Research finding · October 2025
Standard suicide risk assessments used in rural primary care settings are detecting risk
Rural communities in the U.S. face some of the highest suicide rates in the country, and the gap between rural and urban areas has only grown wider over the past two decades. Factors such as geographic isolation, limited access to behavioral health care, economic stress, and the widespread availability of firearms all contribute to this disparity. Cultural values around self-reliance and persistent stigma surrounding mental health create further barriers, leaving many rural residents without the support they need. For rural Americans, the local doctor’s office may be their only point of contact with the health system. That makes primary care clinics places for routine check-ups, and critical opportunities to identify suicide risk and connect people to care. The challenge is ensuring that providers in these settings have the right tools (i.e., ones that are brief, accurate, and practical) to recognize when someone may be at risk.
To address this, Dr. Mary LeCloux used her AFSP grant to evaluate how well two brief screening tools, the Ask Suicide-Screening Questions (ASQ) and Item 9 of the Patient Health Questionnaire (PHQ-9) that asks about self-harm, detected suicide risk among 214 adults attending rural primary care clinics in West Virginia. Participants completed surveys before their appointments, and about half took part in a one-month follow-up. Results showed that both the ASQ and PHQ Item 9 were effective assessments for risk for suicidal thoughts and behaviors to help primary care physicians engage with their patients about their risk. Screening for pain and opioid use did not meaningfully improve detection. Importantly, LGBTQ+ participants were more likely to report having suicidal thoughts and behaviors, highlighting a subgroup with especially high rates in rural settings. These findings provide preliminary evidence that both ASQ and PHQ Item 9 can serve as practical screening tools in rural primary care, while underscoring the need for larger studies and targeted strategies to support high-risk groups.
Citation: Christensen, M., Culp, S., Campo, J. V., Bridge, J. A., & Horowitz, L. (2025). Evaluation of the Ask Suicide-Screening Questions (ASQ) tool, Item 9 of the Patient Health Questionnaire (PHQ), pain, and opioid screening to detect suicide risk among rural adult primary care patients. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association, 41(3), e70064. https://doi.org/10.1111/jrh.70064
This finding comes from an AFSP-funded study — see the grant below ↓
