PHQ and SCS Working Together to Improve Suicide Risk Detection

Posted December 14, 2021

Craig J. Bryan, PsyD, ABPP, University of Utah / The Ohio State University

Suicide is a leading cause of death among military personnel, and over the past 20 years the U.S. suicide rate has steadily increased by more than 33%.1,2 Nearly half of individuals who die by suicide see a primary care provider in the month preceding their death, which suggests that enhanced screening within primary care settings may improve suicide prevention efforts.2,3 However, current screening methods are insufficient due to false positives and false negatives, which can lead to unnecessary treatment and/or misallocation of limited resources.4,5

Craig J. Bryan, PsyD, ABPP, University of Utah The Ohio State University Dr. Craig Bryan

With Defense Medical Research and Development Program funds from a Military Operational Medicine Research Program Fiscal Year 2013 Applied Research and Advanced Technology Development Psychological Health Award, Dr. Craig Bryan and his team endeavored to develop a brief alert algorithm that could be used by primary care providers to accurately identify high-risk patients and to improve the accuracy of universal suicide prevention screening methods by reducing false-negative rates across various patient population subgroups. Dr. Bryan incorporated a shortened version of the Suicide Cognitions Scale (SCS), commonly endorsed by suicidal individuals, into the Patient Health Questionnaire-9 (PHQ-9) to better identify highest-risk patients.6 The SCS was selected for testing due to prior research showing that SCS item responses prospectively distinguish patients who attempt suicide from those with suicide ideation only.7 Over 2,700 eligible patients, recruited from six military primary care clinics located at five military installations around the U.S., completed self-report measures including the PHQ-9 and 16 items from the SCS during routine primary care clinic visits. Dr. Bryan found that multiple SCS items differentiated patients with suicidal behavior less than 30 days after screening positive for suicide risk.8 Importantly, supplementing the PHQ-9 suicide risk item with SCS items improved the identification of primary care patients who were most likely to engage in suicidal behavior within a month of screening positive.8

Further testing of a two-item screening battery is needed to validate the results. Meanwhile, findings strongly suggest that the accuracy of item 9 in the PHQ-9 can be meaningfully improved with the addition of a single item from the SCS, offering primary care providers a simple, more reliable tool to identify patients at imminent risk for suicide.

If you or someone you know is experiencing thoughts of suicide, please contact the Military Crisis Line by texting 838255, calling 1-800-273-8255, or starting a confidential chat at


Public and Technical Abstracts: Improving Universal Suicide Prevention Screening in Primary Care by Reducing False Negatives


Bryan CJ, Allen MH, Thomsen CJ, et al. 2021. Improving suicide risk screening to identify the highest risk patients: Results from the PRImary Care Screening Methods (PRISM) study. Ann Fam Med 19(6):492-498. doi: 10.1370/afm.2729.

Bryan CJ, Allen MH, Thomsen CJ, et al. 2019. Rationale and design of the PRImary care Screening Methods (PRISM) study. Contemp Clin Trials 84:105823. doi: 10.1016/j.cct.2019.105823.

Bryan CJ, Bryan AO, Anestis MD, et al. 2019. Firearm availability and storage practices among military personnel who have thought about suicide. JAMA Network Open 2(8):e199160. doi: 10.1001/jamanetworkopen.2019.9160.

Bryan CJ, Bryan AO, May AM, et al. 2021. Depression, suicide risk, and declining to answer firearm-related survey items among military personnel and veterans. Suicide Life Threat Behav 51(2):197-202. doi: 10.1111/sltb.12694. PMID: 33876490.

Bryan CJ, May AM, Thomsen CJ, et al. 2021. Psychometric evaluation of the suicide cognitions scale-revised (SCS-R). Military Psychology doi: 10.1080/08995605.2021.1897498.


1Stone DM, Simon TR, Fowler KA, et al. 2018. Vital signs: Trends in state suicide rates--United States, 1999–2016 and circumstances contributing to suicide--27 states, 2015. MMWR Morb Mortal Wkly Rep 67(22):617-624.

2Trofimovich L, Skopp NA, Luxton DD, and Reger MA. 2012. Health care experiences prior to suicide and self-inflicted injury, active component, U.S. Armed Forces, 2001-2010. MSMR 19:2-6.

3Luoma JB, Martin CE, and Pearson JL. 2002. Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry 159:909-916.

4Louzon SA, Bossarte R, McCarthy JF, and Katz IR. 2016. Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? Psychiatric Serv 67:517-522.

5Simon GE, Rutter CM, Peterson D, et al. 2013. Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death? Psychiatric Serv 64:1195-1202.

6Bryan CJ, Rudd MD, Wertenberger E, et al. 2014. Improving the detection and prediction of suicidal behavior among military personnel by measuring suicidal beliefs: An evaluation of the Suicide Cognitions Scale. J Affective Dis 159:15-22.

7Bryan CJ, Rozek DC, and Khazem LR. 2020. Prospective validity of the Suicide Cognitions Scale among acutely suicidal military personnel seeking unscheduled psychiatric intervention. Crisis 41(5):407-411.

8Bryan CJ, Allen MH, Thomsen CJ, et al. 2021. Improving suicide risk screening to identify the highest risk patients: Results from the PRImary Care Screening Methods (PRISM) study. Ann Fam Med 19(6):492-498. doi: 10.1370/afm.2729.

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Last updated Thursday, May 26, 2022