Risk Assessment & Screening Tools Flashcards

The Columbia Suicide Severity Rating Scale (C-SSRS) categorizes suicidal ideation into how many levels?

Answer: 5

The C-SSRS uses a 5-level ideation scale ranging from passive wish to die up to ideation with specific plan and intent.

Which risk factor is considered a STATIC (historical) predictor of suicide rather than a dynamic one?

Answer: Prior suicide attempt

Prior suicide attempt is a static historical variable, whereas hopelessness, substance use, and means access are dynamic and can change.

On the SAD PERSONS scale, what does the letter 'E' stand for?

Answer: Excessive alcohol use

In the SAD PERSONS mnemonic, 'E' stands for Excessive alcohol or drug use.

A patient scores 2 on the Patient Health Questionnaire-9 (PHQ-9) item asking about thoughts of self-harm. This score indicates the thoughts occur:

Answer: Several days

PHQ-9 item 9 uses a 0–3 scale: 0=not at all, 1=several days, 2=more than half the days, 3=nearly every day; a score of 2 means more than half the days.

The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) tool is primarily designed to:

Answer: Structure the clinical interview and document risk level

SAFE-T is a structured clinical tool that guides clinicians through risk and protective factors and documents a risk level and treatment plan.

Which screening tool was specifically developed and validated for use in emergency department settings with suicidal patients?

Answer: Ask Suicide-Screening Questions (ASQ)

The ASQ is a brief 4-item screen validated specifically for use in emergency departments and acute medical settings.

In risk stratification, a patient with chronic suicidal ideation and no new precipitants is typically categorized as:

Answer: Low acute but elevated chronic risk

Chronic ideation without new acute stressors places a patient in the low-acute/elevated-chronic risk category, guiding outpatient safety planning rather than hospitalization.