
the ascertainment of intent to die can result in non-
suicidal behavior being called suicidal. Thus, asking
whether “any part” of a person wanted to die is
preferable to simply asking whether a person wanted
to die or whether they tried to kill themselves.
Frequently, intent is not explicitly stated or is
overtly denied, rendering the ability to infer intent
essential to identification (Oquendo et al., 2003). For
example, a loved one may bring a family member to
the emergency department and the patient denies sui-
cidal thoughts, but the family member shares with the
clinician that he has been talking about suicide for the
past 2 weeks and wrote a suicide note the day before.
Intent can be inferred from (1) outside sources of
information (e.g., psychological assessments or inform-
ant interviews) (Pfeffer et al., 1993) or (2) clinical cir-
cumstances surrounding the lethality (Wichstrom,
2000) or potential lethality of an act as well as an
individual’s beliefs about the behavior. Acts of impres-
sive circumstances, including behavior that is highly
lethal (e.g., jumping from the roof of a tall building)
or potentially lethal (e.g., the gun failing to fire when
attempting to shoot oneself in the heart), may warrant
an inference of intent to die. Additionally, if an individ-
ual denies intent to die but admits to the possibility of
death from the behavior, intent to die can be inferred.
An individual’s beliefs about the lethality or potential
lethality of an act are integral in the ascertainment of
intent to die (e.g., jumping from a tall building due
to the delusion that one can fly would not warrant an
inference of intent to die) (Conwell & Thompson,
2008).
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Chapter 3: Identification and screening of suicide risk
Distinction of suicidal ideation
and behavior
Historically, suicidal ideation and behavior were
conceived as a unidimensional construct, with idea-
tion and behavior and their respective distinctions
existing along a continuum (Posner et al., 2007;
Silverman, 2006), and the definition of suicidal idea-
tion overlapped with that of suicidal behavior (Beck
et al., 1973). The separation of ideation and behavior
is supported, however, based on extant literature that
suggests that suicidal ideation and behavior do not
always co-occur (Fawcett, 1992) and suicidal idea-
tion is predictive of or a precursor to suicidal behav-
ior (Kessler et al., 1999; Posner et al., 2011), in a
manner that may depend on other factors, such as
age (Brent et al., 1993; Pfeffer et al., 1993; Lewinsohn
et al., 1994; Brown et al., 2000; Wichstrom, 2000;
Fergusson et al., 2005; Vannoy et al., 2007;
Conwell & Thompson, 2008; King et al., 2012).
Current consensus on criteria for the utility of risk
assessment instruments includes separate assessment
of suicidal ideation and suicidal behavior (Meyer
et al., 2010). Yet, existing instruments typically assess
either suicidal ideation alone or suicidal behavior
alone, or conflate suicidal ideation and behavior in
a single item. Table 3.1 displays a representative
sample of screening instruments and accompanying
suicide-specific risk factors.
Suicidal ideation
The National Institute of Mental Health (NIMH)
Developing Centers for Intervention and Prevention
of Suicide determined that wish to die, thoughts of
killing oneself, and intent to kill oneself constitute
types of suicidal ideation (Brown et al., 2008).
Thoughts of killing oneself may also include
methods for killing oneself or intent to act with a
specific plan.
Existing scales vary considerably in how they
measure passive ideation, from thoughts of death to
feelings that life is not worth living. The National
Institute of Mental Health (NIMH) Developing
Centers for Intervention and Prevention of Suicide
consensus conference determined that passive suici-
dal ideation includes any internal experience that
indicates a wish or desire to die (“wish to die”) and
excludes thoughts of being better off dead, thoughts
of one’s own death, or that life is not worth living
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Table 3.1 Select screening instruments: measured suicidal ideation and suicidal behavior characteristics

Measure Administration # of items* Ideation Behavior

Method
Thoughts
Thoughts with
Wish Thoughts with intent to Interrupted/ Preparatory
to be of killing intent to act and aborted acts or Intent
min–max dead self act plan Attempt attempt behavior to die Lethality

ASQ Ask Suicide- SR 4 x x x

Screening
Questions (ASQ)
Horowitz et al.,
2012
BSI Beck Scale for SR 6–21 x x x x
Suicide Ideation
(BSI) (self report)
Beck et al., 1979
CHS Columbia Health SR 14 x x x x x
Screen (CHS)
Shaffer et al., 2004
C-SSRS** Columbia-Suicide RA or SR 6–15 x x x x x x x x x
Severity Rating
Scale (C-SSRS),
Adolescent/Adult
Version
Posner et al., 2009
C-SSRS Columbia-Suicide RA or SR 3–6 x x x x x x x x
Screen* Severity Rating
Scale (C-SSRS)
Screen Version
Posner et al., 2009
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MSSI Modified Scale for RA 4–18 x x x

Suicide Ideation
(MSSI)
Miller et al., 1986
P4 P4 Suicidality SR 1–5
Screener (Past
History, Plan,
Probability, and
Preventive
Factors)
Dube et al., 2010
PANSI Positive and SR 14
Negative Suicide
Ideation
Inventory (PANSI)
Osman et al., 1998
PSS Paykel Suicide Scale RA 5 x x x
(PSS)
Paykel et al., 1974
RSQ Risk of Suicide RA 4 x
Questionnaire
(RSQ)
Horowitz et al.,
2001
SASII Linehan Suicide RA 5–46 x x x
Attempt-Self-
Injury Interview
(SASII) – Short
Version
Linehan et al.,
2006
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Table 3.1 (cont.)

Measure Administration # of items* Ideation Behavior

Method
Thoughts
Thoughts with
Wish Thoughts with intent to Interrupted/ Preparatory
to be of killing intent to act and aborted acts or Intent
min–max dead self act plan Attempt attempt behavior to die Lethality
SBQ-14 Suicidal Behaviors SR 14–90 x x x
Questionnaire
Linehan, 1996
SBQ-R Suicide Behavior SR 4 x x x
Questionnaire-
Revised
Osman et al.,
2001
SIQ-JR Suicide Ideation SR 15 x x
Questionnaire –
Junior (SIQ-JR)
Reynolds, 1988
SIS Suicide Ideation SR 10 x x
Scale (SIS)
Rudd, 1989
SITBI-L Self-Injurious RA 24–189 x x x x x
Thoughts and
Behaviors
Interview (SITBI)
Long Form
Nock et al., 2007
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SITBI-S Self-Injurious RA 18–92 x x x x x

Thoughts and
Behaviors
Interview (SITBI)
Short Form
Nock et al., 2007
SPS Suicide Probability SR 36 x
Scale (SPS)
Cull & Gill, 1988
SSI Scale of Suicidal RA 19 x x
Ideation (SSI)
Beck et al., 1979
Single item in depression scales
BDI-II Beck Depression SR 21 x x
Inventory-II
(BDI-II)
Beck & Steer, 1988;
Beck et al., 1996
HRSD Hamilton Rating RA 21 x x
Scale for
Depression
(Suicide Item)
(HRSD)
Hamilton, 1960
IDS Inventory of SR or RA 28 x
Depressive
Symptomatology
(IDS-SR, IDS-C)
Rush et al., 1986
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Table 3.1 (cont.)

Measure Administration # of items* Ideation Behavior

Method
Thoughts
Thoughts with
Wish Thoughts with intent to Interrupted/ Preparatory
to be of killing intent to act and aborted acts or Intent
min–max dead self act plan Attempt attempt behavior to die Lethality
MADRS The Montgomery– RA 10 x x
Åsberg
Depression
Rating Scale
(MADRS)
Montgomery &
Åsberg, 1979
PHQ-9 The Patient Health SR 9–10
Questionnaire –
9 (PHQ-9)
Spitzer et al., 1999
Single item in general clinical scales
SCL-90 Symptom Check- SR 90 x
List-90 (SCL-90)
Derogatis, 1975
* Maximum number of items refers to the total number of items on the scale and may include questions extraneous to the suicide-specific risk factors covered in the table.
** The C-SSRS and C-SSRS Screen can incorporate multiple sources of information and be used across all ages. Mental health training is not required to administer the scale and it has been used by all types of providers and
gatekeepers.

(Brown et al., 2008). Individuals with a high wish to
die/wish to live index have been found to be six
times more likely to end their life in a 20-year
follow-up study on the Scale for Suicide Ideation
(SSI) (Brown et al., 2005). Additionally, non-suicidal
and suicidal self-injurious thoughts or behaviors
are often conflated. For example, a well-established
measure of depression, the PHQ-9, includes one
item that assesses thoughts of self-injurious
behavior (“Thoughts of. . .huting yourself”), which
may confound thoughts of non-suicidal self-
injurious behavior (NSSIB) with thoughts of suicide.
Moreover, “thoughts…of hurting yourself” is
blended with what has been traditionally mistaken
for passive ideation (“thoughts that you would be
better off dead”). Both of these result in identification
of cases that should not be considered suicidal
(i.e., high rate of false positive cases). At Cleveland
Clinic, this PHQ-9 item resulted in 23.8% positive
screens versus 6.2% with the C-SSRS Screener,
while the C-SSRS identified cases that were missed
(Katzan et al., 2013).
Intent to act
Thoughts of killing oneself are thoughts, beliefs,
images, voices, or other cognitions about inten-
tionally ending one’s own life (suicide), and may
include the intent to act on such thoughts. Intent
to act is having any intention of acting on one’s
thoughts of killing oneself. This contrasts with
having thoughts but never intending to do any-
thing about them. While intent to act on suicidal
thoughts is an integral component of the definition
of suicidal ideation, it was historically unacknowl-
edged as a separate entity (Bagley, 1975; Beck
et al., 1979). However, there has been an increasing
trend of recognizing ideation with intent to act as
a distinct type of suicidal ideation (Hawton, 1987;
Silverman et al., 2007; Posner et al., 2011). The
presence of intent to act confers higher risk for
subsequent suicidal behavior (Currier et al., 2009;
Posner et al., 2011, Mundt et al., 2013).
Clinical utility of instruments
The use of a research-supported and evidence-based
tool for screening can help guide appropriate care to
those who need it by redirecting scarce resources. In
order to determine whether a particular instrument
is optimal for screening, assessment, or monitoring,
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Chapter 3: Identification and screening of suicide risk
the following parameters should be considered:
administration time, type of raters and administra-
tion methods, and level of training required for
administration.
Short administration time
Screening instruments should be brief. Brief adminis-
tration time may be enabled by the structure of an
instrument, such as streamlined decision tree and skip
patterns.
Multiple sources of information
Ability to obtain or integrate information from differ-
ent informants gives users the necessary flexibility.
First responders may not be able to obtain information
directly from the victim but could collect it from
relatives.
Format of delivery
Suicide screening instruments may be available in a
variety of paper and electronic mediums (e.g., tele-
phone, tablet, smartphone). Innovative and feasible
delivery methods can facilitate screening of a greater
number of individuals resulting in more blanketed
screening implementation. Format of delivery is
especially crucial post-discharge when patients are
at a very high risk. Research indicates an increased
risk for suicide in the first few weeks after discharge
from psychiatric inpatient hospitalization (Goldacre
et al., 1993; Qin & Nordentoft, 2005). With electronic
methods, post-discharge patients can be monitored
over time from their home at designated time
intervals.
Multiple administration methods
Self-report measures and interviews administered by
an individual or rater are typical methods for screen-
ing for suicide risk. Self-report instruments may have
the advantage of higher sensitivity by eliciting more
accurate self-disclosure for sensitive issues (Greist
et al., 1973; Levine et al., 1989; Hesdorffer et al.,
2013). Self-reports can be instrumental to the disclo-
sure of suicide-related phenomena, which may be
denied face-to-face, including in adolescents (Shain,
2007; Vitiello et al., 2009). The availability of rater-
administered and self-report screening methods are
optimal for providing maximum flexibility in admin-
istration. A brief suicide questionnaire (C-SSRS)
27
 Section 1: Understanding Suicide
administered over the phone has shown improved
detection by approximately 40% of suicide attempts
compared to hospital chart reviews in medical emer-
gency departments (Arias et al., 2014).
Gatekeepers
Screening settings are arguably countless, including
primary care, schools, religious centers, and legal and
forensic settings. Training in the administration of a
screening method provided for those outside mental
health professions may enhance implementation
efforts. It is critical that non-mental health professio-
nals be able to ask the questions; non-clinicians have
demonstrated strong inter-rater reliability using the
C-SSRS in a juvenile justice system (Kerr, et al.,
2014). For example, the ability to screen by non-
professional gatekeepers is important in rural com-
munities where the nearest mental health practitioner
may be hours away and over-burdened.
Generalizability to multiple populations
Similarly, it is important to use screening instru-
ments that can be effectively used across many varied
populations (Peñta & Caine, 2006). Some instru-
ments offer additional questions for specific popula-
tions. Other scales have versions for different age
groups.
Triage capacity
It is important that scales have operationalized
criteria or thresholds that distinguish higher levels
of risk so that next steps can be determined. These
may include referrals to mental health professio-
nals for further evaluation, hospitalization, or
suicide watch protocols for high risk. Without
that, providers will be unable to triage patients
and will remain anxious about everyone. This
over-estimation of risk may cause clinicians to
think they need more one-to-ones than they have
staff to cover, which wastes resources and ulti-
mately reduces the quality of care.
Furthermore, for screening in schools, using a
scale with stratified thresholds that allow for the iden-
tification of the most at risk individuals and others
who are less at risk can help triage students and reduce
the burden on the limited number of mental health
professionals who will need to follow-up (Peñta &
Caine, 2006).
28
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Conclusion
Suicide prevention is a topic of high national and
international importance and identification of at risk
individuals is the first necessary step toward preven-
tion. Screening for suicidal ideation and behavior
should be integrated across public health settings and
made as routine as monitoring for blood pressure.
Knowledge of the full range of suicidal behaviors and
key criteria for differentiating suicidal and non-
suicidal events are paramount to the advancement of
screening efforts. Feasible, brief, and research-
supported screening tools can identify individuals at
increased risk for suicide. Effectiveness of screening
tools should be measured in terms of their relation to
suicide prevention efforts.
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