Limitations of Universal Suicide Risk Screening: Accuracy of Disclosure Among Veterans Screened in Veterans Health Administration Mental Health Settings

Background Prior studies show that inaccurate disclosure of suicidal thoughts is common in health care settings. Little is known about disclosure in the context of universal suicide risk screening programs. This project sought to characterize the frequency of inaccurate disclosure of suicidal ideation during universal suicide risk screening and immediate follow-up in Veterans Health Administration (VHA) mental health settings and to identify predictors of inaccurate disclosure. Methods We conducted a national survey study with linkage to VHA electronic medical records. Analyses incorporated weighting for response and patient characteristics. Seven hundred ninety-two veterans receiving VHA mental health specialty care participated. The survey included questions inquiring about the extent to which participants had responded accurately when asked about suicidal thoughts during screening visits. Results In weighted analyses, 38.1% of screen-negative and 45.8% of screen-positive participants reported responding less than “very accurately” to screening questions. Characteristics associated with less accurate disclosure in both groups included lower beliefs that suicide is not a way out (screen-positive: OR=0.46; 95% CI=0.28-0.77; screen-negative: OR=0.40; 95% CI=0.2-0.79) and greater concern for overreaction (screen-positive: OR=2.36; 95% CI=1.35-4.11; screen-negative: OR=3.73; 95% CI=1.71-8.13). Conclusions Inaccurate disclosure during VHA universal suicide risk evaluation occurs with modest frequency. The results highlight that mental health clinicians and care systems should not overly rely on screening results and suggest that screening accuracy may be improved using a patient-centered approach including orientation of patients to the screening process.