Is It Time for Universal Suicide Screening?

US suicide rates have reached alarming levels, with data from Centers for Disease Control and Prevention (CDC) showing a 37% increase from 2000 to 2022. Nearly 49,000 people died by suicide in 2022 alone, translating to one death every 11 minutes. 

The increase has prompted calls for expansion of universal suicide screening, in which all individuals in medical or mental health care settings are screened for suicide risk, regardless of the purpose for their visit. But the psychiatric field is split on the issue, with some experts citing false positives and a lack of mental health care resources for those deemed at risk.

In 2022, when the US Preventative Services Task Force released its recommendations first in children and adolescents, and then in adults on suicide prevention, the authors said there was insufficient evidence to support universal suicide screening. 

Proponents of the practice pushed back on that finding, arguing that universal suicide screening could help identify those at high risk who might otherwise go undiagnosed, leading to earlier, potentially lifesaving, intervention.

So, what is the case for — and against — universal screening? 

Sounding An Alert

The introduction of universal screening was driven by a confluence of factors that began with a 1999 report by then-US Surgeon General David Satcher, MD. This was followed by a report in 2016 from the Joint Commission on Detecting and Treating Suicidal Ideation that called for healthcare organizations to improve detection and treatment of suicidal ideation in all healthcare care settings. 

Data from the alert showed that a significant number of people who died by suicide had a healthcare visit before their death. Half had seen a clinician a month before their death; nearly 30% had a medical visit just the week before — all with no detection of increased suicide risk. 

It was that sort of finding that led Parkland Health and Hospital System in Dallas to become the first US hospital to implement universal suicide screening. Since the program launched in 2015, the system has screened more than 4.3 million patients in its emergency department, inpatient units, and 20 primary care clinics.

“Since the program began, we’ve completed between 40,000 to 50,000 screenings per month,” Kimberly Roaten, PhD, associate chief quality and safety officer for behavioral health at Parkland Health, told Medscape Medical News. 

Clinicians at Parkland use the five-item Ask Suicide-Screening Questions to assess suicidal intent, a commonly used tool that was originally developed for use in pediatric emergency rooms. The tool, which takes about 20 seconds to administer, has since been validated in both children and adults. 

Based on a patient’s response, a clinical decision support system integrated into the electronic health record classifies suicide risk as none, moderate, or high.

Patients identified as moderate risk are offered a more in-depth assessment with a mental health clinician, though participation is not mandatory, said Roaten. Those at high risk receive a more thorough evaluation. 

The proportion of ER patients at Parkland who screen positive for any suicidal intent has consistently remained at about 7%, and at 2% in the primary care clinics, she said. 

To better understand what the program may have had on suicide prevention, Roaten is leading a National Institute of Mental Health-funded study to link a decade of mortality data from the state of Texas to patient data from Parkland Health. Investigators will analyze information about patients identified at risk for suicide, those patients’ characteristics, and who dies by suicide. 

Universal Screening Expands

Other health systems have adopted universal suicide screening including the Indian Health Service and the US Veterans Health Administration. Universal suicide screening is also in place in a growing number of primary care practices and hospitals throughout the United States and will be mandatory for patients aged ≥ 12 years in all acute care hospitals in California beginning in 2025.

There is also a push for universal screening to be coordinated through local, state, and federal government, nonprofit, and private sectors. The National Action Alliance for Suicide Prevention is charged with advancing the White House’s 2024 National Strategy for Suicide Prevention, a 10-year plan to address gaps in suicide prevention in the United States. 

Sarah Brummett, JD, director of the National Action Alliance for Suicide Prevention’s executive committee, told Medscape Medical News that universal suicide screening is part of the 2024 strategy. “We know there are barriers to universal screening, and so it’s important to recognize what they are so we can address them,” said Brummet. 

Barriers may include adequate staffing, or a system in place to triage patients who screen positive. 

At Parkland, cost and workload have been minimal, Roaten said. “We built a model that only dedicates our highest-value resources to the most at-risk patients.”

She also noted that relief may be on the horizon for health systems where cost is an obstacle to universal screening and subsequent intervention. “There are efforts at the federal level to increase funding for suicide assessment and crisis response,” she said. 

Pushback on Universal Screening

Universal suicide screening has its detractors, including critics who say expansion is unlikely to reduce suicide rates.

“The issue with suicidal ideation is that it is very dynamic. Suicidal ideation changes very quickly—sometimes within hours,” Craig Bryan, PsyD, professor of psychiatry and behavioral health at Ohio State University in Columbus, told Medscape Medical News. 

Universal screening can also lead to false positives, where a patient who screens positive for suicidal ideation has no actual intention of attempting suicide, potentially creating unnecessary concern and burden on health care resources, Bryan noted. 

“What do you do with everyone who screens positive?” Bryan said. “I’ve spoken with leaders of many health systems in the United States, and there is pushback against universal screening because they don’t have enough mental health resources to handle all of the referrals.”

Suicide screening also doesn’t predict who will die by suicide, Bryan added. It only identifies those willing to disclose suicidal thoughts. There is a significant number of people without mental illness who may never seek medical care, so “the warning signs we’re teaching people to recognize — depression, anxiety, and substance abuse — might not be evident in these individuals,” he said.

“Life sideswipes them suddenly, and they go from 0 to 60…and they may have access to a highly lethal method [of suicide] which weaponizes that moment of despair,” said Bryan. No amount of screening could possibly predict those types of suicides, he added. 

Paul Nestadt, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, agrees with Bryan and noted there isn’t a strong correlation between suicidal ideation and death by suicide.

“Suicidal thoughts are very common, but suicide is a rare event,” he told Medscape Medical News. 

He cited a study that showed that two thirds of individuals who died by suicide had denied experiencing suicidal thoughts when asked, and half of them died within 2 days of this denial. Other research suggests that as many as 98% of people who express suicidal ideation do not die by suicide, Nestadt said. 

A Public Health Issue

If universal screening is not the answer to predicting and preventing suicide, what is? One way would be to approach suicide as a public health issue, Nedstadt said. 

“How did we reduce the rate of motor vehicle deaths? We didn’t test each driver’s reaction time behind the wheel,” he said. “Instead, we passed seatbelt and airbag legislation, implemented federal speed limits, and as a result, the number of motor vehicle fatalities decreased.”

Nestadt is an advocate for stronger gun safety legislation, which has proven effective in reducing suicide rates. A study published this year showed that states with child access prevention laws, negligent storage laws, and mandatory waiting periods for gun purchases reported fewer suicide deaths than those without that legislation.

Other measures might be applied in cases of extreme individual suicide risk, including extreme risk protection orders, also known as “red flag” laws, he added. This type of legislation provides a pathway for law enforcement to temporarily remove firearms from individuals who pose a risk to themselves or others. 

“These have been shown to be very effective in saving lives,” Nestadt said.

Nestadt and others are also using machine learning models to predict suicide risk. Those identified as high-risk may be flagged on their electronic medical record. Ideally, when the algorithm becomes more accurate at predicting suicide, anyone treating this patient can then decide if action is needed, said Nestadt. 

In his work with suicidal military personnel, Bryan and his colleagues established a brief form of cognitive behavioral therapy (BCBT) to help participants challenge cognitive distortions and build coping strategies to deal with feel with intense feelings of distress. Data show that BCBT reduced suicide attempts among active-duty soldiers by 60% as compared to standard mental health treatment. It has since been shown to work in civilians as well. 

Bryan is also researching fluctuations in the wish to live vs the wish to die relative to one another and mapping the trajectory of risk states along the way. 

The goal is that these and other suicide prevention strategies currently under study by his team and others will help stem the rise in suicide deaths.

“Overall, we need to train mental health providers to implement suicide prevention therapies and establish suicide risk programs,” Bryan said. “But until we build one of these suicide prevention interventions to scale, we’re putting the cart before the horse.”

Roaten, Horowitz, Brummett, Bryan and Nestadt reported no relevant disclosures.