Funding information

Li Ka Shing Foundation, Grant/Award Number:

AR180055; Hong Kong Research Grants

Council General Research Fund (GRF), Grant/

Award Number: 17103620

Abstract

Objective: Cancer patients have elevated suicide risk compared to the general

population. However, little is known about the characteristics of cancer patients

who have died by suicide. The objectives of the study were to compare the char-

acteristics of suicide cases with, and without cancer, and determine whether age

was associated with differences in characteristics.

Methods: A total of 14,446 suicide cases between 2003 and 2017 in Hong Kong

were identified using Coroner’s Court reports. Cases were grouped by cancer sta-

tus, based on medical history in the reports. Information extracted from the reports

included sociodemographic variables and detailed descriptions of the suicide event.

Univariate analyses and overall and subgroup multiple logistic regressions were

performed to compare characteristics between the two groups.

Results: Of the 14,446 suicide cases, 1,461 (10.11%) had a cancer history.

Compared to noncancer cases, cancer patients were generally older and less likely

to live alone; more likely to use violent methods; less likely to have histories of

physical and psychiatric problems; and more likely to communicate about their

suicidal intent before death. Age was significantly associated with differences be-

tween cancer and noncancer cases.

Conclusions: Cancer suicide cases have different characteristics from noncancer

cases. Mental health screening may not be sufficient for suicide prevention among

cancer patients. Healthcare professionals and caregivers should be aware of cancer

patients’ suicide risk, even when there are no signs of psychiatric disturbance.

K E YWORD S

cancer, mental health, psycho-oncology, suicide p

General Hospital Psychiatry 68 (2021) 52–58

Available online 13 November 2020
0163-8343/© 2020 Elsevier Inc. All rights reserved.

Validation of the ask suicide-screening questions (ASQ) with youth in
outpatient specialty and primary care clinics

Laika D. Aguinaldo a,*, Shayla Sullivant b, Elizabeth C. Lanzillo c, Abigail Ross d, Jian-Ping He c,
Andrea Bradley-Ewing b, Jeffrey A. Bridge e,f, Lisa M. Horowitz c, Elizabeth A. Wharff g,h

a Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (MC 0862), La Jolla, CA 92093, USA
b Children’s Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO 64108, USA
c National Institute of Mental Health, 10 Center Drive, Bethesda, MD 20892, USA
d Graduate School of Social Service, Fordham University, 113 W 60th St #7, New York, NY 10023, USA
e The Abigail Wexner Research Institute at Nationwide Children’s Hospital, 575 Children’s Crossroad, Columbus, OH 43215, USA
f Department of Pediatrics, Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
g Department of Psychiatry, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
h Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02215, USA

A R T I C L E I N F O

Keywords:
Screening
Prevention
Instrument validation

A B S T R A C T

Objective: Validate the Ask Suicide-Screening Questions (ASQ) with youth in outpatient specialty and primary
care clinics.
Method: This is a cross sectional instrument validation study assessing the validity of the ASQ with respect to the
standard criterion, Suicidal Ideation Questionnaire (SIQ/SIQ Jr.). The sample included 515 English speaking
youth ages 10–21 years old from outpatient specialty and primary care clinics. ASQ sensitivity, specificity,
positive and negative predictive values (PPV/NPV), positive and negative likelihood ratios, c statistic and
respective receiver operating characteristic curves were assessed.
Results: A total of 335 outpatient specialty and 180 primary care clinic participants completed the study. In
outpatient specialty clinics, the ASQ showed a sensitivity of 100.0% (95% CI: 80.5–100.0%), specificity of 91.2%
(95% CI: 87.5–94.1%), and NPV of 100.0% (95% CI: 98.7–100.0). In the primary care clinic, the ASQ showed a
sensitivity of 100.0% (95% CI: 59.0–100.0%), specificity of 87.9% (95% CI: 82.0–92.3%), and NPV of 100.0%
(95% CI: 97.7–100.0). Forty-five (13.4%) outpatient specialty clinic participants and 28 (15.6%) primary care
clinic participants screened positive for suicide risk on the ASQ.
Conclusions: The ASQ is a valid screening tool for identifying youth at elevated suicide risk in outpatient clinical
settings.

1. Introduction

Suicide is an increasingly devastating public health problem in the
United States (U.S.) and the current rate is the highest it has been

Development of the Uni Virtual Clinic: an online programme for
improving the mental health of university students
Louise M. Farrer , Amelia Gulliver, Natasha Katruss, Kylie Bennett *, Anthony Bennett*,
Kathina Ali† and Kathleen M. Griffiths ‡

Centre for Mental Health Research, The Australian National University, Canberra, Australia

ABSTRACT
There is growing recognition of the importance of addressing the mental
health needs of young people attending university. Anonymous, scalable,
and evidence-based online interventions can help to reduce burden on
university services and increase access to care for marginalised or
disconnected students. This paper reports the participatory design
methods used to develop the Uni Virtual Clinic (UVC), a comprehensive
online programme that was designed to prevent and treat mental
health problems and related issues in university students. Data
evaluating the participatory design process is also presented. The
potential for the implementation of the UVC within university-based
counselling services is strong, and has potential to reduce the
prevalence of mental disorders in a high-risk group of young people.

ARTICLE HISTORY
Received 19 December 2018
Revised 17 August 2019
Accepted 9 February 2020

KEYWORDS
University; student; mental
health; online; technology

Introduction

Young adults attending university face high age and life-stage related risks for developing mental
health problems, with approximately 30-50% of university students meeting criteria for a mental dis-
order (Auerbach et al., 2018; Eisenberg, Hunt, Speer, ; Zivin, 2011; Said, Kypri, ; Bowman, 2013). An
Australian study demonstrated a prevalence rate of 33.6% (Stallman, 2010), and in a large scale, epi-
demiological study of over 5000 college students in the US, the 12-month prevalence of any mental
disorder was almost 50%, with the highest rates of disorder being substance use disorders (29%),
anxiety disorders (11.9%) and mood disorders (10.6%) (Blanco et al., 2008). University students
may be at greater risk of mental health problems than their community-based counterparts, with
research demonstrating that the prevalence of severe psychological distress is significantly higher
in tertiary students (19-48%) compared to their age-matched peers not undertaking tertiary edu-
cation (3-11%) (Leahy et al., 2010; Stallman, 2010).

Despite the high prevalence of mental disorders among students, very few receive appropriate
mental health care (Eisenberg et al., 2011). Similar to young people in the general community (Rick-
wood ; Braithwaite, 1994; Rickwood, Deane, ; Wilson, 2007), when university students seek help for
mental health problems, they typically approach friends, family, or other non-clinical sources of
support (Eisenberg et al., 2011). Although these informal sources may be a useful starting point (Rick-
wood ; Braithwaite, 1994

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122 Journal of Doctoral Nursing Practice, Volume 14, Number 2, 2021 © 2021 Springer Publishing Company
http:// dx. doi. org/ 10. 1891/JDNP-D-20-00049

Improving Suicidal Ideation
Screening and Suicide

Prevention Strategies on Adult
Nonbehavioral Health Units

Anne C. Lindstrom, DNP, APRN
Rush University, Northwestern Medicine Central DuPage Hospital,

Winfield, IL
Melinda Earle, DNP, RN

Rush University, Chicago, IL

Background: Suicide is a risk in hospitalized patients within and outside of behavioral health units.
Williams et al. (2018). Incidence and method of suicide in hospitals in the United States. Williams
et al. (2018), suicides occur annually in hospitals, 14%–26% of occurrences outside of a behavioral
health unit. Objectives: The purpose of this project was to improve compliance with universal
patient suicide ideation screening and targeted actions for patients screening positive admitted
to nonbehavioral health units. Methods: Electronic medical record (EMR) changes to support
screening and targeted patient safety measure documentation were implemented. Nursing educa-
tion was provided to support these changes. Pre- and postassessments were used to measure knowl-
edge gained from the education. A compliance report was generated from the EMR to measure
compliance with universal screening and patient safety measures. Results: In a 4-month period,
screening compliance improved by 20.6%, bedside safety companion use was 100%, suicide precau-
tions, documentation 82.5%, and a behavioral health social work note documented 76% of the time.
Conclusions: Universal screening improvement is feasible and has the potential to improve patient
safety. Implementation should be considered across health care organizations. Implications for
Nursing: Providing nursing education and easier EMR workflows for nursing documentation of
suicide screening and prevention strategies improves patient safety.

Keywords: suicide; screening; interventions; behavioral health

Background

Suicide is the 10th leading cause of death in the United
States, furthermore the rate is increasing in almost all
states despite a decrease worldwide (Grumet et al.,
2019). Currently, suicide claims one life every 40 sec-
onds in the United States (World Health Organization
[WHO], 2014). The majority of suicides are preceded

by warning signs, either verbal or behavioral (WHO,
2014).

Healthcare organizations have been identified by
the U.S Surgeon General as a setting that can impact
suicide rates (U.S. Department of Health and Human
Services, 2012). Many people who die by suicide present
to healthcare organizations for nonbehavioral health

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