ASQ Suicide Screening: Ask Suicide-Screening Questions

The ASQ (Ask Suicide-Screening Questions) is a brief suicide risk screen developed at the National Institute of Mental Health (NIMH) for people seen in medical settings ¹. It asks four yes/no questions; a yes to any of them is a positive screen, and a fifth acuity question decides how urgently the person needs a safety evaluation ⁴.

The ASQ is a screen, not a risk assessment. It identifies who needs a closer look, and the follow-up conversation sets the level of risk and the plan.

What does the ASQ measure?

The ASQ screens for suicide risk. It was built so that clinicians outside mental health, in emergency departments, inpatient units and primary care, can identify people who need further evaluation ³.

The four screening questions cover ⁴:

1. A recent wish to be dead (past few weeks)
2. A recent feeling that the person or their family would be better off if they were dead (past few weeks)
3. Thoughts of suicide in the past week
4. Any past suicide attempt, and if so, how recently

If the person answers yes to any of the four, the clinician asks a fifth acuity question about thoughts of suicide right now ⁴. The exact wording is published in the free NIMH toolkit and is not reproduced here; use the official form so the questions match the validated version.

How do you give the ASQ?

• Who asks. The ASQ is designed for non-psychiatric clinicians such as nurses and physicians in medical settings ³. The questions are asked directly, as written.
• Time. NIMH states that the screen takes about 20 seconds ³.
• Ages and settings. The toolkit covers people aged 8 and older in emergency departments, inpatient medical and surgical units, and outpatient primary care and specialty clinics ³. Developed in people aged 10 to 21 ¹, it was later validated in adults on medical and surgical units ².
• Languages. NIMH publishes translations of the screen in more than 20 languages ³.
• Crisis resources for everyone. The NIMH form asks clinicians to give every person screened crisis resources, including the 988 Suicide and Crisis Lifeline (call or text 988) ⁴.

How do you score and interpret the ASQ?

The ASQ has no total score and no numeric cutoffs. The result is a decision rule from the NIMH screening tool ⁴:

Two further rules on the form ⁴:

• Positive only because of a past attempt. When the only yes is to the past-attempt question, a brief safety assessment may not be needed if, for adults, the most recent attempt was more than a year ago; for youth and young adults (for example, under 25), the attempt must be more than a year ago and a brief safety assessment must have been documented since then.
• Refusal to answer. For youth, refusing the screening questions counts as a non-acute positive screen. For adults, refusal is not a positive screen; document it and act on any other safety concerns.

A positive ASQ is the start of an evaluation, not a diagnosis. NIMH pairs the screen with a brief suicide safety assessment by a trained clinician, which it estimates at 10 to 15 minutes ³. A structured follow-up such as the C-SSRS or the SAFE-T framework can organize that assessment.

When risk is acute

• Stay with the person and keep the environment safe.
• Call or text 988 (the Suicide & Crisis Lifeline in the US and Canada), or contact emergency services (911).
• Arrange an urgent mental health evaluation and document the steps taken.

See crisis resources.

Psychometric properties

• Youth development study. In 524 people aged 10 to 21 at three urban pediatric emergency departments, 17 candidate questions were tested against the Suicidal Ideation Questionnaire. The best four-question set had a sensitivity of 96.9% and a specificity of 87.6%; the negative predictive value was 99.7% for medical and surgical presentations and 96.9% for psychiatric presentations ¹.
• Adults on medical units. In a validation study of 727 adults on medical and surgical units at four hospitals, compared against the Adult Suicidal Ideation Questionnaire, the ASQ had a sensitivity of 100% (95% CI 90%-100%) and a specificity of 89% (95% CI 86%-91%), with a negative predictive value of 100% (95% CI 99%-100%) in that sample. It performed best of all the candidate questions tested ².

These figures describe agreement with a longer ideation questionnaire in the study samples. They are not estimates of how well the ASQ predicts future suicidal behaviour.

Limitations

• A screen, not an assessment. The ASQ flags who needs further evaluation. It does not set a risk level, a plan or a disposition on its own.
• Criterion, not outcome. Validation compared the ASQ with a longer suicidal ideation questionnaire, not with later suicide attempts or deaths.
• Specificity trade-off. Specificity was lower than sensitivity in both validation studies ^{1 2}, so some positive screens will not be confirmed as elevated risk on full assessment. Services need capacity for the brief safety assessments that follow.
• Self-disclosure. Like any question-based screen, it depends on the person's willingness to answer; a negative screen does not rule out risk, and clinical judgement can override it.
• Setting. Validation was in emergency departments and hospital medical units; performance in other settings rests on fewer studies.

How does the ASQ compare with other suicide risk screens?

• C-SSRS. The Columbia screener and full scale rate the severity of ideation and behaviour, and are a common next step after a positive ASQ.
• PHQ-9 item 9. The PHQ-9 is a depression measure; its ninth item asks about thoughts of being better off dead or of self-harm. The ASQ was built specifically to screen for suicide risk rather than depression.
• SIDAS. A self-report measure of how severe suicidal thoughts have been over the past month, used to monitor ideation over time.
• SAFE-T. A five-step clinical framework for a full risk formulation and triage after a positive screen.
• SAD PERSONS. A risk-factor checklist whose predictive value has not held up in later studies; it is not a substitute for a validated screen such as the ASQ.

If you or someone you know is in crisis, call or text 988 or contact local emergency services. Help is available 24/7.