Screening and Evaluation » Screening
With regard to selecting a universal screening tool, we suggest the use of the Patient Health Questionnaire-9 (PHQ-9) item 9, to identify suicide risk.
Grades and Definitions
- Strong for
- or "We recommend offering this option …"
- Weak for
- or "We suggest offering this option …"
- No recommendation
- or "There is insufficient evidence …"
- Weak against
- or "We suggest not offering this option …"
- Strong against
- or "We recommend against offering this option …"
Categories and Definitions
|Evidence Reviewed*||Recommendation Category*||Definition*|
|Reviewed||New-added||New recommendation following review of the evidence|
|New-replaced||Recommendation from previous CPG that has been carried over to the updated CPG that has been changed following review of the evidence|
|Not changed||Recommendation from previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed but the recommendation is not changed|
|Amended||Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed and a minor amendment has been made|
|Deleted||Recommendation from the previous CPG that has been removed based on review of the evidence|
|Not reviewed||Not changed||Recommendation from previous CPG that has been carried forward to the updated CPG, but for which the evidence has not been reviewed|
|Amended||Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has not been reviewed and a minor amendment has been made|
|Deleted||Recommendation from the previous CPG that has been removed because it was deemed out of scope for the updated CPG|
|*Adapted from the NICE guideline manual (2012): The guidelines manual. London: National Institute for Health and Care Excellence;2012. and Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated recommendations: An assessment of NICE clinical guidelines. Implement Sci. 2014;9:72.|
PHQ-9 item 9 screens for the presence and duration of suicidal ideation. Several studies were identified that support the use of the PHQ-9 item 9 as a universal screening instrument to identify suicide risk.
This section includes training information about the PHQ-9 item 9.
- PHQ-9 item 9 can be accessed here:
Patient Health Questionnaire-9 (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Use "✔" to indicate your answer)
Not at all Several days More than half the days Nearly every day
- Thoughts that you would be better off dead or of hurting yourself in some way
0 1 2 3
- PHQ-9 item 9 Administration Tips
- This is a self-report measure.
- The item can be administered aloud or in written format.
- A positive screen should always be followed by further assessment of suicide risk. Ensure procedures are in place to safely hand off to licensed staff when needed.
This section includes a link to the Patient Health Questionnaire instruction manual.Return to Resource Options
This section includes links to recommended articles about using the PHQ-9 item 9 in practice.
- 2020). Assessment of Rates of Suicide Risk Screening and Prevalence of Positive Screening Results Among US Veterans After Implementation of the Veterans Affairs Suicide Risk Identification Strategy. JAMA network open, 3(10). e2022531. https://doi.org/10.1001/jamanetworkopen.2020.22531 (