Despite the facts, suicide screening is taking place in a number of emergency departments, often done by the triage nurse. Suicide screening tools are embedded in some electronic medical records. There is no “best practice” screening tool. Many use a four-question tool (Are you here because you tried to hurt yourself? In the past week, have you been having thoughts about killing yourself? Have you ever tried to hurt yourself in the past? Has something very stressful happened to you in the past few weeks?).⁷ Any single positive answer is considered a positive screen. A recent study of this tool in an emergency department setting demonstrated a very high false-positive rate, though it did appear to be successful in identifying individuals who had suicidal ideation. Overall, nearly 42 percent of all patients screened positive, but with secondary screening, only 1.5 percent were true positives. Among adolescents, 51 percent screened positive, but only 5 percent were true positives. Although the numbers screened were low, all patients with mental health complaints screened positive, but none of them were determined to be suicidal.⁸ Other tools developed since then and currently under development now may have better sensitivity and specificity and may be better accepted by providers.⁹

Screening positive has significant implications for emergency physicians and staff. Should all patients who screen positive be cleared by psychiatry? Should all patients who are discharged receive referral to mental health resources? Should patients who screen positive, particularly those screening positive for more than one question, have 1:1 observation, at least until they can be assessed by the emergency physician? What are the legal implications of sending home patients with positive screens, particularly if they, sometime in the future, attempt or complete a suicide? All of these issues remain unclear.

Mental health treatment is not universally successful. Successful suicides during inpatient mental health treatment are not uncommon. More important, suicide risk is highest in the first few weeks after discharge from a mental health facility. Inpatient treatment itself has been questioned. David J. Knesper, MD, of the department of psychiatry at the University of Michigan in Ann Arbor, noted “there is no evidence that psychiatric hospitalization prevents suicide” in the immediate postdischarge period.¹⁰ The stress that led to the patient’s decompensation is often still present in the community, with the addition of the stigma of being in a mental health facility.

There is no necessity for universal screening, though screening of “high-risk” populations is a recommendation of The Joint Commission. Current screening tools are imperfect, and referral options for inpatient and outpatient assessment are not able to absorb a large influx of false positives. Treatment, once available, has limitations. Screening is potentially valuable in high-risk patients. Suicide is an important and serious public health problem. We need better screening tools and better referral systems before universal screening of all patients in the emergency department can be embraced.