Risk Model–Guided Clinical Decision Support for Suicide Screening
Authors: Walsh Colin G. , Ripperger Michael A. , Novak Laurie , Reale Carrie , Anders Shilo , Spann Ashley , Kolli Jhansi , Robinson Katelyn , Chen Qingxia , Isaacs David , Acosta Lealani Mae Y. , Phibbs Fenna , Fielstein Elliot , Wilimitis Drew , Musacchio Schafer Katherine , Hilton Rachel , Albert Dan , Shelton Jill , Stroh Jessica , Stead William W. , Johnson Kevin B. 
Published: January 2025

ImportanceSuicide prevention requires risk identification, intervention, and follow-up. Traditional risk identification relies on patient self-reporting, support network reporting, or face-to-face screening. Statistical risk models have been studied and some have been deployed to augment clinical judgment. Few have been tested in clinical practice via clinical decision support (CDS). Barriers to effective CDS include potential alert burden for a stigmatized clinical problem and lack of data on how best to integrate scalable risk models into clinical workflows.ObjectiveTo evaluate the effectiveness of risk model–driven CDS on suicide risk assessment.Design, Setting, and ParticipantsThis comparative effectiveness randomized clinical trial was performed from August 17, 2022, to February 16, 2023, in the Department of Neurology across the divisions of Neuro-Movement Disorders, Neuromuscular Disorders, and Behavioral and Cognitive Neurology at Vanderbilt University Medical Center, an academic medical center in the US Mid-South. Patients scheduled for routine care in those settings were randomized at visit check-in. Follow-up was completed March 16, 2023, and data were analyzed from April 11 to July 24, 2023. Analyses were based on intention to treat.InterventionsInterruptive vs noninterruptive CDS to prompt further suicide risk assessment using a real-time, validated statistical suicide attempt risk model. In the interruptive CDS, an alert window via on-screen pop-up and a patient panel icon were visible simultaneously. Dismissing the alert hid it with no effect on the patient panel icon. The noninterruptive CDS showed the patient panel icon without the pop-up alert. When present, the noninterruptive CDS displayed “elevated suicide risk score” in the patient summarization panel. Hovering over this icon resulted in a pop-up identical to the interruptive CDS.Main Outcomes and MeasuresThe main outcome was the decision to assess risk in person. Secondary outcomes included rates of suicidal ideation and attempts in both treatment arms and baseline rates of documented screening during the prior year. Manual medical record review of every trial encounter was used to determine whether suicide risk assessment was subsequently documented.ResultsA total of 561 patients with 596 encounters were randomized to interruptive or noninterruptive CDS in a 1:1 ratio (mean [SD] age, 59.3 [16.5] years; 292 [52%] women). Adjusting for clinician cluster effects, interruptive CDS led to significantly higher numbers of decisions to screen (121 of 289 encounters [42%]) compared with noninterruptive CDS (12 of 307 encounters [4%]) (odds ratio, 17.70; 95% CI, 6.42-48.79; P &amp;lt; .001) and compared with the baseline rate the prior year (64 of 832 encounters [8%]). No documented episodes of suicidal ideation or attempts occurred in either arm.Conclusions and RelevanceIn this randomized clinical trial of interruptive and noninterruptive CDS to prompt face-to-face suicide risk assessment, interruptive CDS led to higher numbers of decisions to screen with documented suicide risk assessments. Well-powered large-scale trials randomizing this type of CDS compared with standard of care are indicated to measure effectiveness in reducing suicidal self-harm.Trial RegistrationClinicalTrials.gov Identifier: NCT05312437