Ask Suicide-Screening Questions (ASQ) Toolkit

National Institute of Mental Health (USA)

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Overview

The Ask Suicide-Screening Questions (ASQ) Toolkit is a free resource for medical settings (emergency department, inpatient medical/surgical units, outpatient clinics/primary care) that can help nurses or physicians successfully identify youth at risk for suicide.

The ASQ is a set of four screening questions that takes 20 seconds to administer. In an NIMH study, a “yes” response to one or more of the four questions identified 97% of youth (aged 10 to 21 years) at risk for suicide. By enabling early identification and assessment of young patients at high risk for suicide, the ASQ toolkit can play a key role in suicide prevention.

Background

Suicide is a global public health problem and the second leading cause of death for young people ages 10-24 worldwide. Suicide is also a major public health concern in the United States. According to the Centers for Disease Control and Prevention (CDC), more than 5,900 youths killed themselves in 2015. Even more common than death by suicide are suicide attempts and suicidal thoughts.

Screening for Suicide Risk

Early detection is a critical prevention strategy. The majority of people who die by suicide visit a healthcare provider within months before their death. This represents a tremendous opportunity to identify those at risk and connect them with mental health resources. Yet, most healthcare settings do not screen for suicide risk. In February 2016, the Joint Commission, the accrediting organization for health care programs in hospitals throughout the United States, issued a Sentinel Event Alert recommending that all medical patients in all medical settings (inpatient hospital units, outpatient practices, emergency departments) be screened for suicide risk. Using valid suicide risk screening tools that have been tested in the medical setting and with youth, will help clinicians accurately detect who is at risk and who needs further intervention.

About the Tool

Beginning in 2008, NIMH led a multi-site study to develop and validate a suicide risk screening tool for youth in the medical setting called the Ask Suicide-Screening Questions (ASQ). The ASQ consists of four yes/no questions and takes only 20 seconds to administer. Screening identifies individuals that require further mental health/suicide safety assessment.

For medical settings, one of the biggest barriers to screening is how to effectively and efficiently manage the patients that screen positive. Prior to screening for suicide risk, each setting will need to have a plan in place to manage patients that screen positive. The ASQ Toolkit was developed to assist with this management plan and to aid implementation of suicide risk screening and provide tools for the management of patients who are found to be at risk.

Using the Toolkit

The Ask Suicide-Screening Questions (ASQ) toolkit is designed for screening youth ages 10-24 (for patients with mental health chief complaints, consider screening below age 10). The ASQ is free of charge and available in multiple languages, including Spanish, Portuguese, French, Arabic, Dutch, Hebrew, Mandarin, and Korean.

It is recommended that screening be conducted without the parent/guardian present. Refer to the nursing script for guidance on requesting that the parent/guardian leave the room during screening. If the parent/guardian refuses to leave or the child insists that they stay, conduct the screening with the parent/guardian present.

What happens if patients screen positive?

Patients who screen positive for suicide risk on the ASQ should receive a brief suicide safety assessment (BSSA) conducted by a trained clinician (e.g., social worker, nurse practitioner, physician assistant, physician, or other mental health clinicians) to determine if a more comprehensive mental health evaluation is needed. The BSSA should be brief and guides what happens next in each setting. Any patient that screens positive, regardless of disposition, should be given the Patient Resource List.

The ASQ toolkit is organized by the medical setting in which it will be used: emergency department, inpatient medical/surgical unit, and outpatient primary care and specialty clinics. For questions regarding toolkit materials or implementing suicide risk screening, please contact: Lisa Horowitz, PhD, MPH at horowitzl@mail.nih.gov or Debbie Snyder, MSW at DeborahSnyder@mail.nih.gov.

Emergency Department (ED/ER):

 

For help in Australia

CAPS – Talk Suicide Support Service – Free telephone and face to face support      1800 008 255

Salvation Army Care Line     1300 36 36 22

Reach Out     http://au.reachout.com/tough-times

Headspace     Register and chat now at eheadspace, or call 1800 650 890  Headspace

Lifeline    13 11 14

Mensline Australia 1300 78 99 78 (24 hour phone counselling and referral)

Beyond Blue 1300 22 4636

Mates in Construction: 1300 642 111

QLife        1800 184 527    Phone & Chat  3.00 – 12.00 pm everyday

SANE Australia help

SANE Australia Helpline  –  Talk to a mental health professional (weekdays, 10am-10pm AEST) 1800 18 72 63

Helpline chat – Chat online with a mental health professional (weekdays 10am-10pm AEST)

Kids Help Line 1800 55 1800 (24 hour phone counselling)

Suicide Call Back Service 1300 659 467 (Professional call back service referral line operates seven days a week)

Veterans Line 1800 011 046 (after hours professional telephone crisis counselling for veterans and their families

MensLine Australia 1300 78 99 78

Multicultural Mental Health Australia

Local Aboriginal Medical Service

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Opinion: We must tackle all forms of bullying – not just cyber bullying

dollyThe suicide of 14-year-old girl Amy ‘Dolly’ Everett triggered a much-needed national anti-bullying campaign — but lest we forget Aboriginal children, who are twenty times more prone to take their lives because of bullying.

By Gerry Georgatos

22 Jan 2018 – 4:15 PM  UPDATED 22 Jan 2018 – 4:23 PM

sbs national indigenous television

The death of a child is always heartbreaking, but when it is by suicide it is as devastating as it gets; potentially causing long-term psychosocial effects on loved ones. Equally tragic is the majority of child suicides can be avoided.

As a suicide prevention worker, I know at least one in four child suicides are due to bullying. What is painfully bewildering is that in only a third of cases, the child has told someone that they were contemplating suicide.

We need to come to grips with the fact that child suicides are no longer rare — rates are the highest they have ever been. Annually more than 40,000 children between 12 and 17 are estimated to have made a suicide attempt. One-quarter of 16-year-old females self-harm.

And sadly, the child suicide toll does discriminate.

Suicide takes more Aboriginal and/or Torres Strait Islander children, as well as migrant children from non-English speaking cultural backgrounds, than it does others.

Aboriginal and/or Torres Strait Islander suicides comprise 7 per cent of Australia’s total, but a shocking 80 per cent of Australia’s child suicides aged 12 years and under are of Aboriginal children. Thirty per cent of child suicides up to age 17 are Aboriginal children.

 

I have often said “the nation should weep” at this harrowing tragedy, which is more than just a national disgrace, it’s damning evidence of who we are as a nation.

The tragedy of 14-year-old Dolly Everett’s case must galvanise the nation to respond not only to suicides from bullying but also to all child suicides. Full stop.

In the weeks before and after Dolly’s tragic passing there were other children lost to suicide. We must tell their stories, and invest in solutions.

Statistics show vulnerable Aboriginal and/or Torres Strait Islander children are at elevated risk. Aboriginal and/or Torres Strait Islander children who live below the poverty line are 20 times more prone to self-harm and attempting suicide due to bullying.

In general, the more financially disadvantaged someone is, the more susceptible they are to bullying and suicidal ideation. Forty per cent of Aboriginal and/or Torres Strait Islanders live below the poverty line, and my research has found that’s the case for nearly 100 per cent of Aboriginal and/or Torres Strait Islander suicides.

There are no words that could comfort any family in the wake of the loss of their child. This also rings true in tightly-knit Aboriginal communities.

I’ll never forget seeing three children buried in the space of five days in one particular community. There were three graves in a row; the youngest a 15-year-old girl. Two of the tragic losses were blamed on bullying. None of the children ever confided they had suicidal thoughts to anyone.

Recently, I travelled to two island communities which recorded their first suicides. Until last year, they had been sheltered from the internet and social media platforms where bullying and mobbing play out in pronounced ways. Mid 2017, both island communities connected to the internet, prior to this there had never been a recorded suicide attempt.

Migrant children are also often neglected in suicide prevention discourse. They are at an elevated risk primarily because of racism, and the perception that they must “fit in”. This can lead to disordered thinking, internalised conflict, shame, and a diminution of the self.

Indigenous youth want involvement in WA suicide prevention programs

An Aboriginal teenager from WA’s far north who tried to take her own life twice says young people must be involved in the design and delivery of suicide prevention programs.

These stories, although distressing, must be told to demand anti-bullying awareness campaigns, to provide protective factors for potential victims, and to teach perpetrators that what they’re doing is wrong.

Education campaigns cannot be limited to schools because a significant proportion of Aboriginal children who suicide do not attend school. They live in impoverished remote communities, where completing secondary school is rare.

We must counter bullying with the same intensity as other public health issues, such as smoking and domestic violence.

We do not need endless research, just the way forward.

 

Disclaimer: Gerry Georgatos is a suicide prevention researcher and the Humanitarian Projects Coordinator with the Institute of Social Justice and Human Rights. His long-term research focus has been trauma recovery. Gerry is also the National Coordinator Support Advocates for the National Indigenous Critical Response Service. 

“Even warriors need help”: Health workers and Elders gather on Suicide Prevention Awareness Day Babana Aboriginal Men’s Group has held its second Suicide Prevention Awareness Day, bringing together people from all over NSW with the aim to curb suicide among our mob.

Readers seeking support and information about suicide prevention can contact:

Lifeline on 13 11 14
Suicide Call Back Service 1300 659 467
MensLine Australia 1300 78 99 78
Multicultural Mental Health Australia
Local Aboriginal Medical Service

This Is How To Respond To A Veteran Contemplating Suicide

“I’ll never forget him. Or his voice.  That southern drawl made him sound sleepy, but there was more to it. He was weary, frustrated.

He wanted to kill himself.

It was a story as old as war: He made it home. His buddies didn’t.

He was a cavalry scout, an Iraq war veteran. Somewhere in Baghdad, one of the 15-month tours during the surge. He swapped with someone on patrol, the other guy didn’t make it. “Should’ve been me.” That kind of thing.

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I was coming to the end of my career, and volunteering with a local organization as a veteran peer mentor. I wasn’t a mental health counselor yet, just trying help other vets. Someone in the program thought he was thinking of hurting himself.

So I called him and asked him.

That’s the first step: Get them on the phone.

It doesn’t matter that you’re not a medic, or a therapist, or a first responder. It doesn’t matter to your friend, and it shouldn’t matter to you: The fact is, you are now the one connection to life that they have. Intimidating? You better believe it. That veteran’s life is in your hands in a very real and critical way.

That veteran’s life is in your hands in a very real and critical way.

You have to view suicide like any other kind of danger. You would do literally everything you could to save your friend, whether it’s from a burning building, a car accident, or a heart attack. Suicide calls for the same kind of immediate action.

I asked him how he would kill himself.

“I’ve got a gun here at the house,” he told me. “I’ve tried before.”

You have to ask it directly. No messing around. No, “are you in danger?” or “are you going to hurt yourself?” or “you’re not thinking of doing something stupid, are you?” All of these questions can be denied. Don’t mince words. If they are far enough along in their thoughts, they think the danger lies in living, not dying. People struggling with depression view death as peace, not pain.

“Once, I got drunk and put a round in the chamber,” he told me. “I was so wasted, I forgot it had a magazine disconnect. It wouldn’t fire.”

Don’t judge them. That’s first thing to remember: It’s not about you. It’s not about how you feel, what you think, what you did this morning, what you’re doing tomorrow. It’s not about how shocked, or betrayed, or sad, or scared you feel. Your total and complete focus is on your friend, on the other end of the phone, holding onto you, holding on to life.

Once you ask directly, and get a positive answer, then you can move on, because you know what you’re dealing with — a life-and-death situation.

It’s not about you. It’s not about how you feel, what you think, what you did this morning, what you’re doing tomorrow.

Maybe you think you’re done at that point: “Now I know, I can call 9-1-1, it’s out of my hands.” Nothing could be further from the truth. Settle in, because it gets real from here. Listen to their story. Tell them you want to hear about it, hear about what’s going on. You can be clear with one thing, though: are they in a place, head-wise, to talk? If they’ve already taken some pills, or they’ve got some other means, and they are literally seconds away from taking their own life, then 9-1-1 is absolutely one to call. You can even tell them that: “Now that I know what’s going on, if you hang up, I’m calling 9-1-1 immediately. If you don’t want that to happen, then keep talking to me.”

Related: 8 Common Myths About PTSD Debunked »

So, if they’re not in immediate danger, take it slow and listen to their story. Something happened today, or yesterday, or this past week, to get your friend to this place. It is certainly going to be an accumulation of things, leading back to and possibly beyond their time in the service, but the chance is that there is something very specific that happened to get to this point. That’s the story you need to listen to. Without judgment. Is it because something happened with that dude or chick they’ve been messing with, the one you don’t like? Again, not about you. It’s about your friend, and their pain, their story.

At some point, something is going to come up that makes them move back toward life. A reason to live, a reason they want to live. Their kids. Their spouse. You, because you’re important to them too, if there’s nothing else. Don’t throw guilt, don’t throw shame, no “how do you think they’ll feel when you’re gone?” Just listen, and when they start talking about things that could happen in the future, then you may have started to turn a corner.

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After talking for a period of time, they got some stuff off their chest, they might have gotten a reminder that there is some stuff to live for anyway. Here’s where you can start asking questions. What was your plan? What were you going to do? Because we need to figure out how to disable that particular plan. Pills? Let me have them, or give them to someone to keep safe. Guns? Rope? Let’s figure out how to keep them out of the way. Not forever, just for now, until we can make sure you’re safe. Probably best not to get drunk or high right now, because that keeps us from being focused. The best plan is one that you and your buddy come up with together, and then you confirm that plan.

Next step: Where are we going? Who are we going to tell next? Because we want to stay alive, right? If we’re not in the same town, who do you want me to call that will be safe to hang out with you until you can get in to see your doctor, or get into the vet center, or to see a therapist?

Trust and believe me, it is an unparalleled honor to be the one who your buddy reaches out to in their darkest moment …

Once they’re safe — once you know they’re safe — tell them you love them like a brother or a sister, and how thankful you are that they chose you to connect with. Trust and believe me, it is an unparalleled honor to be the one who your buddy reaches out to in their darkest moment, and it will do you good to let them know that. Once you’re 100% sure they are in a better place and have someone safe near them, you can hang up the phone.

Then you can focus on you. It will be one of the most draining and intense experiences of your life, but know this: You just saved a veteran’s life, and that is no small thing.”

How to respond to a veteran contemplating suicide

Duane K. L. France is a clinical mental health counselor practicing in the state of Colorado. He retired from the U.S. Army after 22 years, and deployed to the Balkans, Iraq, Afghanistan, and North Africa multiple times. Follow Duane K. L. France on Twitter @thcounselingvet

For help in Australia

CAPS – Talk Suicide Support Service – Free telephone and face to face support      1800 008 255

Salvation Army Care Line     1300 36 36 22

Reach Out     http://au.reachout.com/tough-times

Headspace     Register and chat now at eheadspace, or call 1800 650 890  Headspace

Lifeline    13 11 14

Mensline Australia 1300 78 99 78 (24 hour phone counselling and referral)

Beyond Blue 1300 22 4636

Mates in Construction: 1300 642 111

QLife        1800 184 527    Phone & Chat  3.00 – 12.00 pm everyday

SANE Australia help

SANE Australia Helpline  –  Talk to a mental health professional (weekdays, 10am-10pm AEST) 1800 18 72 63

Helpline chat – Chat online with a mental health professional (weekdays 10am-10pm AEST)

Kids Help Line 1800 55 1800 (24 hour phone counselling)

Suicide Call Back Service 1300 659 467 (Professional call back service referral line operates seven days a week)

Veterans Line 1800 011 046 (after hours professional telephone crisis counselling for veterans and their families

Batyr Workshops Brisbane Feb 3rd & 4th 2018

Batyr workshops.jpeg

For help in Australia

CAPS – Talk Suicide Support Service – Free telephone and face to face support      1800 008 255

Salvation Army Care Line     1300 36 36 22

Reach Out     http://au.reachout.com/tough-times

Headspace     Register and chat now at eheadspace, or call 1800 650 890  Headspace

Lifeline    13 11 14

Mensline Australia 1300 78 99 78 (24 hour phone counselling and referral)

Beyond Blue 1300 22 4636

Mates in Construction: 1300 642 111

QLife        1800 184 527    Phone & Chat  3.00 – 12.00 pm everyday

SANE Australia help

SANE Australia Helpline  –  Talk to a mental health professional (weekdays, 10am-10pm AEST) 1800 18 72 63

Helpline chat – Chat online with a mental health professional (weekdays 10am-10pm AEST)

Kids Help Line 1800 55 1800 (24 hour phone counselling)

Suicide Call Back Service 1300 659 467 (Professional call back service referral line operates seven days a week)

Veterans Line 1800 011 046 (after hours professional telephone crisis counselling for veterans and their families

*Applications for National Suicide Prevention Research Funding now open

At the beginning of the financial year the Minister for Health announced an extra $53,000,000 for mental health services. I think it was out of this pool of money that $12,000,000 went to Suicide Prevention Australia to fund research into suicide prevention, over 3 years.

NHMRC link to funding – See GAP funding

SPA Newsletter logo

In recognition of the impact of suicide on every Australian, the Australian Government has dedicated $12million to the establishment of the first National Suicide Prevention Research Fund (The Fund).

The world-first fund is designed to provide sustainable financial support for Australian suicide prevention research and ensure outcomes have the greatest impact by addressing nationally agreed priorities.

Suicide Prevention Australia is proud to manage The Fund in partnership with leading experts from the lived experience community, research, government and clinical service delivery.

The Fund has two main objectives :

  • To support world-class Australian research into suicide prevention and facilitate the rapid translation of knowledge into more effective services for individuals, families and communities.
  • To establish a national Suicide Prevention Hub Best Practice Programs and Services to act as a trusted national source of evidence-based suicide prevention programs.

How will the research be funded?

Each year, Australian suicide prevention researchers will be given the opportunity to apply for project funding. The first funding round is now open.

The aim of The Fund is to shift the focus of research from investigator driven to strategic priorities.

To support Suicide Prevention Australia in determining research priorities, the University of Melbourne undertook three studies to gauge current and future priorities in suicide prevention research.

Current priorities were examined by reviews of journal articles published, grants and fellowships funded between 2010 and 2017. Future priorities were informed by the views of a range of groups known to conduct, fund, or use suicide prevention research as well as those who are impacted by suicide. A total of 390 responses were received.

Suicide Prevention Australia is partnering with the National Health and Medical Research Council (NHMRC) to assess scientific excellence, and applications will open in line with the NHMRC timetable.

A Research Advisory Committee has been appointed for The National Suicide Prevention Research Fund that will help SPA’s Board to distribute project grants for research. The RAC will be Chaired by Professor Don Nutbeam, with Members representing Lived Experience, service provision and experts leading scientific research (appointed by invitation only). You can read more about the RAC here.
Grant Application Process and Research Priorities
The Fund is now listed with the National Health and Medical Research Council (NHMRC) and grant applications are open via the NHMRC portal as of Mon 15th January 2018. Researchers seeking funding will be required to address two key priority areas identified through a research priorities scoping project by the University of Melbourne.

Research priorities

Researchers seeking funding will be asked to submit applications that address the following priority areas, including a knowledge translation plan:

1. What works to prevent suicide and suicidal behaviour? For whom? Why? Studies of indicated, selective and universal interventions will be considered, with particular emphasis being given to studies of indicated interventions. Studies employing any type of research design will be considered, providing they can yield meaningful data on effectiveness and, where possible, cost-effectiveness.

2. What factors are protective against suicide? What are the mechanisms by which these protective factors operate? How might we bolster these protective factors for individuals in different communities and/or from different target groups and/or social and cultural backgrounds? Again, studies employing any type of research design will be considered, providing they can yield meaningful data on protective factors and their promotion.

 

For more information about The Fund, email sprf@suicidepreventionaust.org or call SPA on 02 9262 1130.

The Centre for Rural & Remote Mental Health (CRRMH)

Position Paper recommends strategies to save lives and decrease rates of rural suicide

Rural & TRmote Suicide Prevention Plan 2018

Rural Suicide appears to be getting worse rather than better. In 2016 the number of suicides per 100,000 people in rural and remote Australia was 50 per cent higher than in capital cities.

This has prompted the Centre for Rural and Remote Mental Health (CRRMH) to develop a Position Paper on “Rural Suicide and its Prevention”. This paper proposes five key focus areas for action to address the need to save rural lives now and to lower the number of deaths and rates of suicide in the future.

Director of the CRRMH, Professor David Perkins said that recommendations outlined in the Position Paper draw on the suggestions and ideas obtained from participants who attended the CRRMH’s Rural Suicide Prevention Forum held at the Sydney Royal Easter Show as well as local and international sources, and the CRRMH’s experience and research.

“Rural suicide causes enormous distress to individuals, families, schools, workplaces, and communities and must be addressed seriously. We believe that the higher rates of suicide in rural and remote Australia and the current upward trend in rural suicide rates are not acceptable,” he said.

“Clearly the way we currently think about and respond to the problem of suicide prevention is not working in regional, rural and remote Australia. While the evidence to inform the prevention of suicide in rural areas is not perfect, this should not prevent us from taking action,” said Professor Perkins.

Patron of the CRRMH, His Excellency General The Honourable David Hurley AC DSC (Ret’d) Governor of NSW has endorsed the Position Paper and says the purpose of this paper is twofold: to describe the problem and to suggest how we might address it based on the best available evidence.

You can watch his introduction here.

The paper outlines two focus areas for immediate action that include strategies to: prevent people who experience suicidality from taking their own lives and to help those who are affected by the suicide of others.

The other three focus areas include suggestions designed to: prevent deaths in the future including providing support to vulnerable groups in rural and remote populations, building protective factors in children and young people and; building healthy and resilient people and communities.

The paper also provides concrete suggestions for addressing the high rates of suicide in Aboriginal and Torres Strait Islander communities specifically looking at indigenous leadership and participation in suicide prevention strategies.

Strategies outlined advocate that leadership for rural suicide prevention is needed at the Commonwealth, State and Local Government level. Local communities also have a role to play and are best-placed to identify local opportunities for suicide prevention, both in terms of how to help those who might be at risk of experiencing suicidality and how to improve the resilience of their community.

“Decreasing the suicide rates is not just the responsibility of the health sector; it goes beyond health,” said Professor Perkins.

“It can’t be one size fits all approach; these strategies must consider the unique social, economic and environmental strengths and weaknesses that exist in individual rural communities.

“Everyone needs to be part of the solution to the under-recognised and unacceptable problem of rural suicide.”

The CRRMH welcomes the opportunity to partner with organisations that wish to take action and have a positive impact on rural suicide.

To assess the Position Paper

Download the Position Paper here: Rural Suicide and its Prevention: a CRRMH position paper (5 MB)

Summary – Position Paper

Download the our Summary Document here: Summary – Rural Suicide and its Prevention: a CRRMH Prevention Paper (254 KB)

Contact us

Please email us crrmh@newcastle.edu.au or call 02 6363 8444.

Help services

If you or someone else is in immediate danger, call 000 or go to your nearest hospital emergency department.

If you’re concerned about your own or someone else’s mental health, you can call the NSW Mental Health Line 1800 011 511 for advice.

Having a tough time and need someone to talk to right now? The following services are here to help. They are confidential and available 24/7.