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In law school, students are taught how to act, dress, and talk in court. They are told where to stand, what color suit to wear, what to say, and how to say it. They practice in lifelike simulations, held in courtrooms.

Psychiatrists—often called to testify in court—receive little if any of this training.

 They can feel unprepared when they first step on a 

stand. This article will help psychiatrists feel more comfortable with the testifying process by providing some necessary vocabulary, an outline of the judicial process, and practical tips on courtroom behavior.

There are many types of courtroom proceedings.

 There are hearings, in which judges make preliminary decisions on specific judicial issues, such as a civil commitment hearing. There are depositions, in which attorneys “discover” what the other side’s witnesses plan to say at trial. Finally, there are trials, in which cases that did not settle or otherwise resolve are ultimately decided.

Each of these judicial proceedings has its own set of rules and procedures, which vary from state to state. Psychiatrists can be asked or subpoenaed

 into any of these venues to testify under oath. This article focuses on trial 

, but the concepts are useful in any context.

When a psychiatrist testifies, it is either as a party or non-party. In criminal court, there are defendants and prosecutors. In civil court, there are plaintiffs, who file suit, and defendants, who are being sued. If a psychiatrist is sued by their patient, the patient becomes the plaintiff; the psychiatrist becomes the defendant. If that psychiatrist testifies at trial, they testify as a party.

More commonly, psychiatrists testify as a non-party—either as a fact witness or as an expert witness.

 A fact witness testifies about what they personally experienced. An expert witness testifies about their opinion. For example, after a car accident, a pedestrian who saw the collision would be a fact witness. A psychiatrist hired by the plaintiff to assess psychological damages would be an expert witness.

Another example would be a bank teller injured in a bank heist who sues their employer for emotional distress. If the bank teller (as the plaintiff) subpoenas their treating psychiatrist to testify about the bank teller’s pre-existing psychiatric condition, that psychiatrist would be a fact witness. If the bank teller’s attorney hires a psychiatrist to conduct an independent medical examination (after the robbery), that psychiatrist would be an expert witness.

Fact witnesses are usually unpaid. Expert witnesses are paid by the retaining attorney or the court. 

 can serve in a consulting role (reviewing a case and giving advice about trial strategy or chances of success) or a testifying role (reviewing a case and forming an opinion, and then testifying about a specific issue)—or both.

 In the bank teller example, a testifying expert witness could be asked to form an opinion on whether the bank teller had posttraumatic stress disorder and, if so, whether it was due to the bank robbery. In many states, physicians are required to offer their opinions with reasonable medical certainty. This is a legal standard that most often means more likely than not. For a summary of some of the roles, and responsibilities, of psychiatrists in court, see the 

As a witness, you should take advantage of your attorney’s expertise. Attorneys are trained in courtroom procedure. If you are a defendant, your attorney is on your side and should be a particularly helpful resource (make sure you meet with them before any proceeding). If you are a non-party witness, you should still avail yourself of the attorney who hired or subpoenaed you to ask logistical questions.

When you are asked to appear at a court proceeding, make sure you know where you need to be and at what time. Judges do not tolerate lateness. Plan to arrive at the courthouse at least 30 minutes early. Bring a government issued identification card. Know which courtroom in which you will be testifying and where you should wait (inside or outside of the courtroom). As a witness, you will not know exactly when you will be called to testify; you might be given a window of several hours. Bring relevant materials to review or a book to read.

When your name is called, go straight to the witness stand. At some point, either on the way there or once you sit down, you will be sworn in. The courtroom is the judge’s domain. Unlike a hospital, you are a guest. Act accordingly.

During a trial, questions are asked in a very stylized format. Your attorney will begin with direct examination. You should have discussed your testimony with your attorney before the trial and educated them on pertinent psychiatric concepts. Their ability to ask the right questions will depend on how well you have helped them understand your analysis and psychiatric opinions.

During direct examination, your attorney will guide you through a series of open-ended questions. Your fundamental responsibility is to present your opinions cogently and convincingly. On cross-examination, the opposing attorney will ask specific questions based on what was covered during direct examination.

The American court system is adversarial. One of the main purposes of cross-examination is to discredit you and/or your opinion. The key role of an opposing attorney is to knock you off balance. After cross-examination, attorneys have a chance for redirect, to help rehabilitate you (in the event any damage was done) and to give you an opportunity to clarify your answers. Then there is re-cross—the opposing attorney’s second chance to discredit you.

Your value as a witness is not just in what you say, but how you say it and how you come across (how credible you are). No matter how smart you are, if the judge or jury do not believe you, you will be an ineffective witness.

You always need to tell the truth, even when it goes against the side for which you are testifying. You need to be professional and likeable. Particularly with jury trials, it helps to act like the jury expects you (as a doctor) to act and look like they expect you to look.

Juries decide whether to believe a witness, including an expert witness, based on what they deem credible

 Credibility is judged on a variety of factors. This includes your professional credentials (where you went to school, how long you have practiced, what you have published, and so on), whether you appear biased, and your conduct.

Just like we evaluate our patients’ demeanor and appearance, judges and juries evaluate a witness’s demeanor. An important aspect of demeanor is attitude. It is okay to be nervous. It is not okay to be grandiose, entitled, or overly professorial. The worst sin is to appear arrogant. Do your best to be likeable.

Likeability is hard to teach. Even people who are likeable in real life can become hostile on cross-examination. It is helpful to view cross-examination as a tennis match; a series of volleys between 2 sides. Wait for the entire question to be asked, then pause and think. Only answer the question that is asked. Do not feel as if you need to keep talking. Embrace the silence, or pregnant pause, which opposing attorneys may use strategically to get a witness to keep talking.

Do not let the opposing attorney provoke you8, which they often try to do. For instance, if you are a defendant in a medical malpractice claim, the plaintiff’s attorney might lead you through a series of yes or no questions (eg, whether you ordered a series of tests you believed unnecessary)— knowing that you will answer “no” on each question. This can feel uncomfortable. Maintain your poise and calm demeanor. Take the high road. Be your professional self and avoid getting into arguments with the cross-examining attorney.

Your professional identity should come across in your appearance 

). Your look serves as jury’s first impression.

 Do not wear anything distracting, such as bright clothing or “loud” jewelry. Dress as if you are going to a job interview. Wear a nicely tailored, crisply pressed, dark-colored suit. Men should wear a light-colored dress shirt with a simple tie. Women should wear a high-cut blouse and closed-toe shoes, preferably with a low heel. Both men and women should pay particular attention to their grooming, making sure their hair is neatly styled.

It takes years of practice to become a stellar witness. But, even their first time, a psychiatrist can do a good job testifying.

 Just prepare adequately, remain calm, tell the truth (in easy-to-understand language), and remember that you are there as a doctor.

The courtroom is designed to be adversarial. To be an effective witness, credibility is key. Witness credibility hinges not just on what the witness says, but how they say it and their overall demeanor.

is a forensic psychiatry fellow, University Hospitals Cleveland Medical Center.

is professor of psychiatry, Case Western Reserve University School of Medicine. He serves on 

1. Williams J, Elbogen E, Kuroski-Mazzei A. Training directors’ self-assessment of forensic education within residency training. 

 17th ed. Chicago, IL: Thomson West; 2008.

3. Mossman D. ‘You’ve been served’: What to do if you receive a subpoena. 

4. Piel J, Resnick P. Psychiatrists as Expert Witnesses. 

5. Gutheil TG. The psychiatric expert witness. 

https://www.psychiatrictimes.com/view/psychiatric-expert-witness

6. Brodsky SL, Griffin MP, Cramer RJ. The witness credibility scale: An outcome measure for expert witness research. 

7. Discovery and depositions. In: Gutheil TG. 

 Washington, DC: American Psychiatric Press, Inc. 1998:59-75.

The Expert Expert Witness: More Maxims and Guidelines for Testifying in Court.

 Washington, DC: American Psychological Association. 1999:108-111.

9. Pitera M. Courtroom attire: ensuring witness attire makes the right statement. 

Strategies to remain calm under pressure; to be clear and concise; and to know what is expected in courtroom battles.

Tips for Testifying in Court

Many experts predict a sharp rise in psychiatric emergencies as the nation emerges from sheltering-in-place, especially since individuals are dealing with unprecedented stressors and have been unable to access traditional treatment settings. Mental health crises may be one area in which therapeutic professionals might be a logical substitute for traditional police interventions. But what services comprise the crisis spectrum of care? And, if you treat patients in a private office or clinic, how might you best access these services when you encounter a psychiatric emergency?

Crisis services for behavioral health emergencies may include a wide variety of approaches, and they tend to vary depending on your state, county, or community. Yet, there are general overall concepts applicable to most crisis programs and their target patient populations.

A mental health crisis is a situation in which a person’s thoughts, emotions, and behaviors can put them in jeopardy of harming themselves or others and/or put them at risk of being unable to care for themselves or access food, clothing, and shelter. Crises also include acute conditions that could quickly deteriorate into dangerousness or inability to care for self, even if those issues do not currently pose a problem.

A mental health crisis can surface anywhere—in public, in the home or work environment, or in any number of clinical settings. This discussion will focus on the considerations when an apparent crisis arises in patients under a clinician's direct care.

The following questions will help determine if a mental health crisis exists and if crisis services should be accessed 

1. Due to their behavioral health conditions, is this individual acutely dangerous to self or others, or unable to care for self?

2. If the answer to question 1 is not clear, are there concerns that, without prompt intervention, the behavioral health situation could evolve into dangerousness or inability to care for self?

If the answer to question (1) or (2 ) is “yes,” then answer (A) and (B) below.

A. Is this condition unlikely to be resolved by interventions without the need for a higher level of care?

B. Even if our interventions can temporarily stabilize the situation, is there a high degree of concern that dangerousness or inability to care for self will return shortly after our contact has ended?

If the answer to (A) or (B) is “yes,” then there is a crisis situation requiring acute external interventions.

Determining dangerousness and/or inability to care for self

The clinician should consider several factors when assessing a patient for dangerousness and ability to care for self.

. Is this the first time you have met with this individual, or are they well known to you?

. How certain are you about the veracity of their statements? Do you believe them when they say they will follow through with a plan?

. What is your understanding of how they have acted when experiencing similar behavioral issues in the past?

. Has this person made suicide attempts or become aggressive in the past?

. What do family, significant others, co-workers, and caregivers say about the patient’s current behavior and their concerns about these behaviors?

These considerations and questions help to determine the acuity and level of intervention needed. For example, an initial meeting with reported symptoms requires a different level of evaluation than if the patient and their symptom history are well-known to you. Similarly, a patient that is well-known who reports a sudden change or demonstrates a marked difference from their usual behavior should raise the level of acuity. Based on familiarity, you must evaluate your level of trust with the patient. If trust is nebulous, then it is paramount to delve into collateral opinions of family and significant others. Concerns may first arise from a patient’s report, their significant others’ report, or your personal assessment. Regardless of the source of the initial warning, the response should be comparable.

Although an individual’s mention of the word 

 in discussing previous thoughts or incidents may not be considered a reason for accessing crisis services, any concern that patients may be at risk to harm themselves should be considered a reason for action. It is most important to learn about an individual’s thoughts around suicide, especially if there is any suicidal plan or intent. To determine if a patient needs a higher level of care, clinicians should consider the following issues. 

 Is the person thinking/talking about suicide, or saying that death seems to be an option, or expressing that the world would not miss them/would be a better without them?

 Does the person have a specific idea about how they would kill themselves? How lethal is this method?

 How much does the person want to use a particular method to kill themselves? How serious are they about it?

 Does this individual have access to the means they have described to kill themselves?

 Does the person have strong religious or cultural beliefs that forbid suicide? Do they have others who rely on them that they feel they cannot leave?

Chronic symptoms of psychosis may be a well-controlled part of an individual’s life and not necessitate an emergency referral. Acute psychosis, however, may lead the patient to harm themselves or others or may cause an inability for them to care for themselves. For example, if the patient is currently stable and the hallucinations are tolerable and not placing the patient at risk, then long-standing auditory hallucinations (eg, a running commentary of what the patient sees) may be fine. On the other hand, a new delusion may necessitate intervention, especially if the hallucinations have negative consequences for the patient (eg, hallucinations dictating all food is poisonous and must be avoided, which results in the patient starving themselves). Similarly, command auditory hallucinations to attack family members or delusions that one has the ability to fly and should jump off a tall buildingare clearly psychiatric emergencies. Thus, there are many issues that must be considered.

 Is the person newly experiencing auditory hallucinations or experiencing a substantial increase in chronic hallucinations? Are the hallucinations commanding them to do things, especially to harm themselves, others, or objects? Are the hallucinations derogatory or highly critical of the patient? Does the patient feel they are unable to resist doing what the hallucinations are telling them?

 Does the person feel others wish to harm them and they might have to defend themselves or preemptively attack others? Does the person believe other people want to kill them? Is the person obsessively fixated on another person who may not share their feelings? Is the patient paranoid or delusional about anything that would prevent them from accessing food, clothing, or shelter (eg, if they go inside they will die, all foods are poisonous, they are impervious to cold and do not require a coat in subzero weather)?

. Has the individual become so confused or withdrawn that they are unable to appropriately interact with others and their environment and, thus, unable to access food, clothing and/or shelter?

When symptoms of mania are uncontrolled, there is risk for harm to self or others as a result of rash judgements, impulsivity, inability to rest, grandiosity, and impaired decision-making. Evaluating the severity of a manic or hypomanic episode may be determined with the following considerations.

 Is the person displaying poor judgment, unable to differentiate between right and wrong, spending money they do not have, placing themselves into dangerous situations unwittingly?

 Is the patient going without sleep or doing specific activities nonstop for long hours?

 Is the person easily angered, lashing out, or easily moved to anguish and sobbing?

, unlike uncontrolled mania, is often more objectively apparent in terms of current intoxication or effects of drug misuse. The severity of substance abuse may be apparent in terms of mood, judgement, or disorganization.

 Is the person despondent about their substance abuse or inability to quit? Have they mentioned suicide?

 Is their current intoxication or level of withdrawal clouding their judgment and putting them at risk?

 Can the person safely leave the facility and get home on their own?

Fortunately, there are a variety of crisis programs that can assist the clinician in providing help for their patient. Programs vary in their level of care and support as well as cost. By becoming familiar with the options in your area, you will be better able to offer information to patients before a crisis occurs as well as when the need arises.

 number is available in most areas; it can be reached via 800-273-TALK. The FCC has approved a 3-digit hotline number—988—to make it easier for people to access mental health resources, which should be available by summer 2022. If you are in direct contact with a patient, you likely will not need to refer them to a hotline; however, you will want to ensure patients are informed about such resources and should add the information to your voicemail message.

. Although technically not crisis programs, many county and municipal programs have a 24-hour mental health line, sometimes called an ACCESS line, to arrange for prompt mental health appointments, referrals, and links to services. These programs can also direct individuals to appropriate 

 These are crisis professionals, typically therapists or social workers, who will go to an individual in crisis for an onsite assessment. When possible, they will attempt to de-escalate and stabilize the patient at the site, so the patient does not need to be moved offsite to access a higher level of care. Based on the assessment, mobile crisis teams will often transport patients to an appropriate destination, which could be a community crisis center, a psychiatry emergency department (ED), a psychiatric inpatient unit, or a general hospital ED. Mobile crisis models can operate independently or may partner with the police; frequently the mobile crisis team can be accessed via police dispatch.

Community crisis programs/centers/mental health urgent care

. In recent years, many locations around the country have created drop-in crisis facilities. These can range from a simple set-up, like a section of the community mental health clinic staffed with crisis therapists, to a comprehensive crisis center with crisis intervention, 23-hour crisis stabilization units (intensive outpatient stabilization services which typically have a limit of 23 hours 59 minutes—anyone requiring a longer stay is moved to an inpatient unit), and substance abuse and/or detox programs. Patients typically need to arrive voluntarily, but mobile crisis teams, case managers, and police officers can also bring them to these centers. Although they may be able to accommodate involuntary detention patients, including initiation of involuntary holds, these patients are typically transferred to a medical ED or hospital rather than remaining onsite involuntarily.

. Although not available in every region,, a substantial number of locations have Psychiatric Emergency Programs that are designated as the main receiving site for involuntary and high-acuity psychiatric detentions. These programs typically accept voluntary patients and self-presenting individuals, but most patients tend to be involuntary cases that arrive via police or ambulance. These programs offer immediate assessment and treatment (including medication) with 23-hour crisis stabilization capacity. These units are invariably locked, so anyone entering will have to be discharged by a clinician before they can leave. For this reason, it may be the preferred option for individuals who refuse emergency care or who are flight risks.

. Most inpatient psychiatric hospitals accept the majority of their patients via direct referrals from psychiatrists with hospital admitting privileges or via referrals from regional medical and psychiatric EDs. However, many programs have intake hours in which an individual can self-present on recommendation from their outpatient therapist. In such situations, a member of the psychiatric hospital staff will assess for a possible admission to the inpatient unit.

. In the United States, the default location to send a crisis patient is the nearest general hospital medical ED, which is open 24 hours a day and obliged to evaluate any individual who requests services. The numbers of behavioral emergency patients presenting at medical EDs around the country has climbed in recent years, and it is currently estimated that 1 in every 8 patients in EDs 

with a behavioral emergency as the chief complaint.

 Most EDs, however, have little more to offer than a medical clearance, (perhaps) sedating medications, or a referral to an inpatient hospital bed.

A promising trend has been to offer higher levels of psychiatric care in medical EDs, including psychiatric assessment and treatment recommendations via on-demand telepsychiatry. Another new and useful trend is the availability of EmPATH (Emergency Psychiatry Assessment Treatment and Healing) units, which are specialized psychiatric emergency programs affiliated with the ED, analogous to an ICU dedicated for emergency behavioral health patients.

. When there are no other alternatives, calling 911 remains a legitimate best option for activating emergency services. It allows for a patient assessment and transport to a crisis facility or ED. Depending on your community or state as well as the acuity of the emergency, response may be from a crisis team, emergency medical services, and/or police.

 is Vice President for Acute Psychiatry with the physician partnership 

 and Assistant Clinical Professor of Psychiatry, 

is a registered nurse working as Operations Consultant for 

 Psychiatry/Neurology practice line. Dr Zeller and Ms Kircher have no disclosures to report regarding the subject of this article.

1. Kalter L. Treating mental illness in the ED. AAMC. September 3, 2019. Accessed July 27, 2020. 

https://www.aamc.org/news-insights/treating-mental-illness-ed

Inevitably, some of your patients will need of emergency psychiatric services. These tips will help prepare you and your patients when a crisis unfolds.

Understanding Crisis Services: What They Are and When to Access Them

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Suicide is a global public health crisis and is the 

 In 2018, more than 45,000 adults in the US died by suicide, surpassing the number of homicides by more than 2-fold. Moreover, suicide risk is even higher among individuals with comorbid medical illnesses. Illness such as cancer, diabetes, and asthma have all been shown to increase risk for suicide.

 Given that medical illness is a concerning suicide risk factor, medical settings provide an optimal venue for suicide risk detection and intervention.

Medical settings are well positioned to detect suicide risk. The majority of people who died by suicide visited a health care professional months before their death, placing medical providers on the frontlines of suicide risk detection and suicide prevention.

 However, many patients with suicidal thoughts who present to the health care system with somatic complaints do not disclose suicidal thinking unless asked directly, and most medical settings do not screen for suicide risk.

Notably, suicides in the hospital are one of the top 5 most frequently 

sentinel events to The Joint Commission (TJC).

 Many are surprised to learn that although in-hospital suicides are relatively rare for patients undergoing general medical care, a sizeable portion of them occur on non-behavioral health units, such as intensive care units or emergency departments (EDs). Given these striking statistics and the goal of leveraging hospitals as partners in suicide prevention, TJC revised National Patient Safety Goal 15.01.01 (NPSG 15) in 2019.

 NPSG 15 outlines several elements to optimize patient safety and the reduction of suicide risk in medical settings. In particular, NPSG 

performing environmental safety assessments, removing ligature risks, screening patients with behavioral health issues for suicide risk, and providing further assessment of at-risk individuals who screen positive.

 Although NPSG 15 refers to suicide risk screening of all patients who are being treated or evaluated for a behavioral health condition as their primary reason for care, the TJC issued Sentinel Event Alert 56 in 2016, recommending suicide risk screening for all patients, using brief, evidence-based screening tools.

Following these recommendations, a growing number of health care systems have implemented suicide risk screening programs for all patients, including those presenting with medical complaints. Such a program at 

 (PHHS) is an example of how to successfully implement hospital-wide universal suicide risk screening. Using one of the screening tools recommended by TJC, PHHS screened more than 325,000 patients in the first 6 months of implementing their screening program and detected a positive screen rate of below 4% among patients undergoing medical care.

 It will be important for hospitals to work with frontline clinicians to develop safe and feasible procedures for implementing the safety guidelines outlined in NPSG 15 across diverse rural and urban settings and to be able to articulate their procedures to TJC surveyors when they assess hospitals for safe care delivery.

Several suicide risk screening tools are commonly used, with varying levels of evidence to support their use among these patients. Thom and colleagues

 reviewed several brief suicide risk screening tools and discussed the benefits and limitations of each for use in a hospital setting.

 Their review discusses 6 screening tools, including the Ask Suicide-Screening Questions (ASQ), the Patient Safety Screener (PSS-3), and the Columbia-Suicide Severity Rating Scale (C-SSRS), most of which are also TJC-recommended screening tools.

 The authors highlighted that only 2 of the tools discussed, the ASQ and the PSS-3, were developed and validated specifically for patients undergoing medical care.

Notably, the C-SSRS, a tool used by many hospitals due to its application to both youth and adults, has not been validated specifically for use in medical settings. Although Thom and colleagues highlighted that no suicide risk screening tools have been validated for use among both pediatric and adult patients undergoing medical care, recent data show that the ASQ, originally validated for use among youth, also has excellent psychometric properties among adult medical patients, potentially allowing for the use of 1 screening tool across hospitals.

Some medical settings utilize depression screeners to identify patients at risk for suicide. For example, the Patient Health Questionnaire (PHQ-9), which is an excellent depression screen, is sometimes utilized as a suicide-risk screening tool.

 Although there is a well-documented association between suicide and depression, extant research shows that the 2 are not synonymous. In 1 study, 90% of suicide decedents met criteria for diagnosis of a mental illness; however, only 28% of suicide decedents met the criteria for major depressive disorder.

 Moreover, screening solely for depression in patients undergoing medical care may not adequately detect suicidal ideation.

Question 9 on the PHQ-9, which asks about the frequency of a patient being bothered by “thoughts that you would be better off dead, or of hurting yourself in some way,” contains both an “or” and the word hurting instead of killing. Some studies have used this item to identify large numbers of at-risk patients.

However, specific concerns exist regarding the sensitivity and specificity of item 9

; the awkward wording of the question leading to inaccurate responses

; and that relying solely on item 9 may miss a large portion of patients at risk for suicide.

Using depression screeners such as the PHQ-9 as a proxy for suicide risk screening may be insufficient to detect suicide risk. Additionally, other mental health disorders, such as substance use disorders, schizophrenia, and anxiety disorders are associated with risk of suicide, which would go undetected by screening only for depression.

 Asking directly about suicide risk and using validated tools specific to hospital settings is necessary to accurately screen for suicide risk.

risk screening tools that was created and tested specifically for use among patients undergoing medical care, the ASQ is also part of a 3-tiered suicide risk screening clinical pathway.

 Although this pathway was designed for use among youth, the 3-tiered system can be applied to all such patients, including adults. The proposed pathway starts with the use of a brief screening instrument to rapidly screen all medical patients for suicide risk. For this step, Brahmbhatt and colleagues

 recommended the use of the ASQ due to its brevity and focus on patients undergoing medical care. The PSS-3 is the other screening tool that has been tested on adult patients in the ED and makes an excellent first-line brief screener.

After a patient screens positive for suicide risk, the second and essential step is to have a trained clinician (eg, a mental health clinician, nurse practitioner, physician assistant, primary care physicians) conduct a 10- to 15-minute brief suicide safety assessment (BSSA) to determine how to effectively manage the patient’s suicide risk. The secondary safety assessment step was created to avoid a one-size-fits-all planfor anyone who screens positive on a primary screener. All positive screens should not be treated as an 

; in fact, the majority of positive screens will be non-acute positives that do not require full safety precautions, but rather need further assessment.

This second step helps to ensure that mental health resources are used effectively and patients who reveal suicidal thoughts are not treated in a way that may seem punishing. For the BSSA, the clinical pathway published by Brahmbhatt and colleagues suggested the C-SSRS or the ASQ BSSA. Anecdotal evidence from frontline screeners suggests that the C-SSRS, which is a good in-depth suicide risk severity rating scale, is lengthy as a first-line screener and is more appropriate as a secondary suicide safety assessment tool for use among patients who screen positive for suicide risk. The ASQ and the ASQ BSSA are available as part of the ASQ Toolkit.

 The aim of the BSSA is to help a clinician further assess suicide risk in order to determine next steps in the pathway—whether a full mental health evaluation is needed at that particular medical visit, or if it can wait for an outpatient mental health referral.

Following a positive suicide risk screen, an essential component of ensuring patient safety is safety planning and lethal means counseling. Stanley and Brown

 published a safety plan worksheet that can help clinicians assist patients in planning how they will handle a future suicidal crisis. This worksheet consists of 6 steps that includes identifying personal warning signs, internal coping strategies, people and settings that can provide distraction, trusted people who can provide help, contact information for mental health resources, and ways to make the environment safe. The last step refers to the process of lethal means safety counseling, which is a detailed discussion on how to limit access, remove, or safely store dangerous items (eg, pills, firearms, knives, and ropes).

Implementation of suicide risk screening has been a specific challenge for many hospital systems due to difficulty selecting an evidence-based tool across the lifespan and across medical/surgical specialty settings that work in both inpatient and outpatient settings. In addition, guidance around how positive screens should be interpreted have led to systems developing untenable rules, such as “all positive screens require 1-to-1 sitters” and “strict safety precautions.”

Somewhat surprisingly, the rate of positives screen results due to reporting a past suicide attempts is significant. Past suicidal behavior is one of the most predictive risk factors of future behavior, but many reported attempts were in the distant past (eg, more than 10 years earlier). How should these truthful responses be interpreted? Such past behavior may be important clinical history when delivering a poor medical prognosis to a patient. Clearly more implementation research is needed on how to handle past attempt history and how frequently patients should be screened.

Suicide risk screening is especially challenging in the time of a pandemic. Data are not yet available to ascertain how COVID-19 will affect the suicide rate. However, the 3-tiered clinical pathway needed to be revised to accommodate mostly telehealth screening. Due to the urgent need, we revised the suicide risk screening clinical pathways published by Brahmbhatt and colleagues to reflect the need for phone 

Typically, anyone who is in imminent danger requires an urgent psychiatric evaluation in an ED. The pathway needed to be revised to help patients with acute suicide risk avoid exposure to COVID-19 in the ED and to spare the ED from over-crowding during the pandemic crisis. Separate adult and youth versions of this 

were created and are available as part of the ASQ Toolkit (

 However, they have not yet been empirically tested. A critical part of this pathway is for the health care practitioner to provide 

 to the patient and family members or friends to ensure safe storage or removal of potentially dangerous items (eg, pills, firearms, belts, knives).

Detection and management of suicide risk screening in the medical setting is no longer theoretical. There are many hospitals successfully implementing suicide-risk screening programs with validated instruments. Universal suicide risk screening can be successfully implemented without incurring a need for additional resources. Use of the intermediate step of a brief suicide safety assessment provides critical guidance for determining appropriate follow up in a safe and efficient manner. Given the increasing suicide rates in the general population, medical venues offer important opportunities for early detection, assessment, and referral. With evidence-based tools and pathways to guide them, every health care provider can be a partner in suicide prevention.

is the Clinical Director of the National Institute of Mental Health (NIMH) Intramural Research Program at the National Institutes of Health, she is also the Deputy Scientific Director, NIMH; 

is an Intramural Research Training Award Fellow at the NIMH; 

 is a Staff Scientist and Clinical Psychologist at the National Institute of Mental Health Intramural Research Program at the National Institutes of Health, she also serves as a senior attending with a specialty in pediatric psychology on the Psychiatry Consultation Liaison Service in the Hatfield Clinical Research Center at NIH.

Acknowledgement—This research was supported in part by the Intramural Research Program of the NIMH (Annual Report Number ZIAMH002922).

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5. Frankenfield DL, Keyl PM, Gielen A, et al. Adolescent patients”: healthy or hurting? Missed opportunities to screen for suicide risk in the primary care setting. 

6. The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. 

https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

7. The Joint Commission. Hospital National Patient Safety Goals. NPSG.15.01.01. 

https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf

8. The Joint Commission. Detecting and treating suicide ideation in all settings. 

9. Roaten K, Johnson C, Genzel R, et al. Development and implementation of a universal suicide risk screening program in a safety-net hospital system. 

10. Thom R, Hogan C, Hazen E. Suicide-risk screening in the hospital setting: A review of brief validated tools. 

11. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. 

12. Boudreaux ED, Jaques ML, Brady KM, et al. The patient safety screener: validation of a brief suicide-risk screener for emergency department settings. 

13. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. 

14. The Joint Commission. Validated/ Evidence-Based Screening Tools. Suicide Prevention Resources to support Joint Commission Accredited organizations implementation of NPSG 15.01.01. 

https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/suicide-prevention/suicide_prevention_resources_ep2_npsg150101.pdf

15. Horowitz LM, Snyder DJ, Boudreaux ED, et al. Validation of the Ask Suicide-Screening Questions (ASQ) for adult medical inpatients: a brief tool for all ages. 

16. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. 

17. Conwell Y, Duberstein PR, Cox C, et al. Relationships of age and axis I diagnosis in victims of completed suicide: a psychological autopsy study. 

18. Recklitis CJ, Lockwood RA, Rothwell MA, Diller LR. Suicidal ideation and attempts in adult survivors of childhood cancer. 

19. Simon GE, Coleman KJ, Rossom RC, et al. Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice. 

20. Simon GE, Rutter CM, Peterson D, et al. Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? 

21. Uebelacker LA, German NM, Gaudiano BA, Miller IW. Patient health questionnaire depression scale as a suicide screening instrument in depressed primary care patients: a cross-sectional study. 

22. Suarez L, Beach SR, Moore SV, et al. Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease. 

23. Razykov I, Hudson M, Baron M, Thombs BD. Utility of the Patient Health Questionnaire?9 to assess suicide risk in patients with systemic sclerosis. 

24. Louzon SA, Bossarte R, McCarthy JF, Katz IR. Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? 

25. Dueweke AR, Marin MS, Sparkman DJ, Bridges AJ. Inadequacy of the PHQ-2 depression screener for identifying suicidal primary care patients. 

26. Brahmbhatt K, Kurtz BP, Afzal KI, et al. Suicide-risk screening in pediatric hospitals: Clinical pathways to address a global health crisis. 

27. National Institute of Mental Health. Ask Suicide-Screening Questions (ASQ) Toolkit, 2017. 

28. Stanley B, Brown GK. Safety Planning Intervention: a brief intervention to mitigate suicide risk. 

The authors share evidence-based guidance for patient safety that minimizes suicide risk in medical settings.

Implementation Challenges of Universal Suicide Risk Screening in Adult Patients in General Medical and Surgical Settings

On any given day, there are more than 400,000 children in foster care in the US (

). Children in foster care are at a higher risk for health and mental health problems.

In honor of National Foster Care Month, this article sheds light on these issues and provides information for psychiatrists caring for this vulnerable population.

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