Does Suicide Screening in Triage Even Work?
Suicide screening in the ED had extremely poor diagnostic accuracy for predicting subsequent suicide within a month, with a sensitivity of just 18%.
Why does this matter? Wouldn’t it be great if with a few simple questions we could tell who is at risk of suicide? With very little real-world evidence, The Joint Commission (JCAHO) mandated, “screening for suicidal ideation using a validated tool starting at age 12 and above.” This is a great concept, but does it actually work, or are we accomplishing the ironic byline of JCAHO: “Leading the Way to Zero?”
Suicide screening? This was an evaluation of the Columbia-Suicide Severity Rating Scale (C-SSRS)- Clinical Practice Screener's ability to predict self harm and suicide in the following year after screening. The C-SSRS long version performed well in emergency psychiatric patients in a research setting but has not been vetted in a general ED population for mass screening. Of the 92,643 patients screened, 11 committed suicide. Sensitivity and specificity of screening for suicide by 30 days was 18% and 99%, respectively. Nine of 11 people who died by suicide screened negative; one had an ED psychiatric assessment. The instrument performed better for predicting self harm by 30 days, but had a sensitivity that rose to only 53%. I think this shows us that people who commit suicide usually don’t tell us they have suicidal ideation; hence, the lack of utility of this form of mass screening in a general ED population. The editorial notes, “More than 99% of people who screened positive for suicide risk did not die of suicide and 73% of the people who died of suicide had screened negative. Put simply, for every true positive, 2.7 people who die by suicide were missed and 196 people screened positive requiring further assessment.” This strains psychiatric assessment services, who are already at a breaking point. We all want a solution to reduce suicide. This is not it.
Suicidal ideation is insensitive to suicide risk after ED discharge: performance characteristics of the Columbia-Suicide Severity Rating Scale Screener. Acad Emerg Med. 2020 Dec 21. doi: 10.1111/acem.14198. Online ahead of print.