Identifying Subgroups of Youth Suicide Decedents Based on Clinical Profiles of Psychiatric and Medical Diagnoses: A Latent Class Analysis.

PURPOSE: To identify risk subgroups of youth suicide decedents using demographic and clinical psychiatric and medical diagnostic profiles to inform tailored youth suicide prevention efforts. METHODS: This study linked Ohio Medicaid and death certificate data for Medicaid enrolled youth aged 8-25 years who died by suicide between January 1, 2010, and December 31, 2020 (N = 511). Latent class analysis was used to identify distinct clinical risk subgroups. RESULTS: Three latent classes were identified. Internalizing problems were common across all classes, but especially prevalent in class 1, the High Internalizing + Multiple Comorbidities group (n = 152, 30%). A prior history of suicidal behavior was confined to class 1 decedents, who were otherwise characterized by substance misuse, and multiple psychiatric and medical comorbidities. Class 2 decedents, the Internalizing + Externalizing group (n = 176, 34%), were more often younger, male, Black, and unlikely to have a history of substance misuse. Decedents in class 3, the Internalizing + Substance Misuse group (n = 183, 36%), were more often older and likely to have a history of substance misuse, but unlikely to exhibit other externalizing problems. DISCUSSION: Internalizing psychopathology is particularly common among youth who die by suicide, with comorbid externalizing psychopathology, substance misuse, and medical problems contributing to youth suicide risk. Because less than a third of youth who die by suicide have a prior history of recognized suicidal thinking or behavior, universal screening for youth suicide risk should be considered, particularly in younger children, and efforts to integrate suicide prevention in traditional health care settings should be prioritized.

Suicide in young people: screening, risk assessment, and intervention.

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

Spatiotemporal Patterns of Deaths of Despair Across the U.S., 2000-2019.

INTRODUCTION: Deaths of despair (i.e., suicide, drug/alcohol overdose, and chronic liver disease and cirrhosis) have been increasing over the past 2 decades. However, no large-scale studies have examined geographic patterns of deaths of despair in the U.S. This ecologic study identifies geographic and temporal patterns of individual and co-occurring clusters of deaths of despair. METHODS: All individuals aged ≥10 years who died in the U.S. between 2000 and 2019 and resided within the 48 contiguous states and Washington, District of Columbia were included (N=2,171,105). Causes of death were limited to deaths of despair, namely suicide, drug/alcohol overdose, and chronic liver disease and cirrhosis. Univariate and multivariate space-time scan statistics were used to identify individual and co-occurring clusters with excess risk of deaths of despair. County-level RRs account for heterogeneity within each cluster. Analyses were conducted from late 2021 to early 2022. RESULTS: Six suicide clusters, four overdose clusters, nine liver disease clusters, and three co-occurring clusters of all three types of deaths were identified. A large portion of the western U.S., southeastern U.S., and Appalachia/rust belt were contained within the co-occurring clusters. The co-occurring clusters had average county RRs ranging from 1.17 (p<0.001) in the southeastern U.S. to 4.90 (p<0.001) in the western U.S. CONCLUSIONS: Findings support identifying and targeting risk factors common to all types of deaths of despair when planning public health interventions. Resources and policies that address all deaths of despair simultaneously may be beneficial for the areas contained within the co-occurring high-risk clusters.

How can social workers facilitate suicide prevention in primary care? Findings from a national survey of primary care physicians.

There are currently no national data regarding U.S. Primary Care Physicians' (PCPs') suicide screening practices. This study surveyed 302 U.S. PCPs about their current suicide screening practices to identify service gaps and intervention points for social workers. Although one-third of PCPs reported providing screening and safety planning, few were using evidence-based tools. Factors that increased the likelihood of routine screening were belief in the importance of screening (p < .01), time (p < .01), and access to co-located behavioral health (p < .01). Findings support the role of social workers in primary care and suggest areas for training and collaboration.

Youth Suicide During the First Year of the COVID-19 Pandemic.

OBJECTIVE: To identify potential differential changes in youth suicide deaths associated with the coronavirus disease (COVID-19) pandemic to better inform suicide prevention strategies. METHODS: This cross-sectional study analyzed national suicide data for US youth aged 5 to 24 years from 2015 to 2020. Annual and monthly numbers of suicides were extracted overall and by sex, age, race and ethnicity, and method. Expected suicides were modeled from the trend in monthly deaths before COVID-19 (January 1, 2015-February 29, 2020), by using interrupted time-series analyses with quasi-Poisson regression. Rate ratios (RR) and corresponding 95% confidence intervals (CI) were used to compare expected and observed suicides during the first 10 months of COVID-19 (March 1, 2020-December 31, 2020). RESULTS: Among 5568 identified youth suicides during the 2020 pandemic, 4408 (79.2%) were male, 1009 (18.1%) Hispanic, 170 (3.3%) non-Hispanic American Indian/Alaska Native, 262 (4.7%) Asian/Pacific Islander, 801 (14.4%) Black, and 3321 (59.6%) white. There was a significant increase in overall observed versus expected youth suicides during the COVID-19 pandemic (RR = 1.04, 95% CI = 1.01-1.07), equivalent to an estimated 212 excess deaths. Demographic subgroups including males (RR = 1.05, 95% CI = 1.02-1.08), youth aged 5 to 12 years (RR = 1.20, 95% CI = 1.03-1.41) and 18 to 24 years (RR =1.05, 95% CI = 1.02-1.08), non-Hispanic AI/AN youth (RR = 1.20, 95% CI = 1.03-1.39), Black youth (RR = 1.20, 95% CI = 1.12-1.29), and youth who died by firearms (RR = 1.14, 95% CI = 1.10-1.19) experienced significantly more suicides than expected. CONCLUSIONS: Suicide deaths among US youth increased during COVID-19, with substantial variation by sex, age, race and ethnicity, and suicide method. Suicide prevention strategies must be tailored to better address disparities in youth suicide risk.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis.

OBJECTIVE: Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP). METHODS: A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates. RESULTS: Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH. CONCLUSIONS: These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

Racial Differences in Emergency Department Visit Characteristics and Management of Preadolescents at Risk of Suicide.

OBJECTIVE: Suicide rates and frequency of pediatric emergency department (ED) visits for suicidal thoughts and behaviors have increased among Black preadolescents in the United States in recent years. This study examined whether characteristics of ED visits and treatment management of preadolescents with suicidal thoughts and behaviors differed by race. METHODS: An electronic medical record query identified patients ages 8-12 (N=504) who visited a pediatric ED with a psychiatric-related chief complaint in 2019. The authors examined suicidal thoughts and behaviors that were reported with the Ask Suicide-Screening Questions tool, ED clinical impression, and ED disposition overall and by race. RESULTS: Compared with other racial groups, Black preadolescents were less likely to report suicidal thoughts, despite equivalent lifetime histories of suicide attempts, and were more likely to be brought to the ED by police and discharged (instead of being admitted to inpatient psychiatric care). CONCLUSIONS: Research to better understand racial disparities in suicide risk among preadolescents can inform prevention efforts.

Editorial: The Enigma of Suicide Risk in Childhood and Its Evolution Across Development.

The problem of suicide can appear incomprehensible at any stage of the life cycle, but little is more puzzling than suicidal thinking and behavior in young children. Despite preadolescent suicide being rare in comparison to suicide later in life, it is the fifth leading cause of death for children ages 5 to 12 in the United States1 and a serious public health problem deserving of study. The study of preadolescent suicide risk also has potential to inform our understanding of suicide across the lifespan. In an important effort to expand our limited understanding of the developmental aspects of suicidal thoughts and behaviors (STBs), Whalen and colleagues2 report on the longitudinal trajectories of STBs for a sample of more than 300 preschool children recruited between the ages of 3 and 6 years and followed prospectively through age 17 years. Longitudinal studies allow researchers to collect more detailed information than could be obtained from a single cross-sectional survey and can offer insights into how psychopathology and associated risks evolve over time. This study is relatively unique in prospectively assessing STBs and associated risk and protective factors from the preschool period through adolescence.

Mortality and Cause of Death Among Youths Previously Incarcerated in the Juvenile Legal System.

Importance: More than 50 000 youths are incarcerated in the United States on any given day, and youth incarceration has been linked to lasting adverse outcomes, including early mortality. Improving our understanding of the factors associated with early mortality among incarcerated youths can inform appropriate prevention strategies. Objective: To examine mortality rates and causes of death among youths previously incarcerated in the juvenile legal system. Design, Setting, and Participants: This retrospective longitudinal population-based cohort study compared mortality rates between youths aged 11 to 21 years incarcerated from 2010 to 2017 with same-aged nonincarcerated Medicaid-enrolled youths in the state of Ohio. Data from January 2017 to December 2019 were collected from juvenile incarceration, Medicaid, and death certificate information in Ohio. Exposure: Incarceration in the state of Ohio's juvenile legal system. Main Outcomes and Measures: Number, characteristics, and causes of deaths. Poisson regression incidence rate ratios (IRRs) compared mortality rates between previously incarcerated and Medicaid-enrolled youths. Results: Among 3645 incarcerated youths, 3398 (93.2%) were male, 2155 (59.1%) Black, 1307 (35.9%) White, and 183 (5.0%) other race and ethnicity. Overall, 113 youths (3.1%) died during the study period. Homicide was the leading cause of death in formerly incarcerated youths (homicide: 63 [55.8%]; legal intervention [ie, death due to injuries inflicted by law enforcement]: 3 [2.7%]). All-cause mortality rates were significantly higher among previously incarcerated youths than Medicaid-enrolled youths (adjusted IRR [aIRR], 5.91; 95% CI, 4.90-7.13) in every demographic subgroup. Compared with Medicaid-enrolled youths, mortality rates for previously incarcerated youths were highest for homicide (aIRR, 11.02; 95% CI, 8.54-14.22), overdose (aIRR, 4.32; 95% CI, 2.59-7.20), and suicide (aIRR, 4.30; 95% CI, 2.22-8.33). Formerly incarcerated Black youths had a significantly higher risk of homicide (aIRR, 14.24; 95% CI, 4.45-45.63) but a lower risk of suicide (aIRR, 0.18; 95% CI, 0.04-0.89) and overdose (aIRR, 0.31; 95% CI, 0.10-0.99) than White youths who were incarcerated. Previously incarcerated youths aged 15 to 21 years were significantly more likely to die than youths aged 22 to 29 years, irrespective of cause of death (aIRR for youths aged 22-29 years, 0.09; 95% CI, 0.06-0.14). Conclusions and Relevance: In this study, youths with a history of incarceration were significantly more likely to experience early mortality compared with nonincarcerated Medicaid-enrolled youths. Delinquency and violence prevention strategies that incorporate a culturally informed approach and consider sex and developmental level are critical.

Characteristics and Precipitating Circumstances of Suicide Among Children Aged 5 to 11 Years in the United States, 2013-2017.

Importance: Suicide is the eighth leading cause of death among children aged 5 to 11 years, with rates increasing during the past decade. A better understanding of factors associated with childhood suicide can inform developmentally appropriate prevention strategies. Objective: To examine characteristics and precipitating circumstances of childhood suicide. Design, Setting, and Participants: This qualitative study examined restricted-use data from the National Violent Death Reporting System (NVDRS) regarding child suicide decedents aged 5 to 11 years in the US from 2013 to 2017. The NVDRS is a state-based surveillance system that collects data on suicide and violent deaths in 50 states, with restricted-use data available from 37 states. Details and context related to suicide deaths were identified through a content analysis of case narratives from coroner or medical examiner and law enforcement reports associated with each incident. Exposures: Characteristics and precipitating circumstances associated with suicide cited in the coroner, medical examiner, and law enforcement case narratives. Main Outcomes and Measures: Suicide incidence and risk factors for suicide including mental health, prior suicidal behavior, trauma, and peer, school, or family-related problems. Results: Analyses included 134 child decedents (101 [75.4%] males; 79 [59.0%] White individuals; 109 [81.3%] non-Hispanic individuals; mean [SD] age, 10.6 [0.8] years). Most suicides occurred in the child's home (95.5% [n = 128]), and more specifically in the child's bedroom. Suicide by hanging or suffocation (78.4% [n = 105]) was the most frequent method, followed by firearms (18.7% [n = 25]). Details on gun access were noted in 88.0% (n = 22) of suicides by firearm, and in every case, the child obtained a firearm stored unsafely in the home. Findings revealed childhood suicide was associated with numerous risk factors accumulated over time, and suggest a progression toward suicidal behavior, especially for youth with a history of psychopathology and suicidal behavior. An argument between the child and a family member and/or disciplinary action was often a precipitating circumstance of the suicide. Conclusions and Relevance: This qualitative study found that childhood suicide was associated with multiple risk factors and commonly preceded by a negative precipitating event. Potential prevention strategies include improvements in suicide risk assessment, family relations, and lethal means restriction, particularly safe firearm storage. Future research examining the myriad aspects of childhood suicide, including racial/ethnic and sex differences, is needed.

Universal suicide risk screening: Views of rural adults on acceptability and implementation in primary care.

OBJECTIVE: This study gathered data from rural adult primary care patients regarding the acceptability of universal suicide risk screening and preferred methods of implementation. METHOD: Patients from a rural primary care clinic in southern West Virginia participating in a pilot test of a suicide risk screening program were administered a Screening Opinions Survey and resulting data were evaluated using descriptive and content analyses. RESULTS: The majority of participants (96%) believed that primary care providers (PCPs) should screen patients for suicide and noted multiple benefits to screening. Most participants described the experience of screening in primary care as positive or neutral and preferred a personalized screening process where the provider asked questions directly. Demographic analyses indicated that males and older adults were less likely to report being previously screened for suicide and that older adults were less likely to support the practice of screening. CONCLUSIONS: Results provide support for the acceptability of universal suicide risk screening programs to patients in rural primary care and suggest that PCP involvement in the screening process may encourage patient participation. Additional training for PCPs and psychoeducational interventions for older adults may help to address demographic influences on screening practices and engagement.

Health Services Use by Children in the Welfare System Who Died by Suicide.

OBJECTIVES: To examine characteristics and health service use patterns of suicide decedents with a history of child welfare system involvement to inform prevention strategies and reduce suicide in this vulnerable population. METHODS: A retrospective matched case-control design (120 suicide decedents and 1200 matched controls) was implemented. Suicide decedents included youth aged 5 to 21 who died by suicide and had an open case in Ohio's Statewide Automated Child Welfare Information System between 2010 and 2017. Controls were matched to suicide decedents on sex, race, and ethnicity. Comparisons were analyzed by using conditional logistic regressions to control for matching between the suicide and control groups. RESULTS: Youth in the child welfare system who died by suicide were significantly more likely to experience out-of-home placements and be diagnosed with mental and physical health conditions compared with controls. Suicide decedents were twice as likely to access mental health services in the 1 and 6 months before death, regardless of the health care setting. A significantly higher percentage of suicide decedents used physical health services 6 months before their death or index date. Emergency department visits for both physical and mental health conditions were significantly more likely to occur among suicide decedents. CONCLUSIONS: Suicide decedents involved in the child welfare system were more likely to use both mental and physical health care services in the months before their death or index date. Findings suggest that youth involved in the child welfare system may benefit from suicide prevention strategies in health care settings.

Association of Cannabis Use With Self-harm and Mortality Risk Among Youths With Mood Disorders.

Importance: Cannabis use and cannabis use disorder (CUD) are common among youths and young adults with mood disorders, but the association of CUD with self-harm, suicide, and overall mortality risk is poorly understood in this already vulnerable population. Objective: To examine associations of CUD with self-harm, suicide, and overall mortality risk in youths with mood disorders. Design, Setting, and Participants: A population-based retrospective cohort study was performed using Ohio Medicaid claims data linked with death certificate data. The analysis included 204 780 youths (aged 10-24 years) with a diagnosis of mood disorders between July 1, 2010, and December 31, 2017, who were followed up to 365 days from the index diagnostic claim until the end of enrollment, the self-harm event, or death. Statistical analysis was performed from April 4 to July 17, 2020. Exposure: Physician-diagnosed CUD defined using outpatient and inpatient claims from 180 days prior to the index mood disorder diagnostic claim through the 365-day follow-up period. Main Outcomes and Measures: Nonfatal self-harm, all-cause mortality, and deaths by suicide, unintentional overdose, motor vehicle crashes, and homicide. Marginal structural models using inverse probability weights examined associations between CUD and outcomes. Results: This study included 204 780 youths (133 081 female participants [65.0%]; mean [SD] age at the time of mood disorder diagnosis, 17.2 [4.10] years). Cannabis use disorder was documented for 10.3% of youths with mood disorders (n = 21 040) and was significantly associated with older age (14-18 years vs 10-13 years: adjusted risk ratio [ARR], 9.35; 95% CI, 8.57-10.19; and 19-24 years vs 10-13 years: ARR, 11.22; 95% CI, 10.27-12.26), male sex (ARR, 1.79; 95% CI, 1.74-1.84), Black race (ARR, 1.39; 95% CI, 1.35-1.44), bipolar or other mood disorders (bipolar disorders: ARR, 1.24; 95% CI, 1.21-1.29; other mood disorders: ARR, 1.20; 95% CI, 1.15-1.25), prior history of self-harm (ARR, 1.66; 95% CI, 1.52-1.82), previous mental health outpatient visits (ARR, 1.26; 95% CI, 1.22-1.30), psychiatric hospitalizations (ARR, 1.66; 95% CI, 1.57-1.76), and mental health emergency department visits (ARR, 1.54; 95% CI, 1.47-1.61). Cannabis use disorder was significantly associated with nonfatal self-harm (adjusted hazard ratio [AHR], 3.28; 95% CI, 2.55-4.22) and all-cause mortality (AHR, 1.59; 95% CI, 1.13-2.24), including death by unintentional overdose (AHR, 2.40; 95% CI, 1.39-4.16) and homicide (AHR, 3.23; 95% CI, 1.22-8.59). Although CUD was associated with suicide in the unadjusted model, it was not significantly associated in adjusted models. Conclusions and Relevance: Cannabis use disorder is a common comorbidity and risk marker for self-harm, all-cause mortality, and death by unintentional overdose and homicide among youths with mood disorders. These findings should be considered as states contemplate legalizing medical and recreational marijuana, both of which are associated with increased CUD.

Neurocognitive vulnerability to youth suicidal behavior.

Neurocognitive deficits have been associated with suicidal behavior in adults with major depressive disorder (MDD), but it is unclear if similar impairments are linked to youth suicidal behavior. This study compared neurocognitive functioning in suicidal and non-suicidal youth with a lifetime history of MDD and explored whether neurocognitive functioning predicted future suicide attempts. Neurocognition was examined using the Cambridge Neuropsychological Test Automated Battery (CANTAB) and Iowa Gambling Task (IGT) in 309 youths ages 12-15 (117 suicide attempters; 132 suicidal ideators; 60 never-suicidal). Prospective analyses included 284 youths (41 youth with a future attempt; 243 without a future attempt). Multivariate analysis of variance (MANOVA) yielded a significant group-by-sex interaction effect [Wilks' Λ = 0.901, F (16, 560) = 1.87, p = .021] for the primary neurocognitive outcomes, guiding the decision to stratify the sample by sex. Female suicide attempters and ideators were slower to respond correctly to both positive and negative emotion words than never-suicidal controls on tests of affective bias. Male suicide attempters and ideators made significantly more total and between errors than never-suicidal subjects. Exploratory analyses found that total commission errors on the Affective Go/No-Go (AGN) test significantly predicted future suicide attempts in females, and that higher strategy scores on Spatial Working Memory (SWM) tests predicted future male attempts. Study findings identified sex-specific neurocognitive deficits that differentiate suicidal and non-suicidal youth with histories of MDD. Extended longitudinal studies are needed to elucidate the temporal association between neurocognitive impairments and suicidal behavior and frame targets for early preventive interventions.

Association of Timely Outpatient Mental Health Services for Youths After Psychiatric Hospitalization With Risk of Death by Suicide.

Importance: Timely outpatient follow-up care after psychiatric hospitalization is an established mental health quality indicator and considered an important component of suicide prevention, yet little is known about whether follow-up care is associated with a reduced risk of suicide soon after hospital discharge. Objective: To evaluate whether receipt of outpatient care within 7 days of psychiatric hospital discharge is associated with a reduced risk of subsequent suicide among child and adolescent inpatients and examine factors associated with timely follow-up care. Design, Setting, and Participants: This population-based, retrospective, longitudinal cohort study used Medicaid data from 33 states linked with National Death Index data. The study population included all youths aged 10 to 18 years who were admitted to a psychiatric hospital from January 1, 2009, to December 31, 2013. Data analysis was completed from October 9, 2019, through May 15, 2020. Exposure: Mental health follow-up visits received within 7 days of hospital discharge. Main Outcomes and Measures: Suicides occurring in the 8 to 180 days after hospital discharge. Logistic regression modeled the association between demographic, clinical, and mental health service history factors and receipt of an outpatient visit within 7 days after discharge. Poisson regression estimated the association between suicide risk and outpatient visits within 7 days after discharge, adjusting for confounding using inverse probability of treatment weights from the logistic model. Results: Of the total 139 694 youths admitted to a psychiatric hospital, 51.9% were female, 31.1% were aged 10 to 13 years, and 68.9% were aged 14 to 18 years. A total of 56.5% of the youths received a mental health follow-up visit within 7 days of discharge, and this was associated with a significantly lower odds of suicide (adjusted relative risk, 0.44; 95% CI, 0.23-0.83; P = .01) during the 8 to 180 days postdischarge period. Youths with longer lengths of stay (4-5 days: adjusted odds ratio [AOR], 1.20 [95% CI, 1.17-1.24]; 6-7 days: AOR, 1.47 [95% CI, 1.43-1.52]; 8-12 days AOR, 1.75 [95% CI, 1.69-1.81]; 13-30 days: AOR, 1.71 [95% CI, 1.63-1.78]), prior outpatient mental health care (AOR, 1.58; 95% CI, 1.51-1.65), and foster care placement (AOR, 1.32; 95% CI, 1.28-1.37) were more likely to receive 7-day follow-up, whereas those who were non-Hispanic Black (AOR, 0.82; 95% CI, 0.79-0.84), were older (AOR, 0.82; 95% CI, 0.80-0.84), were medically ill (AOR, 0.77; 95% CI, 0.74-0.81), and had managed care insurance (AOR, 0.88; 95% CI, 0.87-0.91) were less likely to receive follow-up visits. Conclusions and Relevance: In this cohort study, risk of suicide during the 6 months after psychiatric hospitalization was decreased among youth who had an outpatient mental health visit within 7 days after discharge. Addressing disparities in timely continuity of care may help advance health equity agendas.

The Feasibility and Impact of a Suicide Risk Screening Program in Rural Adult Primary Care: A Pilot Test of the Ask Suicide-Screening Questions Toolkit.

OBJECTIVE: The purpose of this study was to evaluate the feasibility and impact of a suicide risk screening program in a rural West Virginia primary care practice. METHODS: Patients presenting for routine and sick visits were asked to participate in electronic suicide risk screening using the Ask Suicide-Screening Questions tool; screen positive individuals were assessed with the Ask Suicide-Screening Questions Brief Suicide Safety Assessment. Screening program feasibility was evaluated by the proportion of patients consenting to participate, participant Ask Suicide-Screening Questions and Brief Suicide Safety Assessment completion rates, and response to a question asking whether primary care providers should ask about suicide. Screening impact was evaluated quasi-experimentally by comparing electronic medical record documentation of suicide risk screening, assessment, and risk determination in practice patients before and after implementing the screening program. RESULTS: Over half of the patients approached agreed to participate in a research study about suicide (N = 196; 57.7%). Feasibility of the screening program was demonstrated by the high completion rates for the Ask Suicide-Screening Questions (99.0%) and the Brief Suicide Safety Assessment (100.0%) among study participants. Additionally, 95.4% (N = 187) of participants agreed primary care providers should screen patients for suicide. Suicide screening rates rose significantly between the baseline and intervention phases (5.8% to 61.0%; X2 = 200.61, P < 0.001), as did suicide risk detection rates (0.7% to 6.2%; X2 = 12.58, P < 0.001). CONCLUSION: Suicide risk screening was feasible and well accepted by adult patients in rural primary care and has potential to improve suicide risk detection in this setting.