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PSS-3: Three-question suicide screener for the ER


October 1, 2018

In the chaos of the emergency department (ED), it’s easy to miss something you’re not searching for. Up to one in five people who die by suicide visit an ED in the four weeks prior to their death. And those who die by suicide are more likely to come to the ED with a non-psychiatric complaint than a psychiatric one.

BHS’ sister publication Patient Safety Monitor Journal has run an ER checklist of items to be removed from rooms designated for treatment of suicidal patients. But that doesn’t help patients who aren’t screened for suicidality.

Enter the Patient Safety Screener 3 (PSS-3), a suicide screening tool developed for the fast-paced world of the ED. The tool consists of a short introduction and three questions, with an optional fourth item if the person has previously attempted suicide. It’s meant to be given during triage or primary nursing assessment and has been validated for use on patients 18 and older.

The three questions are:

  1. Over the past two weeks, have you felt down, depressed, or hopeless?
  2. Over the past two weeks, have you had thoughts of killing yourself?
  3. Have you ever attempted to kill yourself?

If the person answers “yes” to item three, then you follow up by asking them when the suicide attempt took place.

A “yes” to question one is a positive screen for depression. A “yes” to question two or if the person’s attempted suicide in the last six months is a positive screen for suicide risk.

The tool was created as part of the National Institute of Mental Health (NIMH)’s ED-SAFE study in 2009. The tool has been further tested, refined, and validated by Edwin D. Boudreaux, PhD, a professor at the departments of emergency medicine, psychiatry, and quantitative health sciences at the University of Massachusetts Medical School. Boudreaux led the steering committee of suicide prevention experts that created PSS-3.

Quick and effective

Back in 2017, PSMJ wrote about universal suicide screening at Parkland Health and Hospital Systems in Dallas. Parkland used two suicide screening tools: ASQ and the Columbia-Suicide Severity Rating Scale. What differentiates PSS-3, Boudreaux says, is its simplicity. It was made to be short, straightforward, and easy to memorize, and it provides clear “yes/no” response options.

“Other tools that are longer or more complex are more difficult for nurses to administer,” he says. “So we kept the instrument short, clean, and easy to administer.”

It’s also the only universal screener that Boudreaux knows of that’s been specifically validated for use in the ED. The ED-SAFE study found that routine use of PSS-3 doubles the rate of suicide risk detection. In the study, detection rates went from 2.9% to 5.7%.

“The psychometric studies show that it correlates well with other, longer, more established instruments and that when you use it clinically it improves detection,” he says. “I don’t think there’s any other screener that’s gone through those two steps.”


Back in 2013, a 66-year-old man stepped on a nail while in his garden and went to the ED. He had a history of hypertension and claimed not to take drugs or alcohol. He was “affable and in no obvious physical or emotional distress.”

It thus came as a shock to the care team that upon asking him PSS-3 questions, the man “matter-of-factly” explained his plans to kill himself. He had a detailed plan intended to look like an accident “so his sister would receive his life insurance benefit.”

When asked why, he revealed that it was the one-year anniversary of his partner’s death and that he was being evicted from his home and beloved garden. 

The man was given a diphtheria, tetanus, and pertussis booster for the rusty nail and was admitted to a psychiatric hospital for the suicidal ideation. He was later discharged with medicine and hasn’t had another suicidal incident.

But what if no one had asked him those questions?

“That story [in the case study] is representative of many stories that people have told us in places that have implemented the screening,” says Boudreaux.

As part of the NIMH study, PSS-3 was implemented at eight EDs across the country between 2009 and 2014, giving Boudreaux and his colleagues plenty of opportunities to see it in action. But despite obvious successes, there’s a huge amount of clinician resistance to implementing these kinds of screeners.

“Clinicians don’t want to do it,” he says. “They feel like it’ll take too much time, will be burdensome, and they don’t want to ask these questions of every patient. It sometimes seems awkward with patients to ask them these questions because they are often related to things not relevant to their ED visit.”

But Boudreaux and his colleagues noticed that once the screening is implemented, people find it’s not that bad. The questions are relatively easy to integrate into practice, and patients don’t usually react as negatively as clinicians might fear.

“Once they get experience with it, the nurses become less resistant,” Boudreaux says. “But really what puts them over is when they start to detect hidden risks and find patients they normally wouldn’t have found. It acts as kind of a motivator and reinforces asking the questions. They feel like it’s worth it at that point; they realize they may have saved that patient’s life so it was worth asking the question.”

One thing to keep in mind, he says, is that PSS-3 shouldn’t be the only part of your suicidality screening program. PSS-3 is a primary screener—it’s just meant to detect if there’s a risk that can’t be ignore. After a person screens positive, that should be the trigger for a more in-depth screen and assessment.

Stay on script

One of the most common mistakes people make with suicide screeners is ad-libbing the questions. Every question in PSS-3 was validated using a specific wording, says Boudreaux, and that wording shouldn’t be changed because doing so could unpredictably affect the test results.

“A common example is the second question, ‘Over the past two weeks, have you thought about killing yourself?’ ” he says. “That’s a tough question to ask patients, and many clinicians are resistant to asking it. So they’ll change that term ‘killing’ with ‘harming’ or ‘hurting yourself,’ because hurting yourself sounds less jarring.”

However, the distinction between “harming” and “killing” is a significant one. There are people who deliberately cut and burn themselves who aren’t suicidal, for example. Changing the term can change the answer received.

Another problem is blending the questions together, which tends to confuse patients.

For example, a clinician might try to combine the PSS-3 questions into “Have you been depressed, thought about killing yourself, or attempted killing yourself?” That question is asking three different things. Which one does the patient answer? Maybe the person is depressed but not thinking about suicide. Or the person might be thinking about suicide but has never attempted it before. Perhaps the person has attempted it before but isn’t depressed now.

When faced with a large compound question like this, a typical patient will either say, “I don’t know what you mean” or issue an inaccurate response.

When they say no

While patients are often more open to talk about suicide than expected, that doesn’t mean all of them are. Using any suicide screener, you’ll eventually come across a patient who tests negative to the screener whom you still have concerns about—or one that refuses to answer the questions altogether. What can you do then?

“That’s a difficult situation, and it happens relatively frequently,” says Boudreaux. “Particularly with the kind of patient who comes in intoxicated. [Maybe] there’s some evidence, something they were saying while intoxicated or something someone else observed, suggesting they might hurt themselves. But once they sober up they say, ‘No, I’m not thinking about it.’ That’s a classic case.”

In other cases, people will try to minimize the problem or don’t feel comfortable talking about it.
The first step is to lay the groundwork for the patient to allow him or her to be open and honest. Ensure the patient feels listened to and that the clinician is genuinely interested in the answers, not just trying to check off a list. This creates a rapport between the patient and clinician that will make it easier to talk about difficult subjects.

“Which is true for all clinical care, but for something as sensitive as suicide risk it is important to pay attention to that,” Boudreaux says. “Sometimes it’s not the questions themselves but how the questions are asked that are really important.”

The second thing providers need to realize is even when they do everything right, people still might minimize, hide, or recant their thoughts. In those cases, it’s ultimately up to the clinician’s judgment on how to proceed.

“I’d highly recommend a clinician who has any suspicions work on the rapport with the patient to make them more forthcoming,” he says. “And in some cases you can still deliver interventions that might impact suicide, even if the person is saying, ‘I’m not suicidal.’ ”

That might seem counterintuitive. But there are ways to get patients into behavioral healthcare, possibly to treat the psychiatric symptoms that might be driving a person’s suicidal thoughts.

“If they’re depressed, or anxious, or have a substance abuse problem, treating those primary problems can influence their suicide risk,” says Boudreaux. “But also something like a safety plan can be done if it’s couched the right way.”

Safety plan

A safety plan is a tool used to help prevent suicide that helps an individual identify his or her triggers for suicidal thoughts and specific actions he or she should take when feeling suicidal.

“If a person is saying, ‘I’m really not thinking about killing myself,’ but have any previous history of it, you can potentially say, ‘I’m glad you’re not thinking about it right now. But what sometimes happens is that people get triggered to think about it again in the future. I’d like to work with you on developing an action plan in case this happens to you,’ ” Boudreaux says. “You’re not forcing the person to admit it, but you’re [using the] context of ‘let’s just be safe.’ ”

This way, patients leave the ED with a safety plan intervention that can be used if they admit to suicidal thoughts later on.

Suicide Prevention Hotline Card
One thing you can do if you suspect a patient is suicidal is give them a card with the number of the Suicide Prevention Hotline number: 800-273-8255. This isn’t to imply that giving them a card can be the entirety of a suicide intervention—but it’s a good resource to have.

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