The ASQ (Ask Suicide-Screening Questions) is a four-item yes/no screen for suicide risk. The items ask about a current wish to be dead, feeling that oneself or one's family would be better off if the patient were dead, current thoughts of killing oneself, and any past suicide attempt. A fifth question - asked only when any of the first four is endorsed - establishes acuity by asking whether the patient is having thoughts of killing themselves right now.
Unlike symptom-severity questionnaires, the ASQ does not produce a graded score. It is a triage instrument: its single job is to sort patients into negative, non-acute positive, and acute positive screens so that scarce clinical time is directed to the patients who need a fuller suicide risk assessment. It takes around 20 seconds to administer and was designed so that nurses and non-mental-health clinicians can use it in any setting.
02 - Origin & purpose
Where it comes from.
The ASQ was developed by Lisa Horowitz and colleagues at the National Institute of Mental Health and published in 2012 in Archives of Pediatrics & Adolescent Medicine. The team evaluated 17 candidate questions in 524 patients aged 10-21 across three urban paediatric emergency departments, against the Suicidal Ideation Questionnaire as the criterion; the best-fitting model was the four-question set used today.
The driving problem was that most young people who die by suicide have contact with healthcare in the months beforehand, usually for reasons unrelated to mental health, and clinicians without psychiatric training had no feasible way to screen. NIMH now publishes the ASQ as a free toolkit with pathways for emergency, inpatient and outpatient care, and the instrument has since been validated in adults, making it one of the few suicide screens usable across the lifespan from age 10 up.
03 - Scoring & cutoffs
How scoring works.
There is no summed score. A patient screens positive if they answer yes to any of questions 1-4, or refuse to answer. A positive screen triggers question 5; a yes to question 5 is an acute positive screen indicating possible imminent risk, which requires an immediate safety assessment, keeping the patient in sight, and removal of dangerous objects. A non-acute positive screen (yes to any of 1-4 but no to 5) requires a brief suicide safety assessment (the NIMH BSSA is designed for this) before the patient leaves. A negative screen requires no further action beyond usual care.
Score
Severity
Interpretation
0–0
Negative screen
No suicide risk identified on this screen.
1–4
Positive screen
Positive screen - a brief suicide safety assessment is required to determine if a full mental health evaluation is needed.
5–5
Acute positive screen
Current suicidal thoughts indicate imminent risk; the patient requires urgent safety assessment and must not be left alone.
04 - Validation evidence
How well it performs.
In the original derivation study (n=524, ages 10-21, three paediatric EDs), the four-item ASQ had sensitivity 96.9% (95% CI 91.3-99.4) and specificity 87.6% (95% CI 84.0-90.5) against the SIQ, with negative predictive value 99.7% in medical/surgical patients and 96.9% in psychiatric patients. In 727 adult medical inpatients (Horowitz et al., 2020), sensitivity was 100% (95% CI 90-100), specificity 89% (95% CI 86-91) and NPV 100% against the Adult Suicidal Ideation Questionnaire. A further validation in 515 youth aged 10-21 in outpatient specialty and primary care clinics (Aguinaldo et al., 2021) supported use outside the emergency department.
96.9%
Sensitivity
Youth ED sample, against the SIQ
87.6%
Specificity
Youth ED sample
100% / 89%
Sensitivity / specificity
Adult medical inpatients (2020)
99.7-100%
Negative predictive value
Across validation settings
05 - How it compares
How it compares to the alternatives.
Instrument
Items
Time
When to reach for it
ASQ
4 (+1 acuity)
~20 sec
Universal rapid triage, ages 10+, any clinical setting.
Self-harm ideation in perinatal screening; positive responses need the same follow-up logic as an ASQ positive.
06 - When to use it
Right tool, wrong tool.
The ASQ is built for universal screening rather than case formulation. Use it as the front door of a defined pathway, and let the brief safety assessment that follows carry the clinical judgement.
Reach for it when
-Universal screening in emergency departments, medical inpatient units and outpatient clinics
-Patients aged 10 and up
-Settings where non-mental-health staff do the screening
-Systems that need a defined positive-screen pathway (pairs with the NIMH BSSA)
Reach for something else when
-You need a diagnosis or a severity measure
-You need a full suicide risk assessment rather than a screen
-The patient is under 10 years old (not validated)
-You want to track change over time
-A negative screen conflicts with clinical concern - if the presentation worries you, assess anyway
07 - Confidence & precision
Reading the score with care.
Because the ASQ is binary rather than scored, SEM and meaningful-change thresholds do not apply. The relevant precision figures are predictive values: NPV approaches 100% across validation settings, so a negative screen is highly reassuring. Specificity of 87-89% means roughly one in nine patients without significant ideation screens positive; in low-prevalence settings the positive predictive value is correspondingly modest, which is why a positive screen leads to a brief safety assessment rather than automatic psychiatric admission. Refusal to answer is treated as a positive screen by design.
08 - Limitations
What it cannot tell you.
Validation samples were convenience samples in US hospitals; it relies on honest self-report, and patients may conceal ideation; it captures ideation and attempt history but not the wider risk formulation (access to means, protective factors, recent losses); the low base rate of suicidal behaviour means most positive screens will not go on to attempt; it screens current state and is not a prediction instrument. Screening programmes only reduce risk if a follow-up pathway exists.
See how Aisel removes friction where it costs most. A 20-minute walkthrough tailored to your clinic.
We value your privacy
We use cookies to analyse site usage and improve your experience. Analytics and embedded media (e.g. YouTube) only load if you accept. Read our cookie policy.