suicide-screening - SKILL.md Agent Skill

name: "suicide-screening" description: "Use when screening for suicide risk (suicidal thoughts, self-harm urges, hopelessness, plans or intent to die), patient has positive PHQ-9 Item 9, recent suicide attempt, psychiatric crisis, or establishing safety planning. Provides ASQ (brief) and C-SSRS Columbia Protocol (comprehensive risk assessment). Critical safety-focused."

Suicide Risk Screening

Description

This skill helps administer and interpret validated suicide risk screening instruments. The ASQ provides a brief initial screening, while the C-SSRS (Columbia-Suicide Severity Rating Scale) offers comprehensive assessment of suicidal ideation and behavior.

Clinical Context: These tools help identify individuals at risk for suicide, assess severity of suicidal thinking, and guide clinical decision-making about safety interventions. They are support tools that supplement, not replace, comprehensive suicide risk assessment and clinical judgment.

⚠️ CRITICAL SAFETY NOTICE

ANY positive suicide screen requires IMMEDIATE action. DO NOT leave patient alone. Comprehensive risk assessment and safety planning required before patient leaves your care.

Universal crisis protocols: ../../docs/references/crisis-protocols.md

Quick Reference

Assessment Comparison

Assessment	Items	Time	Purpose	When Positive	When to Use
ASQ	4 (+1 acuity)	20 sec	Brief screening	Any "yes"	Quick triage, medical settings
C-SSRS	Multiple sections	5-15 min	Comprehensive assessment	Determines risk level	Full assessment, positive ASQ

For detailed comparison: See references/screening-comparison.md

Risk Level Quick Reference

Risk Level	Ideation	Plan/Intent	Behavior	Immediate Action
Low	Passive or none	None	None recent	Safety plan, 1-week follow-up
Moderate	Active, vague	Uncertain	Past attempt (not recent)	Same-day eval, intensive monitoring
High	Active, specific	Intent present	Recent attempt/preparatory	Psychiatric hospitalization likely
Imminent	Active, immediate	Has means, immediate intent	Attempt in progress	Call 911, emergency hospitalization

For detailed risk levels: See references/risk-levels.md

Interactive Administration (Optional)

Use this mode when the clinician says "start" or "administer" ASQ or C-SSRS.

Confirm readiness and ensure a safe setting; if the patient is in crisis, initiate emergency protocols immediately.
Ask one item at a time (verbatim from the asset file) and wait for a response before continuing.
If any response is positive, pause the screening and move immediately to comprehensive risk assessment and safety planning.
For ASQ: any "yes" requires the acuity question and full assessment.
For C-SSRS: follow the sections in order; if imminent risk is identified, stop and implement safety interventions.
Document risk level, protective factors, and immediate actions.

Assessment Tools

ASQ (Ask Suicide-Screening Questions)

Complete assessment: assets/asq.md

4 questions (20 sec), Ages 10+. Any "yes" = positive → comprehensive assessment required.

Questions: (1) Wished dead? (2) Family better off without you? (3) Thoughts of killing yourself? (4) Ever tried? If positive → Ask: "Thoughts right now?"

C-SSRS (Columbia-Suicide Severity Rating Scale)

Complete assessment: assets/c-ssrs.md

5-15 minutes. Multiple sections: ideation (severity 0-5), intensity, behavior (attempts, prep acts), timeline. Determines risk level with clinical judgment.

Clinical Workflow

1. Choose Assessment

digraph assessment_selection {
    rankdir=LR;
    node [shape=box, style=rounded];

    start [label="Need Suicide\nScreening", shape=ellipse];
    time_check [label="Time\navailable?", shape=diamond];
    phq9_check [label="PHQ-9 Item 9\npositive?", shape=diamond];
    asq [label="Start with\nASQ\n(20 sec)", style="filled", fillcolor=lightblue];
    asq_result [label="ASQ\nPositive?", shape=diamond];
    cssrs [label="C-SSRS\nFull Assessment\n(5-15 min)", style="filled", fillcolor=orange];
    negative [label="Negative Screen\n(Still assess\nclinically)", style="filled", fillcolor=gray90];

    start -> time_check;
    time_check -> asq [label="<1 min"];
    time_check -> phq9_check [label="5-15 min\navailable"];
    phq9_check -> cssrs [label="yes"];
    phq9_check -> cssrs [label="no\n(suspected\nrisk)"];
    asq -> asq_result;
    asq_result -> cssrs [label="yes"];
    asq_result -> negative [label="no"];
}

2. Administer Assessment

ASQ: assets/asq.md - 4 questions, 20 seconds C-SSRS: assets/c-ssrs.md - Multiple sections, 5-15 minutes

3. Determine Risk Level

Risk Assessment Decision Tree

digraph risk_determination {
    rankdir=TB;
    node [shape=box, style=rounded];

    ideation [label="Suicidal\nIdeation?", shape=diamond];
    passive [label="Passive Only\n(wishes to die)", shape=diamond];
    active [label="Active Ideation\n(thoughts of\nkilling self)", style="filled", fillcolor=yellow];

    plan_intent [label="Plan AND\nIntent?", shape=diamond];
    means [label="Access to\nMeans?", shape=diamond];
    recent_behavior [label="Recent\nAttempt/Prep?", shape=diamond];
    immediate [label="Imminent\nPlan?", shape=diamond];

    low [label="LOW RISK\n• Safety plan\n• 1-week f/u\n• Resources", style="filled", fillcolor=lightgreen];
    moderate [label="MODERATE\n• Same-day eval\n• Safety planning\n• Remove means\n• Close monitoring", style="filled", fillcolor=yellow];
    high [label="HIGH RISK\n• Psychiatric eval\n• Hospitalization\n  likely\n• Do not leave\n  alone", style="filled", fillcolor=orange];
    imminent [label="IMMINENT\n• Call 911\n• Emergency\n  hospitalization\n• Constant\n  observation", style="filled", fillcolor=red, fontcolor=white];

    ideation -> passive [label="yes"];
    ideation -> low [label="no\n(denied)"];
    passive -> low [label="yes"];
    passive -> active [label="no\n(active)"];
    active -> plan_intent;
    plan_intent -> recent_behavior [label="no"];
    plan_intent -> means [label="yes"];
    means -> immediate [label="yes"];
    means -> high [label="no"];
    immediate -> imminent [label="yes"];
    immediate -> high [label="no"];
    recent_behavior -> moderate [label="no"];
    recent_behavior -> high [label="yes"];
}

Use comprehensive protocol: → references/risk-assessment-protocol.md

Integrate all factors:

Ideation (presence, frequency, intensity)
Plan and intent (specificity, access to means)
Behavior (attempts, preparatory acts)
Protective factors (reasons for living, social support)
Risk factors (prior attempts, mental illness, substance use)
Mental status (hopelessness, agitation, impulsivity)

Risk levels: See references/risk-levels.md

4. Immediate Safety Interventions

ALL risk levels:

Create safety plan (see references/safety-planning.md)
Provide crisis resources
Remove means when possible
Document thoroughly

Moderate-High risk:

Same-day psychiatric evaluation
Intensive monitoring
Remove ALL lethal means
Involve support system

High-Imminent risk:

Call 911 or crisis team
DO NOT leave alone
Emergency hospitalization

5. Document

Use documentation templates in:

Documentation standards: ../../docs/references/documentation-standards.md

⚠️ CRITICAL SAFETY PROTOCOLS

ANY positive response: (1) DO NOT leave patient alone, (2) Comprehensive assessment, (3) Assess plan/intent/means, (4) Remove lethal means, (5) Determine risk level, (6) Intervene appropriately, (7) Document thoroughly, (8) Ensure continuous safety.

Essential questions: Plan? Access to means? Intent to act? When? What's kept you safe? Prior attempts? Complete protocol: references/risk-assessment-protocol.md

Crisis resources (provide ALL patients): 988 Lifeline (call/text), Text HOME to 741741, Veterans: 988 press 1 or text 838255, Trevor Project (LGBTQ+ youth): 1-866-488-7386, Emergency: 911.

Safety planning (required all risk levels): Warning signs, coping strategies, distraction, support contacts, crisis services, means restriction, reasons for living. Guide: references/safety-planning.md

Means restriction (CRITICAL, saves lives): Firearms—remove completely (preferred) or lock separately from ammunition with someone else controlling access. Medications—remove excess, family/pharmacy holds, weekly dispensing. Other—remove based on plan (ropes, cords, chemicals).

NEVER: Leave patient alone, assume others will handle, accept "I'm fine" without assessment, discharge without safety plan, minimize suicidal statements, skip means restriction, use "no-suicide contracts" (not evidence-based).

Special Considerations

High-risk populations: Adolescents (impulsivity, social media), LGBTQ+ individuals (minority stress), veterans (combat trauma, firearm access), older adults (isolation, higher lethality), post-discharge patients (first weeks post-hospitalization).

Screen when: Severe depression (PHQ-9 ≥15), psychosis, substance use, PTSD, chronic pain, terminal illness, recent loss. See PHQ-9 Item 9 protocol.

Cultural: Ask directly across cultures; expression varies; use interpreters; understand protective factors.

Referral Guidelines

When to Refer/Hospitalize

Immediate (Emergency Services/911):

Imminent risk (plan, intent, means, immediate)
Attempt in progress
Cannot keep self safe
Psychosis with command hallucinations

Urgent (Same-Day Psychiatric Evaluation):

High risk (plan and intent but not imminent)
Moderate risk unable to safety plan
Recent attempt (past week)

Routine (Within 1-3 Days):

Low risk needing mental health treatment
Moderate risk with good safety plan
Follow-up after higher level of care

Complete referral guidance: ../../docs/references/referral-guidelines.md

Limitations

Cannot predict suicide with certainty. Patients may not disclose; risk changes rapidly. Tools support clinical judgment, not replace it. Negative screen ≠ no risk. When in doubt: assess thoroughly, consult, err on side of safety.

Usage Examples

Example requests: "Screen for suicide risk", "ASQ positive—what now?", "Guide C-SSRS", "Create safety plan", "Assess risk level"

References

Primary Literature:

Horowitz LM, et al. Ask Suicide-Screening Questions (ASQ). Arch Pediatr Adolesc Med. 2012;166(12):1170-1176.
Posner K, et al. The Columbia-Suicide Severity Rating Scale. Am J Psychiatry. 2011;168(12):1266-1277.
Stanley B, Brown GK. Safety Planning Intervention. Cognitive and Behavioral Practice. 2012;19(2):256-264.

Clinical Guidelines:

American Psychiatric Association. Practice guideline for assessment and treatment of patients with suicidal behaviors. 2003.
VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. 2019.

Resources:

NIMH ASQ Toolkit: nimh.nih.gov/asq
C-SSRS: cssrs.columbia.edu
988 Suicide & Crisis Lifeline: 988lifeline.org

Freely available - NIMH (ASQ) and Columbia University (C-SSRS)

⚠️ This skill addresses life-threatening situations. ALL safety protocols must be followed without exception.