Ask Suicide-Screening Questions to Everyone in Medical Settings (asQ em): Development of a Suicide Risk Screening Instrument for Adult Medical Inpatients

In 2010, the Joint Commission (JC) issued a Sentinel Event Alert highlighting the need to
detect suicide risk in all non-behavioral patients in medical settings. Detecting suicide
risk among medical patients is important because this population is at elevated risk for
suicidal thoughts and behaviors, and because for many of these patients, a medical visit is
their only portal into mental health services. Of note, the vast majority of people who die
by suicide visit a medical setting, such as an inpatient oncology unit, more frequently than
a psychiatric setting in the months leading up to their death. Thus, the inpatient medical
setting is an important stakeholder in decreasing suicide-related morbidity and mortality.
Physicians and nurses working in non-mental health settings require tools to guide them in
recognizing patients at risk. Nonetheless, there are currently no suicide screening
instruments designed specifically for assessing suicide risk in an adult inpatient medical
population.

In 2012, our study team conducted a Quality Improvement Project (QIP) at the National
Institutes of Health Clinical Center (NIH CC) which demonstrated that the asQ em (Ask
Suicide-Screening Questions to Everyone in Medical Settings), a brief instrument piloted to
detect suicidal thoughts and behaviors among adult medical inpatients, was both feasible to
administer and acceptable to both patients and staff. Extending this work, the aim of this
current study is to further develop and psychometrically validate the asQ em among adult
medical inpatients. While most inpatients will not be at imminent risk for suicide, we
hypothesize that the asQ em will identify a number of patients who screen positive for
suicide risk on a longer gold standard instrument, and that they are thus not only at risk
for suicidal behavior in the future, but are also experiencing significant emotional distress
and therefore warrant further mental health evaluation and recommendations for follow-up
treatment.

This study will be a prospective, cross-sectional multisite study with patients enrolled from
the NIH CC, Walter Reed National Military Medical Center, Rhode Island Hospital, and John
Peter SmithHospital. The total planned sample size will be 810 (180 from WRNMMC, 180 from
RIH, 200 from JPS, and 250 from NIH CC). We will administer several short measures of suicide
risk: the 20 asQ em candidate items; a criterion standard Adult Suicidal Ideation
Questionnaire (ASIQ); two questions which assess for suicidal behavior from a second
criterion standard, the Beck Scale for Suicide Ideation (BSI); a brief depression screen, the
Patient Health Questionnaire (PHQ-9); and an exploratory variable questionnaire, to all
eligible inpatients aged 18 years and older. The ultimate goal of this project is the
development of a validated risk of suicide screening instrument that can be administered
rapidly by non-mental health clinicians to medical inpatients and in turn, connecting those
in need with mental health services. Additionally, we hope to pilot the Suicide Implicit
Association Test (S-IAT) in a subsample of recruited patients. The S-IAT is a brief computer
task which measures a person s implicit association between self and either life or death .
We expect to demonstrate that the S-IAT is feasible to administer in the inpatient medical
setting thereby providing a potential alternative to self-report questionnaires for assessing
patients thoughts about death or suicide.

Future studies will focus on examining the practical implications of nurses administering the
asQ em as standard of care during the admission process on a medical inpatient unit and
validating the asQ em in non-English speaking patients, addressing a critical gap in suicide
prevention research. In addition, examining the long-term clinical impact of screening
general medical patients for suicide risk with the asQ em and linking those in need with
mental health services and/or other interventions will be important next steps.

- INCLUSION CRITERIA:

All adult medical inpatients, ages 18 and older, who are admitted to selected medical units
during data collection weeks will be approached for enrollment. Patients will be included
if:

1. they are admitted as an inpatient on the designated medical units;

2. they are 18 and older;

3. they are capable of providing consent;

5) they have not previously been enrolled in this study.

EXCLUSION CRITERIA:

Patients will be excluded if:

1. they are medically or cognitively unable to participate in the screening or assessment
(e.g., sustained altered level of consciousness, psychosis, hostile behavior,
unremitting distress, intubation, persistent vomiting, severe pain, acute or worsening
medical acuity);

2. they have been already enrolled during a previous visit;

3. they are unwilling to provide consent;

4. the patient is non-English speaking (because ASIQ has not been validated in languages
other than English).