Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of CrisisTalk. You can reach her at editor@crisisnow.com.
Blood pressure, pulse, respiration rate and temperature are the vital signs generally measured when assessing someone’s health. Psychologist Kelly Posner, founder and director of the Columbia Lighthouse Project, would add one more to the list – testing for suicide risk using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale. “The data has shown us this is a vital sign we must take,” she said, “otherwise, we won’t find the people suffering in silence.” She notes while the screening is becoming universal, there are discontinuities in its use, including in 988 crisis systems.
The screening tool was first developed more than a decade ago when Posner and her colleagues helped run the first National Institute of Health study on identifying suicide predictors in adolescents. Even though suicide was the second or third leading cause of death at the time, she says there had never been a large intervention trial to look at how to identify suicide risk. The study revealed previous suicide attempts and higher self-rated depression predicted a suicide attempt but so did lower family cohesion and family income. Adolescents who experienced a slower decrease in suicidal ideation were also at high risk.
For the first time, the field had evidence-based thresholds on who was at imminent risk, she says. This has allowed Posner and her team to identify a person’s intent to act. “That’s been a complete game changer,” she said, adding that studies show intention dramatically increases suicide risk. In a meta-analysis of 74,406 Columbia Protocol screenings done between 2009 and 2012, Posner and her co-researchers found intent to act increased a person’s risk by 1,400 percent.
The meta-analysis study also unveiled another startling finding – a person who experiences an interrupted suicide attempt, like “when someone takes a gun out of the person’s hand or a police officer pulls someone off the ledge of a bridge,” is four times more likely to attempt again. Even those who stop themselves amid an attempt are at higher risk. “Interrupted attempts, aborted or self-interrupted attempts are equally or more predictive than an actual suicide attempt of who was going to go on and try to take their life,” said Posner. So, too, are preparatory behaviors such as obtaining a gun, collecting pills, giving away valuables or writing a will or suicide note. Together, these acts represent 87 percent of the serious suicidal behaviors people at risk engage in. Without the screening, Posner says up to nine million behaviors would be missed per year in the U.S.
The brief, six-question questionnaire not only identifies who is at imminent risk of suicide – roughly one-to-two percent of people who take the screening – but has also shattered assumptions about suicide risk, like the notion that younger children are less likely to be high risk. “Six to 12-year-olds who are screened have the same odds as those 13 to 17,” said Posner, noting the study illustrated 3.6 percent of children ages 6-to-12 who had high risk would have been missed. Even so, the U.S. Preventive Services Task Force doesn’t advise screening for suicide risk. After doing an evidence synthesis of 80 studies, the task force recommends beginning to screen for anxiety at eight and depression at 12 but makes no such recommendation for suicide risk. In fact, in 2022, the task force concluded evidence was “insufficient to assess the balance of benefits and harms of screening for suicide risk in children and adolescents.” Posner says the guidance needs to be reexamined.
Identifying who is at high risk – and who isn’t – increases people’s access to services and redirects resources, reducing the burden on already overwhelmed systems. “The ability to risk stratify improves triage and wait times because now we know who needs what,” said Posner, adding that diverting people from unnecessary emergency room visits and hospitalizations also reduces the corresponding financial and psychological costs they might otherwise face. “When you intervene with someone who doesn’t need it, it’s traumatizing and shuts them down from treatment when they do need it.” Most people are best served in the community, she says. “Science has shown that receiving the lowest level of care in the community has better outcomes. People ask for help more often and have a better quality of life.”
In Tennessee, the nonprofit mental health system Centerstone saw suicides drop by 65 percent in the first 20 months after weaving the Columbia Protocol into its standard operating procedure. “Recidivism in the emergency room also decreased from 40 percent to 7 percent,” said Posner. Centerstone uses the screening indiscriminately, screening everyone at every service delivery point. Even after casting a wider net, only one percent of people who are screened fall under high risk. “Doing the screening doesn’t increase overall resource use or length of stay.” Those evaluated as high-risk enter the system’s suicide prevention pathway, which includes safety planning, same-day counseling, more frequent sessions and follow-up. The screening is also added to the person’s electronic health record and their care team is alerted.
The screening isn’t just being used in crisis spaces but also by first responders, schools and children’s services, homeless services, the criminal legal system and national and state parks. Even residential advisors in college dorms are using it. Most states have integrated the screening into their policies across different systems. According to the Substance Abuse and Mental Health Services Administration, the questions can be administered quickly by “responders with no formal mental health training,” making it a low-barrier and practical approach. Posner says this is critical as most people at risk have never seen a mental health professional or been diagnosed with a mental illness.
In Connecticut, 14.1 percent of surveyed high schoolers reported seriously considering attempting suicide and 5.9 percent said they did attempt suicide. Last year, the state passed an act requiring the Connecticut Department of Education to provide a list of recommended suicide risk assessments for each board of education so that when a student is in mental health distress, their suicide risk can be identified. In January, education commissioner Charlene M. Russell-Tucker sent school superintendents her guidance, sharing that the state’s suicide advisory board, Department of Child and Family Services and Department of Mental Health and Addiction Services recommended the Columbia Protocol be “the assessment tool for determining the suicide risk of students.”
When all the systems intersecting with crisis use the same screening, there’s not only more identification of people in crisis but rapid intervention, says Posner. She shares the story of a fourth grader in Connecticut who was in the midst of a mental health crisis. “Because multiple systems, including law enforcement and schools, are using the same screening, the child was identified as high risk and received a more timely response,” she said.
Despite the increasingly ubiquitous use of the Columbia Protocol as a universal screening, Posner says gaps remain – even in 988 crisis systems. While states use the screening across the crisis continuum, including at their crisis lines, she says it’s typically not asked at the first point of contact when someone reaches out to 988. The 988 Suicide and Crisis Lifeline Suicide Safety Policy, which became effective in December 2022 and was updated this year, requires hotline crisis counselors to ask, “Have you had any thoughts of suicide in the past few days, including today?” and “Have you taken any action to harm yourself today?”
After an affirmative response to either question, 988 crisis counselors must assess safety. If the person indicates they have taken action to harm themselves that day, then crisis counselors must also determine if there’s an attempt in progress. However, Posner says the questions themselves aren’t enough. “They don’t get at intent or the full range of predictive behaviors – if you don’t do that, you can’t identify the people at risk,” she said. “It’s also setting yourself up for liability.” Crisis centers using the Columbia Protocol screening from the onset find it effective. Clara Reynolds, president and CEO of the Crisis Center of Tampa Bay, told The Observer News in September that by assessing people’s risk through the screening, the center can get people to a place of safety “98 percent of the time.”
As communities build their 911-988 interconnectivity to divert calls from 911, using a universal screening is especially critical. States and localities, including Virginia, Los Angeles and Maryland, are developing and implementing diversion matrices. Others, like Austin, Houston and Tucson, have mental health professionals co-locate on the 911 call center floor. Some states, such as Indiana, are using the Columbia Protocol as a diversion tool. Posner says the screening needs to be integrated into all diversion matrices. “[Suicide risk] is a vital sign we must take,” she said.
Having a universal screening for suicide risk assists in data collection and analytics. Apps of the screening have made data collection more accessible, helping to identify at-risk populations and regional hot spots. “Approximately 80 percent of people who take their life do it at home, making leveraging technology all the more critical,” said Posner. “It’s a way to get the screening into every home and every parent’s pocket.” The Columbia Lighthouse Project has a free screening app that connects people to nearby resources based on geolocation. So do the Department of Homeland Security and the American Legion Be The One, an initiative designed to help veterans in crisis. Posner and her colleagues are training American Legion staff on administering the protocol.
“We need to reach the seemingly unreachable,” said Posner.
