Suicide Risk Screening in Rural Primary Care

By Heather Hogstrom

In the United States, suicide rates are disproportionately higher in rural areas than urban areas. Data from 2001 to 2015 show that the suicide rate per 100,000 population was 17.32 in nonmetropolitan/rural counties compared with 14.86 in medium/small metropolitan counties and 11.92 in large metropolitan counties. Having access to behavioral health professionals is also more difficult in nonmetropolitan areas, so individuals in these areas are more likely to seek out primary care providers (PCPs). This makes primary care a critical intervention point for suicide prevention in rural areas.

One study, conducted at a primary care clinic in rural West Virginia, evaluated the feasibility and impact of a universal suicide risk screening program in rural adult primary care. Mary LeCloux, PhD, LICSW, an assistant professor and MSW program director at West Virginia University, discussed results of this study in a presentation for the Council on Social Work Education’s 2020 Annual Program Meeting. The study used the Ask Suicide Screening Questions (ASQ) Toolkit in tandem with the Brief Suicide Safety Assessment (BSSA), and determined whether the implementation of these tools as a universal suicide risk screening program would significantly decrease the frequency of screening and suicide risk detection compared with treatment as usual.

The first phase of the study established the baseline, during which the PCP delivered services as usual, and an onsite research assistant mined the electronic medical records for screening questions, level of risk, and disposition plans. Then the intervention phase approached 340 patients and found 204 willing to watch a brief consent video (consent was required because this was a study). Of those, 196 patients consented to be screened, and 194 completed the ASQ electronically. The PCP viewed the results in real time.

Most (175) of the patients who were screened were found to be no/low risk, and therefore didn’t need follow up. Those who did screen positive on the ASQ were identified as either acute (one patient) or nonacute (19 patients) risk and received the intervention—the PCP administered the BSSA and completed disposition planning (i.e., going to the emergency department, going home with a mental health referral, receiving a safety plan, or following up with the PCP).

Feasibility and Impact
Factors such as how many patients consented to screening, the completion rate for the tests, and whether the patients thought it was acceptable for PCPs to screen for suicide helped determine the feasibility of a universal suicide risk screening program. The study found that 95.9% of the patients surveyed agreed that PCPs should ask patients about suicide; importantly, 100% of those surveyed who were identified as “at risk” agreed that PCPs should ask about suicide. The study found that this program wasn’t a time-consuming process since the majority of patients screened negative and did not need follow-up. Implementing the screening program would not require a significant amount of additional time, effort, or burden to the PCP. The PCP was able to provide this care without requiring a mental health professional to be there to step in, which is beneficial for those in rural areas where access to other behavioral health care systems is more limited.

The impact of the screening program compared the proportion of those screened and detected in the baseline phase vs. the intervention phase. In baseline, 5.8% of patients were screened for suicide, with 0.7% suicide risk detected, while in intervention, 61% were screened, with 6.2% risk detected. Additionally, there was a significant increase in some disposition plan items, such as following up with the PCP and receiving a safety plan. All those identified at risk in the intervention phase received a safety plan, while none did in baseline.

While this pilot study was limited in that it included a racially homogenous sample from one provider, it can feed larger, more diverse samples and provides preliminary evidence that a universal suicide risk screening program using the ASQ/BSSA tools is both amenable to patients and feasible in the rural primary care setting.

— Heather Hogstrom is an editorial assistant at Social Work Today.