Asynchronous and Remote Suicide Screening: Facts, Functions, and Fears

Suicide is a public health crisis in the United States, ranking as the tenth leading cause of death. Yet shockingly, most health systems in the country only screen for suicidal ideation when their patient has already been diagnosed with a behavioral or mental health condition. With the majority of mental health conditions going undiagnosed or undertreated, this leaves countless individuals at risk of slipping through the cracks. 

The reality is that many patients are unlikely to be screened for suicide during a clinical encounter if there is no prior knowledge of a mental health condition. This is a major concern, especially since about half of people who die by suicide saw a health care provider at least once in the month before their death. This not only poses a risk to provider liability, but it also eliminates a critical opportunity to intervene and potentially save a life.

The field of mental health care has undergone a major transformation in recent years, with an increasing reliance on technology-based care. In fact, the use of telehealth for mental health treatment skyrocketed by 556% between March 11, 2020, and April 22, 2020, indicating a significant shift toward remote care options. However, despite this trend, the majority of patients still receive suicide screenings within traditional, in-person clinical settings such as primary care, emergency departments, and behavioral health clinics. The predominant use of traditional care methods, combined with the existing mental health stigma, is preventing many people from seeking and accessing help. 

One-quarter of American adults with mental illness fail to notify a professional about their symptoms due to the stigma of a diagnosis or not wanting people to know. This trend is particularly prevalent among Americans aged 14 to 22, with 75% preferring to seek information online and look for personal anecdotes rather than communicate their symptoms to a mental health professional. The same is true among members of the military, with a majority stating a preference for solving their problems on their own. With so many people suffering in silence, it's clear that the time has come for a major shift in how we approach mental health care.

Asynchronous Suicide Screening

The way we approach suicide screening is changing, with the emergence of asynchronous or remote screening methods through technology. Studies have shown people are willing to share sensitive data about their health through a secure and anonymous smartphone app, enabling the ability of health care providers to identify and reach members at risk of suicide and target preventive interventions in real time. This approach allows patients to work through a variety of technology-based channels, such as mobile applications, email and text communication, and online bulletin boards or patient portals. Mental health professionals can then interpret and respond to this information at appropriate times, providing treatment resources as necessary. 

While this approach can provide an important lifeline for patients who might be hesitant to seek care in person, it also requires patients to take an active role in their own assessment and participation. By engaging with these tools, patients can provide care teams with the necessary data to avoid negative mental health outcomes accurately and effectively. 

Currently, most mental health care providers use asynchronous screening alongside synchronous treatment options like telehealth or in-person visits. It is important to note that asynchronous screening tools don't necessarily improve outcome metrics, but they do provide greater accessibility to mental health care for individuals who might not otherwise seek professional support. As we continue to explore these tools, we must prioritize studies that emphasize their value and potential impact on suicide prevention. 

Liability Concerns and Legal Safeguards 

The legal landscape surrounding suicide screening can be a source of fear for health care providers, especially when it comes to using remote or asynchronous screening tools. One critical legal consideration is the concept of foreseeability, which asks whether a clinician performed an adequate assessment of a patient's suicide risk and implemented appropriate safety measures. This concern stems from the increase in patient data that can be collected through asynchronous screening, but it's important to strike a balance between legal obligations and providing the highest quality of care.

Disclosure is a simple yet effective safeguard for providers. When patients access asynchronous suicide screening tools, they are prompted with a "warning message" that clarifies the provider will not respond to patient needs in real time. This initial message gives the patient legal notice that they cannot expect immediate assistance through the asynchronous tool in the case of a mental health emergency. Asynchronous tools can also provide patients with easily accessible options for real-time contact, such as prompts to contact crisis resources.

Although providers are not legally required to screen patients for suicide, the Joint Commission has released recommendations for both inpatient and outpatient settings. These guidelines emphasize the importance of screening all patients, even those without a diagnosed mental health condition. By following these recommendations and implementing safeguards, such as noting that the system is not monitored in real time and offering real-time automatic referrals to crisis resources, providers can more effectively screen a larger population of patients for suicidal concerns without fearing endless lawsuits.

Companies like NeuroFlow are promoting the practice of clinicians screening all patients for suicide, creating an environment where mental health is regularly monitored and treated. It is the responsibility of the health care community to provide patients with access to legitimate pathways for mental health treatment. Practitioners must be comfortable recognizing the legal concerns around asynchronous care and employing the tools to protect themselves against increased risk for the betterment of the patient. By doing so, providers can avoid potential legal liabilities while also providing their patients with the highest quality of care.