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Kate Dickson, MD MPH, PGY 4

Does suicide screening = suicide prevention?

Universal suicide screening is the term for the process of asking every patient that presents to a health care facility, for example an outpatient clinic, the emergency department, or an elective surgery, about thoughts of suicide, regardless of chief complaint. Health care systems across the country adopted universal screening policies and procedures after the Joint Commission released Sentinel Event Alert 56 in 2016, which set the “expectation that hospitals screen all patients for suicide ideation using a brief, standardized, and evidence-based screening tool.” In 2019 the Joint Commission scaled back its mandate to only require screening for patients admitted for behavioral health concerns, and thus so have many health care systems, however some entities continue to screen universally. For the time being, UNCMC has continued to require universal suicide screening for all patients in the ED and on inpatient units.

The literature surrounding universal suicide screening is mixed.  While suicide rates are rising overall, a completed suicide is still a relatively rare event on a population level, so there isn’t much robust or high-quality data supporting the effectiveness of a lot of our assessments and interventions. Because of that, there is a lack of clear evidence showing that screening for suicidal ideation actually prevents deaths by suicide. The question that arises then is, if universally screening for suicide doesn’t clearly prevent suicide, should we do it?

While certainly suicide prevention is important, to me, prevention itself isn’t the only point of universal suicide screening. Reframing suicide screening from being solely a tool to prevent suicide, which is a complex but ultimately rare and binary outcome, to conceptualizing it as a tool to pick up on patients in psychological distress, changes the math. Through this lens, screening at every encounter with the healthcare system becomes a valuable way to connect at-risk patients with extra support and potentially formal mental health treatment. Often people who have never dealt with mental healthcare before don’t know how or who to ask for help, and this process can alleviate some of those barriers by starting the process. In this way, universal suicide screening has the potential to reduce racial, ethnic, economic, and other mental health disparities by asking all patients about suicidal ideation, regardless of their primary reason for seeking healthcare. Asking universally also helps normalize having conversations about mental health and suicide in general healthcare settings, which can reduce stigma and ultimately lessen the historic boundaries between mental and physical health.

Of course, there is still a large amount of work to be done to make this reframing a reality. It is bad practice to screen for a condition that cannot be adequately addressed. And in a state like North Carolina with a limited social safety net, high uninsured population, and an already overwhelmed public mental health system… is it appropriate to screen patients for suicidality if we can’t adequately support their needs after uncovering them? In addition to ensuring access to resources for the outcomes of universal suicide screening for the large, diverse, and growing population in our state, we also need to ensure that the tools we use to screen for suicide risk are validated in diverse populations.  Suicide rates among minority groups such as Black adolescents and the LGBTQ community are rising faster than average, so we need to ensure that our follow-up assessments and interventions are structured in a way that specifically meet the needs of historically marginalized and high-risk groups.  We should also advocate for larger system level changes that support economic equality, fair working conditions, affordable healthcare, and housing stability, all of which are risk factors for suicide that can and should be mitigated at a policy level. I believe that we can and should ask about suicide, but that screening is only a small piece of the complex puzzle that is suicide prevention.