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New Study: An Accurate Subtle Screening of Suicidal Ideation

The SSSI is an effective screener for use in assessment and psychiatric triage.

Key points

  • Discomfort with and avoidance of disclosing suicidal ideation means its accurate detection can be difficult.
  • Via proxy items, a subtle screening for suicidal ideation accurately identifies those with suicidal thoughts.
  • The new SSSI can provide professionals with sound data that leads to good clinical decision-making.
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Suicidal thoughts plague up to 10 million U.S. adults annually, and 49,476 Americans died by suicide in 2022. For every death by suicide, there are an estimated 25 nonfatal attempts in adults and 100-200 attempts in youth (Drapeau & McIntosh, 2020), and 54% of those dying by suicide had no known mental health condition (CDC, 2022). Suicidal ideation (SI) and suicide attempts by family members increase the suicide risk among other members by several times. Therefore, accurate detection of SI is crucial for helping professionals, but assessment experts acknowledge the challenges involved in obtaining frank, truthful answers to questions of a highly sensitive nature (Charles & Dattalo, 2018).

How does one best go about assessing phenomena often associated with guilt, shame, or embarrassment? Many persons who struggle with suicidal thoughts may not be comfortable endorsing the item “Do you have thoughts of ending your life?” They are more likely to endorse proxy items highly correlated with suicidal ideation (Killian, 2024). When conducting psychological triage and assessment (Bennett, 2018), therapists, counselors, psychologists, and behavioral health professionals may have concerns about failures to detect SI due to clients’ discomfort with disclosing thoughts of suicide. In addition, Farber et al. (2019) found that suicidal thoughts were the third most common form of ongoing deception in psychotherapy, involving processes of active lying and deliberate avoidance. In a pilot study investigating suicide survivors, stigma, and concealment, Fulginiti and Frey (2018) found that 29% of survivors did not reveal an actual suicide attempt to anyone in their family.

To address concerns about stigma and false negatives in screening for suicidal thoughts, I conducted a study to develop a 19-item subtle screening of suicidal ideation (SSSI) from a pool of 32 “proxy” items tapping psychological pain, emotional intelligence, and negative alterations in mood and cognitions. Sample items include “I couldn’t take my psychological pain anymore” and “I could not deal with my problems any longer.” Study participants, a non-random, diverse sample of U.S. adults (N = 306), completed an online demographics form, measures of suicidal ideation, anxiety, depression, and traumatic stress, and versions of the Beck hopelessness scale and the interpersonal needs questionnaire (Killian, 2024).

Via principal components analysis and reliability, correlation, and multiple regression procedures, the study’s findings demonstrated excellent reliability (α = .93) as well as convergent and discriminant validity for the subtle screening for suicidal ideation (SSSI). Specifically, the SSSI correlated with traumatic stress, anxiety, and depression as expected and did not correlate significantly with income and education. T-tests pairing all racial groups with one another demonstrated no significant difference in means on the SSSI.

In addition to reliability and validity, clinical utility is another important characteristic of an instrument such that scores inform treatment plans and therapeutic interventions (Snyder et al., 2019). Therefore, a receiver operator characteristic (ROC) curve analysis was conducted to test the SSSI’s ability to discriminate between participants with and without suicidal ideation. ROC curve analysis evaluates the diagnostic ability of scales, i.e., their ability to discriminate the “true state” of participants, and aids researchers in determining an optimal cut-off score (Hajian-Tilaki, 2013). The ROC curve analysis identified a cut-off score of 35 with a sensitivity of .937 and specificity of .81, indicating the SSSI successfully identifies those with and without suicidal thoughts (Killian, 2024). The SSSI can be utilized as a screener in mental health and therapy agencies, behavioral health centers, and in the assessment of personnel in professions with high incidences of suicide, such as the military and law enforcement.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.


Bennett, I. M. (2018). Addressing suicide risk in primary care: A next step for behavioral health integration. Families, Systems, & Health, 36(3), 402–403.

Centers for Disease Control and Prevention. (2022). Suicide rising across the US. Retrieved from

Charles, J. L. K., & Dattalo, P. V. (2018). Minimizing social desirabil- ity bias in measuring sensitive topics. Journal of Social Service Research, 44(4), 587–599. 2018.1479335

Drapeau, C.W., & McIntosh, J.L. (2020). U.S.A. suicide: 2019 official final data. American Association of Suicidology.

Farber, B.A., Blanchard, M., & Love, M. (2019). Secrets and lies in psychotherapy. American Psychological Association.

Fulginiti, A., & Frey, L.M. (2018). Suicide attempt survivorship and designation as a concealable stigmatized identity. Families in Society: The Journal of Contemporary Social Services, 99(3), 193–208.

Hajian-Tilaki, K. (2013). Receiver operating characteristic (ROC) curve analysis for medical diagnostic test evaluation. Caspian Journal of Internal Medicine, 4(2), 627–635. 1161/CIRCULATIONAHA.105.594929

Killian, K.D. (2024). Development of a subtle screening of suicidal ideation: Psychometric characteristics and implications for family therapists. Contemporary Family Therapy. Advanced online publication.

Snyder, D. K., Heyman, R. E., Haynes, S. N., Carlson, C. I., & Balder- rama-Durbin, C. (2019). Couple and family assessment. In B. H. Fiese, M. Celano, K. Deater-Deckard, E. N. Jouriles, & M. A. Whisman (Eds.), APA handbook of contemporary family psychology: Family therapy and training (pp. 35–51). American Psychological Association.

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