CASSY tool effective in predicting adolescent suicide attempts


In a recent study, the Ask Suicide-Screening Questions (ASQ) and the Computerized Adaptive Screen for Suicidal Youth (CASSY) tools both showed predictive viability for suicide attempts in adolescents.

The Ask Suicide-Screening Questions (ASQ) and the Computerized Adaptive Screen for Suicidal Youth (CASSY) tools are both viable methods for screening the risk of suicide attempts in pediatric patients, with slightly greater viability from the CASSY tool, according to a recent study.

Adolescents have experienced rising rates of suicidal ideation (SI) and suicide attempts (SAs) in the past 15 years, with Black and Hispanic adolescents experiencing the most significant increases. To prevent SAs, it is recommended that physicians screen patients for suicidal risk in emergency departments (EDs).

One in 5 youths are estimated to visit EDs at least once per year, and evidence has associated ED visits with a greater risk of suicide. As the number of adolescents visiting EDs for suicidal behavior increases, a need for screening in emergency settings has increased.

CASSY is a recent tool developed to predict suicidal behavior. To measure its efficacy with other measures of screening for suicide risk, investigators compared CASSY to ASQ, a tool for determining concurrent suicide risk.

Data was gathered from the Emergency Department Study for Teens at Risk for Suicide (ED-STARS), a multicenter prospective cohort study including adolescent patients aged 12 to 17 years. The evaluation was based on study 2 of ED-STARS, analyzing 2740 adolescents visiting an ED from July 24, 2017, to October 29, 2018.

Participants completed an ASQ, CASSY, and 3-month follow-up. Baseline assessments were completed on a computer tablet in the ED, while follow-up was completed through computer-assisted telephone interviews.

Four questions on recent SI, lifetime suicidal behavior, and burdensomeness made up the ASQ. All questions were responded to with a yes or no answer. Results from ASQ showed a sensitivity of 96.9% and a specificity of 87.6%.

Items in the CASSY study covered a wide variety of risk and protective factors for suicidal behavior. Items shared with ASQ included past week SI, death wish in the past few weeks, and lifetime history of SA. Demographic information was gathered from parents or legal guardians.

SA was measured as the study’s primary outcome, with suicide-related visits to the ED measured as a secondary outcome. An SA or suicide related event (SRE) was reported in 8.5% of participants who completed the baseline and follow-up measurements, with 1 or more SA in 5.9% of patients, an SRE in 6.1%, both in 3.5%, SA only in 2.5%, and SRE only in 2.6%.

Sensitivity, specificity, positive predictive value, and negative predictive value measurements did not significantly differ between the ASQ and CASSY tools for predicting SA within 3 months. There were also no differences between the 2 tools when observing measurements across demographic groups

When analyzing patients with psychiatric symptoms, the CASSY tool showed improved predictability compared to the ASQ tool. This indicates greater predictive validity from the CASSY tool.


Brent DA, Horowitz LM, Grupp-Phelan J, et al. Prediction of suicide attempts and suicide-related events among adolescents seen in emergency departments. JAMA Netw Open. 2023;6(2). doi:10.1001/jamanetworkopen.2022.55986

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