Originally Published: September 26, 2025
Updated: June 16, 2026
Suicide Screening Protocol
This screening protocol aligns with, but is more comprehensive than, recommendations from the American College of Obstetricians and Gynecologists and MCPAP for Moms. It includes steps that keep mothers safe and prevent automatic referral to the ER and/or Child Protective Services -practices which can do more harm than good.
1. Conduct a mental health history
The Policy Center developed this form to be used by maternity care providers. This mental health history will help identify prior suicide attempts and other risk factors.
2. Screen using the EPDS or PHQ-9
- Determine if a patient reports thoughts of harming herself on the EPDS or PHQ-9
EPDS, Q-10:
[In the past 7 days] The thought of harming myself has occurred to me.
Patient Reports:
Yes quite often or sometimes
PHQ-9:
Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead or hurting yourself in some way?
Patient Reports:
Several Days, More than Half the Days, Nearly Every Day.
Of note: A patient may have active or passive suicidal thoughts/ideation. Passive ideation involves thinking of not wanting to live or what it would be like to be dead. Active suicidal thoughts mean actively creating a plan and wanting to die. This is why further assessment is critical.
If a patient reports thoughts of harming oneself complete steps 3 and 4.
3. Assess for OCD and intrusive (unwanted) thoughts using the OCI-12 to rule out OCD.
- If the patient scores positive for OCD or intrusive thoughts (question 12) and negative for depression on the PQH-9 or EPDS, refer the patient to a therapist who specializes in OCD by referring to her health insurer and/or the International OCD Foundation directory.
- If the patient scores negative for OCD or intrusive thoughts (question 12)
-OR-
- If the patient scores positive for OCD and intrusive thoughts (question 12) and positive for depression, follow the suicide care pathway below.
4. Assess for symptoms of psychosis and mania
- If a patient exhibits signs of psychosis OR mania, direct the patient/her family to the emergency room, or if she is under the care of a psychiatrist, contact the psychiatrist, who may have her directly admitted to a psychiatric inpatient program. It is important for patients with psychosis or mania to be stabilized under the supervision of a neurologist and psychiatrist and proper diagnosis/cause be determined (not all psychosis is caused by an underlying mental health disorder like bi-polar disorder).
Suicide Care Pathway (Outpatient)
If your patient screens positive on the PHQ-9 or EPDS for suicidal thoughts and does not have intrusive thoughts/OCD without depression, and does not have mania/psychosis, follow this suicide screening and care pathway:
1. Screen for suicide ideation frequency/plan (intensity)
May be performed by a non-clinical provider
Ask Suicide Screening Questions (ASQ) (5 questions, if positive, the safety assessment below should be utilized)
-or-
Columbia Suicide Severity Rating Scale (5 questions)
2. Assess suicide risk and protective factors
Must be performed by a clinical provider; clinical judgement is required.
NIMH Suicide Safety Assessment
-or-
SAFE-T Suicide Assessment (see step 4) (Note this version combines the CCSR-S and SAFE-T)
If the patient has high risk
- Contact a mobile crisis unit (Optum has created a national list of mobile crisis units that can be utilized regardless of insurance/insurance type). Mobile crisis generally consists of a peer support worker and a licensed mental health professional trained in providing optimal suicide prevention and support.
- If she is under the care of a psychiatrist, consult with her psychiatrist, who may agree to take over her care and coordinate next steps, which could include psychiatric hospitalization or residential treatment admission.
- If a mobile crisis unit is unavailable and she is not under the care of a psychiatrist and/or the psychiatrist cannot be reached, contact her family or a trusted friend to inform them of the situation and the need for care for the children, and refer the patient to the ER. Ideally, she will agree willingly, and her family will agree to take her to the ER. If not, she can be escorted by ambulance. The hospital will have a social worker to care for children and coordinate with child protective services.
If the patient has moderate risk develop a safety plan
May be created by a non-clinical provider with the patient and ideally with family/friends (who may join by phone or come to the clinic in person).
The Stanley-Brown plan is developed in collaboration between a clinician and a client, with the goal of creating a brief, easy-to-read document that the person can reference when they feel at risk. It is designed to be a tiered approach, with the individual attempting internal strategies first, then reaching out for help, and finally contacting emergency services if the crisis continues.
Childcare for moderate risk
If the patient has young children at home, ask the mother if she has family or friends who can support her and her children at home or at a friend’s or family member’s home.
If she has support, have her contact at least one of those support persons to come to the clinic and escort her home to care for her and her children until her risk is reassessed by you or a mental health provider and determined to be low. Have the family member or friend agree to this responsibility by signing their name(s) in the safety plan containing this language.
In the case where a mother does not have a family or a friend who can support her and the children’s care, contact:
– A childcare crisis nursery or respite center. In many states/counties, 211 information lines can support these inquiries and/or finehelp.org.
– Her health insurer, to request in-home care.
– If services are not available, contact child protective services to request support, flagging that this does not warrant an investigation as you have already assessed for a child-care need.
3. Refer to psychiatry and mental health care
Contact her health insurer together, to ask that she be provided with a warm referal to a reproductive psychiatrist and therapist who provides CBT-ST, CAMS, DBT or other suicide therapies.
Learn more about evidence-based therapies here.
4. Document the steps taken, including screening and assessment results
More Critical Considerations:
Antidepressants and SSRIs may Increase Suicidal Thoughts in Some Patients
Research indicates a connection between increased suicidal thoughts and tendencies and taking antidepressants or selective serotonin reuptake inhibitors (SSRIs). In 2004, the U.S. Food and Drug Administration (FDA) issued a Black Box warning for antidepressants in adolescents and young adults up to age 24. The risk appears to be highest in the first few weeks of treatment so patients who are prescribed an antidepressant or SSRI should be informed of the possibility of worsening symptoms and suicidal thoughts in the early weeks, and medications should be adjusted should symptoms occur.
ERs May Cause More Harm than Good
ERs are typically not equipped to provide suicide care or assessment, as noted above. ERs generally have a psychiatrist evaluate a woman to determine if she can be released or should be sent to a psychiatric unit, which can take up to 72 hours. Women are put in hospital gowns, may lose their phones, and may not be able to see their babies or family members during this time. These experiences can inadvertently cause patients more harm than good. Outpatient providers can and should conduct the ER screening and assessment above, and develop safety plans with patients.
Referrals to Child Protective Services Are Traumatizing for Women and Families
Federal law, the Child Abuse Prevention and Treatment Act (CAPTA), and corresponding state law created a system in which healthcare providers and others are classified as “mandatory reporters” of potential child abuse or neglect. Some clinicians may err on the side of referring cases to child protective services (CPS) rather than offering appropriate mental health care. CPS investigations generally involve law enforcement approaching the family at an unsuspecting time, such as the middle of the night. Older children may be called out of class at school and examined by law enforcement. These investigations are traumatizing for the entire family, and do not lead to additional parental support in the home. Referrals to CPS should only be made when there is a genuine concern for the safety of the baby/children at home. Fear of CPS involvement should never prevent a parent from seeking mental health treatment. Given mental health conditions and suicidal ideation can impact a parent’s ability to parent their children optimally, treatment is essential to enable parents to provide stable and nurturing environments to their children.
Free Training
Though training is not required to administer the suicide intensity screeners, such as the C-SSRS or ASQ, it can be helpful.
Watch a webinar on your own schedule by going to the Columbia University C-SSRS Light House Project’s YouTube channel and selecting an archived webinar. They are available in 30 languages and are less than an hour long.
This 5 minute video on assessment of risk is also a helpful resource.
Editorial Note: This article was first published September 26, 2025, and was updated to include language describing active vs. passive suicidal thoughts, the important step of assessing whether there is and how to find support to care for infants and children when a parent has higher risk for suicidality, and opportunities to refine referral to Child Protectiive Services which investigates whether a child is safe, but does not coordinate securing services to keep mothers and families together and safe.
