Screening Youth for Suicide Risk inMedical SettingsTime to.docx

Screening Youth for Suicide Risk in
Medical Settings
Time to Ask Questions
Lisa M. Horowitz, PhD, MPH, Jeffrey A. Bridge, PhD,
Maryland Pao, MD, Edwin D. Boudreaux, PhD
From the Intra
of Mental He
Pediatric Prac
dren’s Hospit
Columbus, Oh
ment of Psyc
(Boudreaux),
Massachusetts
Address co
Institute of Me
5362, Bethesda
0749-3797/
http://dx.do
S170 Am J
This paper focuses on the National Action Alliance for Suicide
Prevention’s Research Prioritization
Task Force’s Aspirational Goal 2 (screening for suicide risk) as
it pertains specifically to children,
adolescents, and young adults. Two assumptions are forwarded:
(1) strategies for screening youth for
suicide risk need to be tailored developmentally; and (2) we
must use instruments that were created
and tested specifically for suicide risk detection and developed

specifically for youth. Recommen-
dations for shifting the current paradigm include universal
suicide screening for youth in medical
settings with validated instruments.
(Am J Prev Med 2014;47(3S2):S170–S175) Published by
Elsevier Inc. on behalf of American Journal of
Preventive Medicine
Introduction
Suicide remains a leading cause of death for youth
worldwide.1 Screening for risk of suicide and
suicidal behavior is an important and necessary
first step toward suicide prevention in young people.
Implementing effective screening programs involves
targeting high-risk populations in favorable settings.2
Medical settings have been designated as key venues to
screen for suicide risk and are therefore the focus of this
article.
The National Action Alliance for Suicide Prevention
(Action Alliance) developed 12 Aspirational Goals as a
way of structuring a suicide prevention research agenda
aimed at decreasing suicides in the U.S. by 40% over the
next decade. Aspirational Goal 2 pertains to screening for
suicide risk: “to determine the degree of suicide risk
among individuals in diverse populations and in diverse
settings through feasible and effective screening and
assessment approaches.”3
As an adjunct to a separate article in this supplement
that proposes a paradigm shift for suicide screening
mural Research Program (Horowitz, Pao), National Institute
alth, NIH, Bethesda, Maryland; Center for Innovation in
tice (Bridge), The Research Institute at Nationwide Chil-

al and The Ohio State University College of Medicine,
io; and the Department of Emergency Medicine, Depart-
hiatry, and Department of Quantitative Health Sciences
University of Massachusetts Medical School, Worcester,
rrespondence to: Lisa M. Horowitz, PhD, MPH, National
ntal Health, Clinical Research Center, Building 10, Room 6-
MD 20892. E-mail: [email protected]
$36.00
i.org/10.1016/j.amepre.2014.06.002
Prev Med 2014;47(3S2):S170–S175 Published by E
instrument development and research aligned with this
Aspirational Goal,4 this paper focuses on suicide screen-
ing as it pertains specifically to children, adolescents, and
young adults. The aims of this paper are to describe how
youth suicide prevention strategies need to be considered
independently of adult suicide prevention strategies,
underscore the need for universal screening with vali-
dated suicide screening instruments for youths in all
medical settings, and describe paradigm shifts that would
need to occur to achieve reductions in youth suicide/
suicidal behavior.
Assumptions of Screening for Suicide Risk
Assumption 1: Strategies for Screening Youth
for Suicide Risk Need to be Tailored
Developmentally
In the field of pediatrics, there is a well-known maxim:
“Children are not just small adults.” This tenet is
applicable to suicide prevention strategies. As with many
types of public health threats, a one-size-fits-all approach
will not be effective. Suicide risk changes at each
developmental stage of a young person’s life, increasing
with age throughout adolescence and early adulthood.5
Although death by suicide does occur in children under

12 years,6 suicide and suicidal behavior are rare prior to
puberty, in part because mood disorders, for example, are
less common in younger children. Risk of suicide
increases in the late teen years, coinciding with increased
risk of mood disorder onset. Nevertheless, half of all
mental illness onset begins in childhood, making it a
critical period of time to intervene.7
lsevier Inc. on behalf of American Journal of Preventive
Medicine
mailto:[email protected]
dx.doi.org/10.1016/j.amepre.2014.06.002
Horowitz et al / Am J Prev Med 2014;47(3S2):S170–S175 S171
Developmental trajectories are the main character-
istics that set children apart from adults (Figure 1),
considering factors such as variable physical growth;
differences in cognition (ability to think abstractly);
language (ability to communicate needs); and social
competence (ability to make friends). These streams of
development are all happening at different times and
rates in children and adolescents. Converging upon these
trajectories are critical risk factors such as mental illness,
family history of mental illness, and history of suicidal
ideation or behavior. In addition, other psychiatric
comorbid conditions, such as substance abuse, may help
promote the transition from suicidal ideation to
behavior.
Some psychological traits can increase risk, such as
impulsive aggression in which a child may have a
tendency to react aggressively to frustrating situations or

have other maladaptive coping strategies. Environmental
factors such as psychosocial stressors, poverty, and “non-
intact” families may contribute to hopelessness. Many
youth have acute stressors that include interpersonal
conflict, loss, and problems with school.8 These factors
can all increase a young person’s risk for suicide. Ideally,
protective factors such as strong relationships with adults,
academic success, or religious beliefs can modify these risk
factors and reduce risk for suicidal behaviors—but even
these are not always sufficiently protective.
According to the most recent CDC data, 15.8% of all
high school students in the U.S. have seriously consid-
ered suicide.9 Some existential questioning is expected in
adolescence; however, when these thoughts become more
frequent or expand into plans to end one’s life, they
Figure 1. Developmental considerations in youth suicide
SI, suicidal ideation; SB, suicidal behavior; hx, history of; dx,
diagnosis
September 2014
become clinically significant. Manifestations along the
continuum of suicide, from thoughts to behavior, are
important because they can all be predictive of death by
suicide. The hope is that screening and early detection
can have an impact and thwart the progression from
ideation to behavior.
Another important difference when evaluating and
treating youth as compared to adults is that most youth
are accompanied by parents or guardians when they visit
a medical setting. This has implications for the first
assumption noted above, as these adult caregivers can
provide useful collateral information that assists with
suicide risk assessment. In addition, having a parent/
guardian aware of elevated suicide risk in their child

affords them the opportunity to help with means
restriction and other important safeguards that can aid
in prevention of suicide. Currently, however, there is no
empirical evidence about whether including parental
questions in a suicide screening tool is more effective
than only screening the child, nor are there clinical
guidelines for how to proceed if parents and youth
disagree in their answers.
Assumption 2: We Must Use Instruments that
Were Developed and Tested Specifically for
Suicide Risk Detection and Developed
Specifically for Youth
This section emphasizes the importance of using instru-
ments that have been validated to detect the condition of
interest—suicide risk in youth. Sometimes, suicide risk
detection strategies are created for the general public and
are then utilized for children and adolescents, even if
Horowitz et al / Am J Prev Med 2014;47(3S2):S170–S175S172
age-specific validity has not been proven. Given all the
variables mentioned above, adult instruments may not
always be appropriate for screening youth for suicide risk.
The current paradigm is that screening occurs in a
non-standardized manner with patients who appear at
high risk to non–mental health clinicians, who may or
may not be knowledgeable about the risk factors. Screen-
ing items and suicide screening practices differ across
and within hospitals depending on knowledge and
training of staff, which varies greatly. The current
national practice for suicide screening in most hospitals
has not been assessed. For example, when the Joint
Commission issued Patient Safety Goal 15A in 2007

requiring all behavioral health patients to be screened for
suicide,10 nurses were asked to screen patients, but were
not given validated instruments for making such inqui-
ries. This would be akin to asking a nurse to guess a
patient’s body temperature without giving them a
thermometer.
Nurses reported a wide range of screening questions,
from indirect questions such as Are you safe? and How
will I know when you’re angry? to very specific questions
such as Have you had any thoughts of wanting to harm
yourself or others? (L. Horowitz, National Institute of
Mental Health, and J. Bridge, The Research Institute at
Nationwide Children’s Hospital and The Ohio State
University College of Medicine, personal communica-
tion, 2013). A national survey on what is being asked and
how to standardize the questions would be useful.
A proposed paradigm shift is to implement validated
tools and training staff to use clinical practice guidelines
developed for managing positive screens safely. Screening
would not be limited to patients with a known psychiatric
history; rather, it would occur universally in certain
settings. However, specific guidelines will need to be
established for setting up screening parameters for who
should administer the screening instrument, when dur-
ing the visit the patient should be screened, and, most
importantly, how positive screens will be managed.
If universal screening is to be implemented, the initial
screening tool will have to be brief, highly sensitive,
highly specific, and validated on the targeted population
for the condition under evaluation. Several measures
have been used to screen patients for suicide risk in
various medical settings: for specific use in the pediatric
emergency department (ED) population, the Risk of

Suicide Questionnaire (RSQ)11 and the Ask Suicide-
Screening Questions (ASQ);12 and in primary care (PC)
clinics, the Behavioral Health Screen (BHS),13 the
Columbia Suicide Severity Rating Scale (CSSRS),14 and
others.2,15 Validation studies should test for sensitivity,
specificity and negative and positive predictive values.
Prospective predictive validity of completed suicide and
suicidal behavior has yet to be established on the tools
mentioned above, and is greatly needed.
Because depression and suicide are frequently linked,
clinicians often use depression screens as suicide risk
detection instruments. Yet, depression screens are not
necessarily designed to be sensitive or specific enough
instruments for recognizing suicidal thoughts and behav-
iors, especially in medical patients.16
A widely used valid and reliable depression screening
instrument, the Patient Health Questionnaire (PHQ-9),17
provides an illustrative example. The ninth item on the
PHQ-9 asks the patient how often he or she is bothered
by the thought that you would be better off dead, or of
hurting yourself in some way and is widely used clinically
and in research studies to screen for suicide risk. This
item simultaneously and indistinguishably measures
both passive thoughts of death and suicide ideation, both
symptoms of depression. Because the question contains
an “or,” it has been found to be overly sensitive in that it
detects patients who have passive thoughts of death or
thoughts of hurting themselves.
In patients with serious medical illnesses, thoughts of
death are common and may be categorically unrelated to
suicide. Recent studies examining the use of Item 9 to
assess for suicide risk in medically ill patients suggest that

this question provides ambiguous, non-specific, and
difficult-to-interpret information that may overburden
already strained mental health resources.18 In addition,
inquiring about hurting and killing oneself, especially for
adolescents, may identify two different problems. In
settings where mental health resources are limited, asking
youth as directly as possible about suicide may be critical
for more accurate detection.
Recommendations
The public health import of utilizing universal screening
in medical settings as a way to identify youth at risk for
suicide and suicidal behavior is immense. Screening
positive on validated instruments may not only be
predictive of future suicidal behavior but also be a proxy
for other serious mental health concerns that require
further mental health attention and follow-up. For
example, it may not be feasible to screen for every
sociobehavioral risk factor in a busy ED setting.
However, once a young person screens positive for
suicide risk and receives a mental health evaluation, they
can be further assessed for serious mental illness, sub-
stance abuse, homicidal ideation, and history of physical
and sexual abuse. The proposed paradigm shift is that an
effective suicide screening instrument not only will detect
imminent risk but can also identify youth with significant
emotional distress warranting further mental health
www.ajpmonline.org
attention, which if otherwise ignored can lead to serious
personal and societal consequences (e.g., school absen-
teeism, antisocial behavior, school dropout, and

increased use of healthcare services).
Any setting in which a healthcare provider delivers
medical care, such as PC clinics, EDs, inpatient medical
units, and school-based clinics, may be ideal venues to
identify youth at elevated risk. More than 80% of youths
visit their PC doctor each year, making the PC clinic well
situated to identify young people at risk. Wintersteen19
showed that there was a 4-fold increase in detection of
suicidal ideation by pediatricians when screening tools
were used in outpatient clinics (base rate¼0.8%, screen-
ing tools¼3.6%). The study, however, emphasized that
these data translated into one additional youth per week
requiring further mental health follow-up, which did not
overwhelm the pediatric care clinics.
Similar results have been found in pediatric emergency
care settings. For those who are not connected to a PC
clinic, estimated to be about 1.5 million youth, the ED is
their sole contact with the healthcare system,20 creating
not only an opportunity but a responsibility to screen for
suicide risk. A recent Canadian study revealed that 80%
of youth who died by suicide visited a PC provider, an
ED, or had an inpatient medical hospitalization within
3 months prior to their death.21 The obvious clinical
challenge is that these individuals do not walk into their
doctor’s office and say, “I want to kill myself”; rather, they
frequently present with somatic complaints (e.g., head-
aches, stomachaches), and may not talk about their
suicidal thoughts unless asked directly.
Pediatric ED studies show that screening for suicide
risk can reveal previously undetected thoughts of suicide
in youth presenting with medical/surgical chief com-
plaints.18 Moreover, screening was found to be acceptable

to clinicians, parents, and youth and was found to be
non-disruptive to ED workflow. Several studies reveal
that young patients embrace the notion of being screened
for suicide risk in medical settings.22,a
Larkin and Beautrais23 describe the ED as an impor-
tant nexus for suicide-related endophenotypes (e.g.,
alcohol and substance abuse, pain syndromes, medical
comorbidities). These high-risk groups include young
people who may be disenfranchised, may have dropped
out of school, are not employed, or are in the foster care
system. These young people are often isolated and do not
have a connection with someone who can recognize that
they need help. An ED visit can provide this opportunity.
A major barrier to screening for suicide risk is the
concern about how to safely manage patients who screen
positive. What does a positive screen on a validated
aContact corresponding author for additional references.
September 2014
instrument that was created to detect suicide risk actually
mean? Screening positive means a patient has a symptom
that requires further evaluation. To use a medical
analogy, this is akin to a pediatric patient who is found
to have high blood pressure during an ED visit. They are
not immediately administered an anti-hypertensive med-
ication; rather, a further assessment ensues to determine
what is causing the high blood pressure and what may
happen to the patient if the hypertension persists.
Screening positive on a suicide risk screen is similar;
something is amiss and further evaluation is necessary. A
patient who screens positive is in need of a psychiatric
evaluation by a trained mental health professional who
can examine related symptoms, judge risk of self-harm,

and, if necessary, guide the primary physician in appro-
priate disposition decisions and link the patient with
mental health treatment if needed. It does not necessarily
mean a constant observer is necessary or that the child
needs to be hospitalized on an inpatient psychiatric unit,
although these are potential outcomes.
Not inquiring about suicide risk would be akin to not
measuring blood pressure because the system did not
want to find out the child had hypertension. In addition,
taking into account developmental needs, a child-sized
blood pressure cuff would be needed to measure blood
pressure properly. The patient has the symptom whether
or not a healthcare provider asks about it. But if we do
not ask, chances are the patient will not tell us, and they
may not get the help they need.
Important research pathways will include validating
screening instruments with targeted populations in the
specific healthcare settings in which they will be used.
This effort would require conducting universal screening
and developing clinical practice guidelines tailored for
youth to manage positive screens safely and effectively in
each setting, with long-term follow-up for youth who
screen positive and negative to determine the validity and
full impact of screening.
Critical stakeholders in the screening process will need
to be identified, such as hospital administrators, whose
commitment to implementing effective screening pro-
grams and providing mental health resources for positive
screens will be essential. Importantly, we will need nurse
and physician champions to help with changing clinical
practice to include screening and reduce stigma associ-
ated with patients who screen positive. We will need to
educate families about what positive screens imply, the

need for mental health follow-up services for the patient,
and guidance sessions for the parents.
Screening for suicide risk can become part of core
performance improvement measures for hospitals and
clinics by adding screening to hospital scorecards and
Healthcare Effectiveness Data and Information Set
Horowitz et al / Am J Prev Med 2014;47(3S2):S170–S175S174
(HEDIS) measures. Currently, more than 90% of Amer-
ican health insurance plans use HEDIS as a tool to
measure performance on critical dimensions of health-
care delivery.24 The current metrics include “adolescent
well-visits” or “anti-depressant medication manage-
ment,” and “cervical cancer screening in adolescent
females,” but suicide screening is notably absent
Barriers to universal screening include strapped men-
tal health resources and limited patient care time. Other
roadblocks include myths of iatrogenic risk. Many,
including healthcare providers, still believe that we may
be putting ideas of suicide into a youth’s mind if we ask
them directly about suicide; however, there have been
several studies that refute this myth.25,a Another barrier is
the lack of mental health resources available in medical
settings to manage positive screens, especially providers
trained in child/adolescent mental health. Linkage rates
to mental health providers have been low with people
who have screened positive, partly due to few resources,
but also because the stigma of having mental health
concerns still plagues patients and prevents them from
initiating conversations about their mental suffering and
seeking help.
Opponents of universal screening may argue that

suicide is a low–base rate event, especially in young
people, so we cannot develop instruments that accurately
predict suicide. Although it is true that we do not
currently have tools that predict which youths will kill
themselves, we do have tools that can detect suicidal
ideation, which should not be minimized in young
people. Nock et al.26 found that approximately one third
of youth with suicidal ideation go on to develop a suicide
plan in adolescence, and about 60% of those with a plan
will attempt suicide. The hope is that intervening early,
during ideation, will lead to prevention.
Conclusions
Youth suicide prevention strategies will need to be
designed with developmental considerations in mind. It
is time for all youth in medical settings to be screened for
suicide risk, just as they are routinely screened for
hypertension, fever, and falls risk. We cannot rely solely
on depression screens or non-validated instruments to
identify young people at risk for suicide. We as research-
ers need to create and test developmentally sound tools
for healthcare providers to use.
Demonstration projects in pediatric medical settings
with these instruments will highlight strengths and
uncover future challenges to overcome. Importantly,
screening can only take us so far. We must turn our
research efforts toward developing more effective inter-
ventions. Lastly, we must hold ourselves, as clinicians and
researchers, accountable for lowering the youth suicide
rate within the next decade. Every healthcare provider
can have an impact.
Publication of this article was supported by the Centers for
Disease Control and Prevention, the National Institutes of
Health Office of Behavioral and Social Sciences, and the

National Institutes of Health Office of Disease Prevention.
This support was provided as part of the National Institute of
Mental Health-staffed Research Prioritization Task Force of
the National Action Alliance for Suicide Prevention.
Dr. Boudreaux receives consulting payment and owns stock
options in Polaris Health Directions, a private company that
creates and markets mental health assessment and intervention
software. This paper does not endorse any specific programs or
products that Dr. Boudreaux has developed.
No financial disclosures were reported by the other authors
of this paper.
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http://refhub.elsevier.com/S0749-3797(14)00269-
4/sbref24Screening Youth for Suicide Risk in Medical
SettingsIntroductionAssumptions of Screening for Suicide
RiskAssumption 1: Strategies for Screening Youth for Suicide
Risk Need to be Tailored DevelopmentallyAssumption 2: We
Must Use Instruments that Were Developed and Tested
Specifically for Suicide Risk Detection

and...RecommendationsConclusionsReferences
JDNP-D-20-00049 Page 122 03/07/21 5:32 AM
122 Journal of Doctoral Nursing Practice, Volume 14, Number
2, 2021 © 2021 Springer Publishing Company
http:// dx. doi. org/ 10. 1891/JDNP-D-20-00049
Improving Suicidal Ideation
Screening and Suicide
Prevention Strategies on Adult
Nonbehavioral Health Units
Anne C. Lindstrom, DNP, APRN
Rush University, Northwestern Medicine Central DuPage
Hospital,
Winfield, IL
Melinda Earle, DNP, RN
Rush University, Chicago, IL
Background: Suicide is a risk in hospitalized patients within and
outside of behavioral health units.
Williams et al. (2018). Incidence and method of suicide in
hospitals in the United States. Williams
et al. (2018), suicides occur annually in hospitals, 14%–26% of
occurrences outside of a behavioral
health unit. Objectives: The purpose of this project was to
improve compliance with universal
patient suicide ideation screening and targeted actions for
patients screening positive admitted

to nonbehavioral health units. Methods: Electronic medical
record (EMR) changes to support
screening and targeted patient safety measure documentation
were implemented. Nursing educa-
tion was provided to support these changes. Pre- and
postassessments were used to measure knowl-
edge gained from the education. A compliance report was
generated from the EMR to measure
compliance with universal screening and patient safety
measures. Results: In a 4-month period,
screening compliance improved by 20.6%, bedside safety
companion use was 100%, suicide precau-
tions, documentation 82.5%, and a behavioral health social
work note documented 76% of the time.
Conclusions: Universal screening improvement is feasible and
has the potential to improve patient
safety. Implementation should be considered across health care
organizations. Implications for
Nursing: Providing nursing education and easier EMR
workflows for nursing documentation of
suicide screening and prevention strategies improves patient
safety.
Keywords: suicide; screening; interventions; behavioral health
Background
Suicide is the 10th leading cause of death in the United
States, furthermore the rate is increasing in almost all
states despite a decrease worldwide (Grumet et al.,
2019). Currently, suicide claims one life every 40 sec-
onds in the United States (World Health Organization
[WHO], 2014). The majority of suicides are preceded
by warning signs, either verbal or behavioral (WHO,
2014).

Healthcare organizations have been identified by
the U.S Surgeon General as a setting that can impact
suicide rates (U.S. Department of Health and Human
Services, 2012). Many people who die by suicide present
to healthcare organizations for nonbehavioral health
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10ID:p0075ID:ti0015ID:p0080ID:p0085
ID:p0090ID:p0095ID:p0100ID:p0105ID:p0110ID:p0115ID:ti00
05ID:p0050ID:p0055ID:p0060ID:p0065ID:p0070ID:ti0010ID:p
0075ID:ti0015ID:p0080ID:p0085
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0075ID:ti0015ID:p0080ID:p0085
ID:p0090ID:p0095ID:p0100ID:p0105ID:p0110ID:p0115
http://dx.doi.org/10.1891/JDNP-D-20-00049
https://orcid.org/0000-0003-3158-2325
JDNP-D-20-00049 Page 123 03/07/21 5:32 AM
123Improving Suicidal Ideation Screening
complaints prior to committing suicide (Grumet et al.,
2019).
Suicide is a risk in hospitalized patients and occurs
both inside and outside of behavioral health units.
Williams et al. (2018) cite 48.5 to 64.9 suicides occur
annually in hospitals and 14%–26% of occurrences
outside of a behavioral health unit. Therefore, univer-

sal screening for suicide ideation in nonbehavioral
healthcare settings is considered to be an important
and effective piece of suicide prevention (Horowitz et
al., 2017). Systematic identification and assessment of
patients at risk for suicide is crucial to decreasing the
incidence (Grumet et al., 2019).
Rapid identification of patients at risk for suicide
accelerates provision of a safe environment for care
(Grumet et al., 2019). Rapid identification of patients
at risk poses a challenge. Targeted screening has the
potential to miss patients who may be at risk, however,
universal screening has the potential to identify patients
not truly at-risk increasing resource use (Grimley-
Baker, 2018). The U.S Preventative Services Task Force
in 2014 stated the current evidence supporting universal
screening is insufficient to assess the benefit versus harm
(LeFevre, 2014). Nonetheless, The Joint Commission
(2018) has encouraged organizations to develop univer-
sal screening policies and requires that all patients who
present with a primary behavioral health complaint be
screened. The discrepancy in recommendations has left
healthcare organization to develop individual policies
and procedures based on local level resource availabil-
ity and expert opinion (Grimley-Baker, 2018). Universal
screening has been adopted in many organizations and
feasibility has been established with a compliance rate
of 84%–92% (Boudreaux et al., 2016; Stuck et al., 2017).
However, barriers to screening exist and mostly focus on
health care provider concerns. Identified barriers include
concern screening may increase suicidal thoughts, lack
of time and privacy to complete screening, lack of
patient willingness to complete, communication chal-
lenges such as language barriers, lack of training, and
lack of standard protocol (Bolton et al., 2015; Giacchero
et al., 2017; Petrik et al., 2015).

Screening is not enough to keep suicidal patients
safe. A safe care environment must be provided while
further assessment is completed. Root cause of suicide
events in nonbehavioral health inpatient units include
lack of risk assessment, poor handoff communication,
lack of staff training, lack of repeated assessments, and
lack of supervision (Grimley-Baker, 2018; Mills et al.,
2014). The stated root causes highlight the importance
of providing a safe care environment. Staff knowledge,
the involvement of clinical experts, establishment of
clinical competence, and a team approach to patient
care can mitigate risks (Grimley-Baker, 2018; Mills
et al., 2014). Additionally, environmental resources offer
means to commit suicide and risk must be mitigated.
The most common methods noted were hanging, over-
dose, and cutting (Mills et al., 2014). Access to means
should be evaluated and any potential risks removed
and the patient supervised at all times including while
in the bathroom (Grimley-Baker, 2018).
At a Midwestern suburban medical center, a policy
requires universal suicidal ideation screening as part of
the nursing admission assessment. Patients are asked
two questions: (a) are you feeling hopeless about the
present/future and (b) have you had any thoughts about
taking your life? A patient who answers yes to the first
question has a behavioral health social work consult
placed. Subsequently, a patient who answers yes to the
second question requires orders placed for a bedside
safety companion, implementation of a prescribed set
of suicide precautions and a consult to the behavioral
health services social worker. The behavioral health
social worker completes the Columbia Suicide Severity
Rating Scale (C-SSRS) (Posner et al., 2011). A com-

pliance report, generated from the electronic medical
record (EMR), 1 year after the policy implementation
indicated a complete screen was documented 79% of
the time. When a positive screen was noted the safety
companion order was placed 35% of the time, suicide
precautions were present 51% of the time, and an order
for a behavioral health social work consult was present
81% of the time.
There is limited literature outlining how to improve
suicide screening in the inpatient setting. A literature
search was completed using CINAHL and PsycInfo
with a date range of 2012–2019. Search terms included
suicide, suicidal ideation, hospital, inpatient, and adult.
Six articles discuss implementation of suicide screen-
ing within the hospital but no literature was found on
how to improve screening compliance when a process is
already established (Adams, 2013; Horowitz et al., 2013;
Huh et al., 2012; Maclay, 2012; Roaten et al., 2018).
At the medical center in this study, there were sev-
eral causal factors, identified through chart reviews
and focus groups with nurses, influencing compli-
ance. Documentation of the screening was optional
in the electronic medical record, the nurse completing
the admission screen could chose not to answer the
question. If the question was answered positively there
were no functions in the electronic medical record
to prompt the nurse to enter the subsequent orders.
Additionally, there was no targeted education pro-
vided to the nurses when universal screening was ini-
tiated. Recurring education around suicidal ideation,
safety of suicidal patients, and the policy was not pro-
vided to nurses. Targeted intervention was needed to
improve identification and safety of suicidal patients,

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JDNP-D-20-00049 Page 124 03/07/21 5:32 AM
124 Lindstrom et al.
reduce risk, and potentially save lives. (Grumet et al.,
2019).
Objective
The primary aim of the project was to improve suicide
screening of patients admitted to nonbehavioral health
units to 100%. The secondary aims were to improve
timeliness of a behavioral health social work consult
note entered into the electronic medical record, with a
goal of 100% entered within 24 hours. Additionally, the
secondary aims were to ensure a safety companion is
provided to 100% of patients and ensure suicide precau-
tions are initiated for 100% of patients who screened
positive for suicidal ideation
Methods
The project was deemed nonhuman subjects research
by the institutional review board. The define, measure,
analyze, improve and control (DMAIC) methodol-
ogy was used as a process improvement framework
for this project. The healthcare organization uses the
DMAIC methodology for quality improvement. The
chosen methodology allowed a logical and standardized

approach to improving clinical care. The problem was
clearly defined and measured. Possible solutions were
analyzed and implemented. Finally, a control plan was
developed to ensure sustainability (American Society
for Quality, 2019).
The interventions were developed based on a review
of the literature discussing initial implementation of
suicide screening (Adams, 2013; Horowitz et al., 2013;
Huh et al., 2012; Maclay, 2012; Roaten et al., 2018) and
focus group findings from key stakeholders, including
bedside nurses. The intervention included a change to
the electronic medical record, education for nurses, and
compliance monitoring.
Electronic Medical Record
Improvements
Roaten et al. (2018) discuss changes to the electronic
medical record as an integral piece to ensuring suicide
screening is complete. This was also an area identified
in the focus group discussions. The electronic medical
record change included adding an additional answer
option to the suicide screening question and making the
question required documentation within the electronic
medical record. Previously, when screening a patient for
suicide on admission the answer options were yes or
no. Unable to assess was added as an additional option.
The addition of this option allows nurses to complete
the question even when a patient is unable to answer.
The answer is used for a patient who is intubated or
otherwise unable to speak. If unable to assess is used as
an answer the nurse is prompted periodically through-
out the patients stay to reassess and answer yes or no.

Nursing Protocol Development
A nursing protocol was developed with the goal of
improving compliance of orders for suicide precau-
tions, safety companion, and behavioral health social
worker consult. The protocol allows nurses to enter
these orders per protocol for patients screening posi-
tive for suicidal ideation. An order for suicide precau-
tions includes an environmental assessment to ensure
no hazardous objects are available to the patient. The
protocol ensures the appropriate orders are entered and
the patient remains in a safe environment under con-
stant 1:1 supervision. The provider is then notified after
the patient’s safety has been assured. The protocol was
approved by the hospital’s Chief Nurse Executive and
the Medical Executive Committee.
A best practice alert for appropriate order entry was
also added. The best practice alert prompts the nurse to
take action in the case of a patient who screens posi-
tive for current suicidal ideation. The best practice alert
includes a reminder to place an order for suicide precau-
tions and a behavioral health social work consult.
Compliance Monitoring
Data on screening compliance and subsequent actions
was collected using a report developed by the analyt-
ics team. The report pulled information directly from
the electronic medical record and included individual
patient level data. Data fields included admission data,
response to screening question and if required date and
time policy actions were taken.
Nursing Education

Compliance with screening and the bundled actions
required by the policy was supported by providing edu-
cation to the nursing staff (Manister et al., 2017; Roaten
et al., 2018). Education was developed in an electronic
learning module and was required of all adult inpa-
tient nurses. The content was developed and evaluated
by behavioral health experts, professional practice and
nursing education, and accreditation experts within the
organization. The education included content detail-
ing the care of a suicidal patient. The screening process
was reviewed in addition to actions required by policy
and the nursing protocol (see Figure 1). The education
included an interactive portion where the nurses were
asked to hover over a picture of a patient room to iden-
tify any objects that could be considered a safety hazard.
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:p0155
05

JDNP-D-20-00049 Page 125 18/07/21 11:50 PM
A pre- and postassessment was included to determine
the knowledge gain (see Figure 2 ).
Th e staffi ng coordinator, who oversees the safety
companions for the hospital, sent a daily report of
patients admitted with suicidal ideation. Observation
and chart audits were completed to ensure suicide pre-
cautions were in place and safety companion was at
bedside. Chart audits were completed to ensure orders
and screening were completed appropriately.
Results
Th e nursing education module was completed by 91.5%
( N = 344) of eligible nurses. Th e pretest baseline knowl-
edge level was noted to be high with 89.2% of the ques-
tions on the pretest answered correctly. Th e posttest
assessment data demonstrated 92.1% of the questions
were answered correctly, an improvement of 2.9% (See
Figure 3 ).
Data was collected from January 1, 2020, through
May 31, 2020. Goals of 100% were identifi ed for each
metric, the organization is a high reliability organiza-
tion and strives for 100% compliance in any metric
related to patient safety. In the data collection period
6,229 patients were admitted to adult nonbehavioral
health units within the hospital. Of these patients
99.6% ( N = 6210) were screened for suicidal ideation.
Of the patients who were screened, 95.8% ( N = 5947)

screened negative, 1% ( N = 63) screened positive, and
3.2% ( N = 200) were unable to be assessed. Th is demon-
strated a 20.6% improvement in screening compliance
(see Figure 4 ).
Patients who screened positive for suicidal ideation
were evaluated for adherence to policy required actions
including an order placed for a consult to the behavioral
health social worker, an order entered for suicide pre-
cautions and an order placed for a safety companion. Of
these patients, 84% ( N = 53) had an order for a consult
to the behavioral health social worker, 57% ( N = 36) had
an order entered for suicide precautions and 47.6% ( N =
30) has an order for a safety companion. Th is represents
a 3%, a 6% and a 12.6% improvement, respectively (See
Figure 5 ).
Observation and chart audits were also performed.
Based on audit data, 100% ( N = 63) of patients had a
safety companion at bedside, 82.5% had safety precau-
tions documented ( N = 52) and 76% ( N = 48) had a
behavioral health social work note in the chart within
24 hours of admission.
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0055ID:p0310ID:p0315ID:p0320ID:p0325ID:p0330ID:ti0060ID
:p0335ID:ti0065ID:p0340
Figure 1. Project intervention overview.
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0305

JDNP-D-20-00049 Page 126 18/07/21 11:50 PM
Figure 2. Nursing education content overview.
Figure 3. Nursing education pre- and posttest assessment.
• Suicide Screening
• Review of assessment questions
• Completion of Columbia Suicide Severity Rating Scale for
those who screen positive or present with a primary behavioral
health complaint
• Electronic medical record workfl ow for screening
completion
• Action to be taken if a patient screens positive.
• Patients who screen positive need to be kept safe
immediately
• Patients should be kept under 1:1 observation
• Institute the Nursing Suicide Protocol
• Nursing Suicide Protocol
• RN ensures 1:1 patient observation initiated
• Protocol orders entered for Suicide Precautions and
Behavioral Health Social Work Consult
• Environmental Mitigations
• Patient and belonging search and removal of possible
hazards
• Room check and removal of possible hazards
• Dietary safety tray
• Patient Monitoring Requirements

• 1:1 observation at all times
• Review of transport and patient ambulation process
• Documentation Requirements
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JDNP-D-20-00049 Page 127 18/07/21 11:50 PM
Conclusion
Th e results are overall positive. An increase in screening
compliance was achieved. Literature suggested a com-
pliance rate benchmark of 84%–92%. ( Boudreaux et al.,
2016 ; Stuck et al., 2017 ). Th e project achieved a compli-
ance rate of 99.6%.
A safe care environment must be provided to patients
identifi ed as at risk for suicide. Th e project aimed to
address the root causes of suicide events discussed in the
literature including lack of risk assessment, lack of staff
training, and lack of repeat assessment and supervision
( Grimley-Baker, 2018 ; Mills et al., 2014 ).
A lack of risk assessment was addressed with uni-

versal screening. Patients who screen positive are kept
under direct supervision, addressing the risk of lack of
supervision. Consistency was obtained in placing orders
for suicide precautions, safety companion, and consult
to the behavioral health social worker. Additionally,
the audits confi rmed the correct actions were taken. A
45ID:p0347ID:p0348
Figure 4. Suicide screening.
Figure 5. Order compliance.
90ID:p0300ID:ti0055ID:p0310ID:p0315ID:p0320
JDNP-D-20-00049 Page 128 03/07/21 5:32 AM
safety companion was providing direct supervision and
a behavioral health social worker evaluated the patient
within 24 hours.
Staff knowledge and training was also identified as an
area that can mitigate patient risk (Grimley-Baker, 2018;
Mills et al., 2014). The education provided to the nurses
was comprehensive and included care of the patient from
the time of the screening to discharge. A large percent-
age of nurses attended the training during the defined
period, 91.5%. The majority of nurses who did not attend
the training were on a leave of absence during the train-
ing period. Clinical leaders received notification of the

training needs and followed up with individual nurses as
needed. New hire training will be addressed during ori-
entation, the electronic learning module will be assigned
as mandatory education to all nurses hired going forward.
In conclusion, the project demonstrated improve-
ment in universal suicide screening and implementation
of appropriate safety measures for patients in adult non-
behavioral health units.
Limitations
The results are limited in generalizability as this project
was completed at one site. Additionally, the project was
implemented two months before the COVID-19 pan-
demic impacted the hospital. Disaster state charting was
implemented which may have impacted documentation
compliance.
Implications for Nursing
Universal suicide ideation screening can be successfully
implemented when nurses are provided clear policies,
targeted education, and nurse-driven protocol order sets
and best practice alerts embedded in the electronic medi-
cal record. Especially when order sets and documentation
mirror established nursing workflow. This allows nurses
to be more efficient and improves screening and interven-
tion compliance. These measures increased nurse auton-
omy and efficiency and avoided multiple phone calls to
providers.
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Disclosure. The authors have no relevant financial inter-
est or affiliations with any commercial interests related
to the subjects discussed within this article.
Funding. The author(s) received no specific grant or
financial support for the research, authorship, and/or
publication of this article.
Correspondence regarding this article should be directed
to Anne Lindstrom, DNP, APRN, Rush University,
Northwestern Medicine Central DuPage Hospital, 25
N. Winfield Rd, Winfield, IL 60190. E-mail: anne.
[email protected]
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1564878_eng.pdf?sequence
https://apps.who.int/iris/bitstream/handle/10665/131056/978924
1564878_eng.pdf?sequence
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Improving Suicidal Ideation Screening and Suicide Prevention
Strategies on Adult Nonbehavioral Health Units
BackgroundObjectiveMethodsResultsConclusionImplications
for NursingReferences
Development of the Uni Virtual Clinic: an online programme
for
improving the mental health of university students
Louise M. Farrer , Amelia Gulliver, Natasha Katruss, Kylie
Bennett *, Anthony Bennett*,
Kathina Ali† and Kathleen M. Griffiths ‡
Centre for Mental Health Research, The Australian National
University, Canberra, Australia
ABSTRACT
There is growing recognition of the importance of addressing
the mental
health needs of young people attending university. Anonymous,
scalable,
and evidence-based online interventions can help to reduce
burden on
university services and increase access to care for marginalised
or
disconnected students. This paper reports the participatory
design
methods used to develop the Uni Virtual Clinic (UVC), a
comprehensive
online programme that was designed to prevent and treat mental
health problems and related issues in university students. Data
evaluating the participatory design process is also presented.
The
potential for the implementation of the UVC within university-

based
counselling services is strong, and has potential to reduce the
prevalence of mental disorders in a high-risk group of young
people.
ARTICLE HISTORY
Received 19 December 2018
Revised 17 August 2019
Accepted 9 February 2020
KEYWORDS
University; student; mental
health; online; technology
Introduction
Young adults attending university face high age and life-stage
related risks for developing mental
health problems, with approximately 30-50% of university
students meeting criteria for a mental dis-
order (Auerbach et al., 2018; Eisenberg, Hunt, Speer, & Zivin,
2011; Said, Kypri, & Bowman, 2013). An
Australian study demonstrated a prevalence rate of 33.6%
(Stallman, 2010), and in a large scale, epi-
demiological study of over 5000 college students in the US, the
12-month prevalence of any mental
disorder was almost 50%, with the highest rates of disorder
being substance use disorders (29%),
anxiety disorders (11.9%) and mood disorders (10.6%) (Blanco
et al., 2008). University students
may be at greater risk of mental health problems than their
community-based counterparts, with
research demonstrating that the prevalence of severe
psychological distress is significantly higher
in tertiary students (19-48%) compared to their age-matched
peers not undertaking tertiary edu-

cation (3-11%) (Leahy et al., 2010; Stallman, 2010).
Despite the high prevalence of mental disorders among students,
very few receive appropriate
mental health care (Eisenberg et al., 2011). Similar to young
people in the general community (Rick-
wood & Braithwaite, 1994; Rickwood, Deane, & Wilson, 2007),
when university students seek help for
mental health problems, they typically approach friends, family,
or other non-clinical sources of
support (Eisenberg et al., 2011). Although these informal
sources may be a useful starting point (Rick-
wood & Braithwaite, 1994), it is critical for those with mental
health problems to seek help from evi-
dence-based sources. Less than half of students with a mental
health problem seek professional help
© 2020 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Louise M Farrer [email protected] Centre for Mental
Health Research, The Australian National University,
Building 63, Eggleston Road, Canberra, ACT, 2061, Australia
*Current affiliation: e-hub Health Pty Ltd
(https://ehubhealth.com/).
†Current affiliation: Research School of Psychology, The
Australian National University, Canberra ACT 2601, Australia.
‡Current affiliation: College of Health and Medicine, The
Australian National University, Canberra ACT 2601, Australia.
BRITISH JOURNAL OF GUIDANCE & COUNSELLING
2020, VOL. 48, NO. 3, 333–346
https://doi.org/10.1080/03069885.2020.1729341
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20.1729341&domain=pdf&date_stamp=2020-06-25
http://orcid.org/0000-0001-5694-4631

http://orcid.org/0000-0003-4160-492X
http://orcid.org/0000-0003-1556-0708
https://ehubhealth.com/
http://www.tandfonline.com
for their symptoms, with help seeking rates as low as 5% for
drug and alcohol use disorders (Blanco
et al., 2008; Wynaden, Wichmann, & Murray, 2013). The most
frequently reported barriers to help
seeking by university students include lack of time, high
treatment costs, and concerns about confi-
dentiality and stigma (Givens & Tjia, 2002; Mowbray et al.,
2006).
Online mental health interventions are easily accessible, can be
utilised in private, are cost-
effective, and typically require less time than face-to-face
appointments (Griffiths & Christensen,
2007). Hence, they may be highly suited to the university
student population. Young people fre-
quently report using the internet for help with their mental
health (Burns, Davenport, Durkin, Lus-
combe, & Hickie, 2010). One study reported that 72% of young
people aged 18–25 years believe
that websites are helpful when managing mental health
problems (Oh, Jorm, & Wright, 2009), and
almost half of the young people in another study stated that they
would use the internet to
access information about mental disorders (Burns et al., 2010).
The internet is also commonly used
by young people to confide in peers about problems and to
access forums for “question and
answer” advice (Burns et al., 2010). Additionally, online
interventions targeting mental health pro-

blems have been found to be effective for university students.
Several systematic reviews have
found that computer, internet, and telephone-based mental
health interventions are promising in
university populations, particularly those aimed at improving
anxiety symptoms (Conley, Durlak,
Shapiro, Kirsch, & Zahniser, 2016; Davies, Morriss, &
Glazebrook, 2014; Farrer et al., 2013; Harrer
et al., 2018). A study investigating student attitudes towards
online mental health resources reported
that almost half (47%) of university students indicated that they
would use an online programme for
student wellbeing if one existed, and highly distressed students
were significantly more likely to indi-
cate intent to use such a programme (Ryan, Shochet, &
Stallman, 2010).
Virtual clinics provide streamlined, continuity of care for
chronic physical and mental health con-
ditions (Jennings, Powell, Armstrong, Sturt, & Dale, 2009;
Kethers et al., 2006). Virtual clinic models
typically focus on self-management in care, and incorporate
multiple tools to manage health pro-
blems including information, symptom screening and
monitoring tools, and other therapeutic
content. They are capable of providing evidence-based
resources that are tailored to the specific clini-
cal needs and preferences of the user.
In its role as an Essential Participant organisation in the
Australian Government funded Young and
Well Cooperative Research Centre, the Australian National
University (ANU) developed the Uni Virtual
Clinic (UVC), which is a comprehensive, online service
targeting mental disorders and mental health
problems in tertiary students. The UVC provides mental health

support to university students and
targets all aspects of the mental health intervention spectrum
including promotion, prevention,
early intervention, treatment, relapse prevention and recovery.
Using participatory design
methods, the content and functionality of the UVC were
developed in consultation with young
people (end-users), as well as university stakeholders and other
service providers.
Participatory design is a user-centred process that promotes the
active involvement of the event-
ual users of a product or service in its design and development
(Schuler & Namioka, 1993). Using par-
ticipatory design methods ensures that the service can be
tailored to the target population, creating
strong potential to foster a sense of empowerment and
ownership, which, in turn, may improve
uptake of and engagement with the service (Bovaird, 2007).
Participatory design methods also
involve other stakeholders such as service administrators or
employees in coproducing the service
(Bovaird, 2007). One of the most powerful features of
participatory design is that these stakeholders
are involved at each step of the design process, so that there is a
focus on evaluation, maintenance
and ongoing progression, as well as an ability to design
iteratively, making changes and improve-
ments to the service along the way (Gregory, 2003). This is
particularly important when creating tech-
nology-based interventions that are subject to rapid
technological evolution.
Our aims in the current paper are (a) to describe the
participatory research and development
activities that were undertaken at the ANU to develop the UVC,

(b) to present the resulting
content and functionality of the UVC intervention, and (c) to
present data evaluating the participatory
design process with students.
334 L. M. FARRER ET AL.
Methods
The UVC was developed through multiple interlinked research
and development stages in consul-
tation with young people, university stakeholders, and other
service providers. These stages and
their results are outlined below.
Stage 1: initial scoping
The initial scoping stage was undertaken to inform the
development of a service model (Stage 2) for
the UVC within a university setting. This stage comprised three
systematic reviews, two surveys, and
four focus groups. Each method in this stage was designed to
capture a different component to
inform the development of the UVC.
Systematic reviews
Three systematic reviews were conducted to examine the current
evidence for online and mobile
interventions designed to support university student mental
health.
The first review (Farrer et al., 2013) found that technology-
based (e.g. mobile phone, internet)
interventions targeting mental health and related problems

offered promise for students in university
settings. The data specifically suggested that technology-based
cognitive behavioural therapy (CBT)
was likely to be particularly useful in targeting anxiety.
The second review (Gulliver, Farrer, et al., 2015) examined
interventions targeting tobacco and
other substance use in students (excluding interventions
targeting alcohol, which had previous
demonstrated efficacy in students [Carey, Scott-Sheldon,
Elliott, Bolles, & Carey, 2009]) and concluded
that technology-based interventions increased abstinence from
tobacco in students. However, there
were too few studies to draw conclusions about the efficacy of
technology-based programmes for
other drugs. Together, these reviews demonstrated the high
potential for the utility of a technol-
ogy-based intervention for mental health problems and
substance use in university students.
The final review (Ali, Farrer, Gulliver, & Griffiths, 2015)
examined peer-to-peer support interven-
tions for mental ill-health in young people, and demonstrated a
lack of high-quality studies examin-
ing peer support interventions, despite their common use as an
adjunct to internet interventions for
mental health problems. This finding emphasised the need to
consider the addition and investigation
of the effectiveness of a peer-to-peer component in the UVC.
Stakeholder perspectives
Multiple cycles of obtaining stakeholder input and feedback
were conducted using both qualitative
and quantitative methods. This development stage focused on
examining the acceptability of a
virtual clinic in the university system. This work aimed to

identify the optimal components and pro-
cesses for the UVC, including feedback on the types of services
the clinic should offer (e.g. infor-
mation, prevention, recovery), the delivery modalities (e.g.
web-based, smart phone), the role and
acceptability of symptom screening and monitoring, the level of
intensity and autonomy of
content delivery (guided versus unguided), options for stepped
care, and potential barriers and facil-
itators of engagement and uptake.
This data was collected initially through qualitative studies
(focus groups with students at the ANU
conducted in December 2012) and quantitative studies (two
large scale surveys – one conducted with
ANU university teaching staff in November-December 2013 and
one conducted with ANU students in
October-December 2014). Analyses were undertaken to identify
factors that could be used as a basis
for tailoring the UVC user experience. In addition, the
university teaching staff survey was undertaken
due to the potential influence of staff on student mental health
and help seeking pathways.
Qualitative studies. The qualitative methods primarily included
four focus groups conducted with
university students (n = 5, 5, 4, 5) at the ANU. The focus
groups (n = 19) demonstrated that students
viewed the concept of a university-specific virtual clinic
favourably (Farrer, Gulliver, Chan, Bennett, &
Griffiths, 2015), despite expressing concerns about the privacy
and security of their personal
BRITISH JOURNAL OF GUIDANCE & COUNSELLING 335

information (Gulliver, Bennett, et al., 2015). Conversely, some
students also believed that an online
service would generate increased feelings of confidentiality
when seeking help (Chan, Farrer, Gulliver,
Bennett, & Griffiths, 2016). Further, students indicated that
they wished to connect with professionals
via the virtual clinic (e.g. make appointments with the
university counselling centre), for the clinic to
provide information tailored to issues faced by students, and for
the clinic to enable peer-to-peer
interaction. Overall, the results of these studies demonstrated a
high level of support for a univer-
sity-specific virtual mental health clinic among students. In
addition, a roundtable conducted with
ANU counselling centre staff demonstrated the need for and
acceptability of a virtual clinic within
this service. However, constraints around current methods for
booking appointments via telephone
and the required system changes needed for integration of the
UVC into the counselling service,
meant that the ability for students to book face to face
counselling appointments through the
virtual clinic was slated for a future iteration of the UVC.
Quantitative studies. The quantitative methods comprised two
surveys, one with university staff
involved in teaching and supervising students, and the other
with students, both at the ANU.
The student survey (Farrer, Gulliver, Bennett, Fassnacht, &
Griffiths, 2016) was designed to examine
prevalence rates of mental disorders, risk factors, and feedback
on UVC content and functionality
among a sample of Australian university students. A total of
611 ANU students were recruited to

the study (response rate 11.6%). The survey yielded a point
prevalence rate of 7.9% for major
depression, and 17.5% for generalised anxiety disorder (GAD)
(Farrer et al., 2016). The results indicated
that students in their first year of undergraduate study were at
greatest risk of depression, whereas
female students, those who moved to attend university, and
students experiencing financial stress
were at greatest risk of GAD. Students with experience of body
image issues and lack of confidence
were at significantly greater risk of major depression. Finally,
factors such as feeling too much
pressure to succeed, having a lack of confidence, and having
difficulty coping with study were signifi-
cantly associated with risk of GAD among respondents. This
survey confirmed the high rates of
common mental health problems in students, and also suggested
that certain groups of students
may particularly benefit from accessing the UVC and other
mental health services.
Although student feedback was critical to the intervention
development process, gaining the per-
spectives of other relevant stakeholders such as academic
staffwas also essential. University staffwho
have regular contact with students (lecturers, tutors, and
research supervisors) are often a first point
of contact for academic accommodations (e.g. extensions of due
dates) and referral to mental health
support. Thus, it is important to understand the attitudes of
teaching staff about offering support to
students, and in particular, the types of support they are likely
to recommend. Accordingly, we under-
took a survey examining the attitudes and mental health literacy
of teaching staff at the ANU (n =
224). This survey demonstrated that many university teaching

staff were highly sceptical about the
quality and effectiveness of online mental health interventions,
with only 22.3% believing they
were a credible treatment option (Farrer, Gulliver, Bennett, &
Griffiths, 2015). Further, a large pro-
portion of staff did not believe that it was part of their role to
intervene in student mental health.
These findings were important as the attitudes of academic
teaching staffmay affect their willingness
to recommend the UVC to students as a source of help. It was
concluded that in order to maximise
uptake of the UVC, it is critical to increase positive attitudes
towards online mental health interven-
tions among university teaching staff.
Stage 2: service model development
The second stage of the development of the UVC involved the
iterative development and refinement
of the service model for the clinic. Based on the research
conducted in Stage 1, the project team
developed a preliminary model which incorporated: (a) concepts
of how a user might experience
or interact with the UVC, including over time; (b) possible
components/features of the UVC; (c)
how the UVC might best communicate with other university
service providers and other stake-
holders; (d) functionality and content of the clinic that may
require tailoring for different sub-
groups of users; and (e) how new or existing users might be
screened or directed to services as part of

their use of the clinic (e.g. stepped care).
Feedback on the service model was obtained through iterative
cycles of prototype development
and user testing. The suggestions raised by users in a feedback
session were used to re-develop the
existing prototype, which was then subjected to further
stakeholder input during the next prototype
session. Three 1-hour prototype testing sessions were conducted
with university students (n = 6; 3
male, 3 female, mean age = 21.2 years) (Gulliver, Bennett, et
al., 2015).
In addition to this, the project team conducted several face-to-
face discussions with university sta-
keholders to assess the information and service needs of
different sub-groups of students (e.g. stu-
dents with a disability, postgraduates, international students).
This was to ensure that the UVC
content and functionality was as relevant as possible to all
potential user groups across the university.
The refinement of the service model was also informed by IT
and clinical perspectives, which ensured
that the model was feasible, that user privacy and
confidentiality could be adequately protected, and
that legal and duty of care obligations were considered.
Finally, a Student Leadership Group was established in 2014
and comprised 10–15 students each
year (2014–2016) from theANU to assist with the development
and testing of the clinic. These students
provided input on all aspects of UVCdesign anddevelopment
including graphic design, aswell as tools
and functionality. A number of students also contributed to
content development by agreeing to be
interviewed about their experiences with mental health issues.

These interviews were recorded, tran-
scribed, and used to inform the creation of real (de-identified)
stories of student experiences of mental
health issues for the UVC. In addition to the input provided by
the students in this group, a web
designer with extensive experience in designing mental health
focused websites partnered with
the project to develop the logo, graphic design, and assist with
the web functionality of the UVC.
Stage 3: software implementation
Stage 3 involved software implementation, which was
undertaken by an in-house technical staff
team within the ANU, and was managed by senior staff with
extensive multi-disciplinary experience
in e-health intervention research. The Student Leadership group
of ANU students were also involved
in providing feedback into the design of the UVC at this stage.
Evaluation of participatory design
To assess the impact of participating in a user-centred design
process, students who participated in
workshops and prototype testing sessions were asked to
complete a brief survey at the end of the
session. Data were collected from 20 participants (male = 7,
female = 12, no answer = 1) from three
prototype testing sessions, a student leadership group workshop,
and the final evaluation of the
pilot UVC by the student leadership group.
Participants were asked to indicate their level of agreement with
32 adjectives, presented after a
statement (e.g. “After participating in today’s session, I feel…
.safe/empowered/interrogated/

valued”). Of these 32 adjectives, 19 were positive (e.g. safe,
empowered, respected) and 13 were
negative (e.g. bored, useless, interrogated). A full list of the
adjectives is provided in Appendix.
Ratings of agreement were made on a 5-point scale ranging
from strongly disagree (−2) to strongly
agree (2). A neutral response of “neither agree nor disagree”
was coded as 0.
Results
The UVC intervention
The resulting intervention that was developed, the UVC, is an
online programme for university stu-
dents to support and manage their mental health. The goal of the
UVC is to connect students
with the mental health information and support they need. This
may include learning more about
mental disorders, completing a symptom quiz, trying a self-help
therapy programme, or finding
out how to make an appointment with a face-to-face treatment
provider.
The UVC is also designed to assist students with varying needs,
including those who want to
manage their mental health, those who want to help their friends
through a crisis, and those who
experience difficulties in times of stress. Figure 1 shows the
original development model for the
UVC, demonstrating the interaction between the UVC and the

student, as well as potential interaction
between other groups on or off campus including clinicians,
researchers, service providers, and
student administration. However, the current pilot version of the
clinic was modelled to accommo-
date student users only. In this version, students are not able to
book appointments directly via
the website and there is no facility for counsellors to access any
of the UVC quiz results or workbooks.
This departure from the planned model was partly a
consequence of the high level of administrative
system change required to integrate the clinic within the
existing university health system (which is
somewhat dependent on non-UVC systems), and partly because
students were highly concerned
about the potential for other staff from the university being able
to access their personal information
(e.g. staff that are not involved in health service delivery)
(Gulliver, Bennett, et al., 2015).
The UVC targets four major groups of mental disorders that
commonly affect university students:
mood disorders (major depression, bipolar disorder); anxiety,
obsessive compulsive, and trauma-
related disorders (generalised anxiety disorder, social anxiety
disorder, obsessive compulsive dis-
order, post traumatic stress disorder, specific phobia, panic
disorder, agoraphobia); substance use dis-
orders (alcohol, smoking, and other drugs); and eating disorders
(anorexia, bulimia, binge eating
disorder).
The UVC also contains resources targeting common issues
experienced by university students that
impact on their mental health including: insomnia; suicide and
self-harm; financial issues; loneliness/

social isolation; relationship issues; homesickness; adjustment
to university (specific focus on inter-
national students); grief and loss; career and life after
university; perfectionism; stress; physical
health (nutrition, exercise), time management and
procrastination, disability, living arrangements;
sexual and gender identity; and exam anxiety.
Figure 1. Original service model of the UVC.
What does the UVC do?
The primary features of the UVC are:
(1) Information (factsheets tailored to the university student
population, services, student stories
about mental health and other problems)
(2) Screening (quizzes, feedback and recommendations)
(3) Self-help tools (tailored guided and unguided pathways to
care, access to online treatment
programmes)
These features are described in more detail below. Features
intended to be added to future ver-
sions of the UVC are also described (e.g. providing access to
professionals via an online booking
system and a peer-to-peer support forum/chat sessions).
Information
There is evidence that online information can be an effective
intervention for mental health problems

(Donker, Griffiths, Cuijpers, & Christensen, 2009; Griffiths,
Christensen, Jorm, Evans, & Groves, 2004).
The UVC comprises factsheets targeting all major mental
disorders and related issues (see Figure 2),
and information about online and face-to-face services within
the university setting and in the commu-
nity. A critical element of the UVC is that all the information
provided is tailored to university students, a
feature not available on more generic online mental health
websites or portals. The UVC contains infor-
mation about the prevalence of mental health problems in
university students, signs and symptoms, risk
factors, impact on university life, help seeking, prevention, and
treatment. Additional information is pre-
sented in the form of real (de-identified) stories of students’
experiences with mental health problems.
Figure 2. UVC factsheets.
These stories are designed to give users an insight into the lived
experiences of other students, which
has been shown previously to reduce stigma (Pinfold,
Thornicroft, Huxley, & Farmer, 2005).
Screening
The UVC contains brief, validated screening measures for all
mental disorders and some related
issues. Screeners provide feedback about symptoms, normative
data that allows students to
compare their symptom levels with other young people their
age, feedback about how their symp-
toms have changed since they last completed the screener, and

recommendations for help based on
their scores.
Self-help tools
The UVC offers a range of self-help tools developed by the
Centre for Mental Health Research (CMHR)
and other leading e-health researchers. These tools are based on
evidence-based psychotherapeutic
principles such as cognitive behaviour therapy (CBT),
interpersonal therapy (IPT), exposure therapy,
relaxation, problem solving therapy, and mindfulness. Users can
complete these tools at their own
pace. Some tools are combined into treatment packages that
guide the user through screening, psy-
choeducation, and treatment for a particular disorder.
Access to professionals
Future iterations of the UVC will explore the capacity for
integration with existing mental health and
other services within and external to the university environment
to facilitate access to professionals.
This may include an integrated booking system that allows
students to make appointments with uni-
versity counselling and health centres, and online therapy
services delivered by clinical psychology
interns through chat, e-mail or Skype.
Peer support
Another proposed function of the UVC will be to enable users
to connect with other students through
an asynchronous forum and/or synchronous chat sessions. The
forum and chat sessions will be mod-
erated to ensure user safety.
Problem-solving tool
A key priority of the UVC is to enable young people to find

right help as quickly and easily as possible.
Young people may differ in their ability to recognise and label
mental health problems in themselves or
their friends. To accommodate this, users have several options
for seeking help from the UVC homepage.
Resources specific to mental disorders and related issues are
clearly accessible from links on the home-
page. For users who are not sure what they are looking for, the
problem-solving tool (see Figure 3) on the
homepage (see Figure 4) allows them to select from options that
reflect their experience from a range of
statements (e.g. I’m feeling stressed, I can’t concentrate, I’m
not coping). These statements link to path-
ways that direct the user to the most relevant content based on
their current experience.
Guided and unguided pathways
Unguided pathways allow the user complete autonomy to
browse all of the available UVC resources
at once, whereas guided pathways using the problem-solving
tool as described above, guide the user
through available resources and make recommendations that
best fit the user’s situation. Users can
choose between guided and unguided pathways at all times
within the UVC.
User control of privacy
The user can choose how they wish to interact with the UVC.
This is achieved by enabling the user to
specify how personal information is collected and stored by the
clinic over time, and to configure
how the clinic interacts with them through personal reminders
and updates.

Evaluation of user-centred design
Demographics
The age of participants ranged from 18 to 23 years (M = 20.8),
and they were evenly distributed from
first year (n = 3; 15%) to fifth year students (n = 3; 15%). Just
over half of participants had previously
experienced a mental health problem themselves (n = 11; 55%),
and a majority had someone close to
them experience a mental health problem (n = 16; 80%). There
were two international students
(10%), half lived on campus (n = 10; 50%), and they were from
a wide range of disciplines including
Figure 4. UVC homepage.
Figure 3. Problem-solving tool.
combined and single degrees in Psychology, Engineering, Law,
International Relations, Arts, Science,
Commerce, Business Administration, and Asia Pacific Studies.
Evaluation data
Overall, attitudes towards participation were positive, with each
of the 19 positive items receiving
average ratings above 0, indicating agreement (M = 0.96, SD =
0.24; range from 0.50 for “energised”
to 1.35 for “valued”). Each of the 13 negative items received
average ratings below 0, indicating dis-
agreement (M =−1.50, SD = 0.46; ranging from −1.05 for

“confused” to −1.70 for “useless”). Adjec-
tives that received the highest average scores (indicating
strongest agreement) were valued (M =
1.35, SD = 0.49), safe (M = 1.30, SD = 0.57), helpful (M =
1.20, SD = 0.41), involved (M = 1.20, SD = 0.41),
respected (M = 1.15, SD = 0.37), and glad (M = 1.15, SD =
0.67). Those that received the lowest
average scores (indicating strongest disagreement) were useless
(M =−1.70, SD = 0.47), powerless
(M =−1.65, SD = 0.49), interrogated (M =−1.65, SD = 0.49),
uncomfortable (M =−1.65, SD = 0.49), and
distressed (M =−1.65, SD = 0.49).
Discussion
In this paper we describe the development of a complex online
intervention for a university student
population. The UVC is an innovative, scalable, and flexibly
built tool that has strong potential for dis-
semination in universities nationally and internationally. The
UVC also has potential to serve as a
model for developing such clinics for young people in other
settings such as schools.
Crucially, given the high rates of mental health problems in
young people at university, the UVC
has the potential to create mentally healthy universities by
reducing the prevalence of mental dis-
orders in a high risk group of young people and averting the
associated distress, poor academic out-
comes, dropout, career loss, and impaired social functioning.
University graduates can take their
learnings from the clinic with them into the workplace and other
settings. However, future invest-
ment in this programme, as well as increased recognition and
funding for the implementation and

evaluation of the UVC is required.
There were several benefits and challenges associated with
using a participatory design approach
in the development of the UVC. Participatory design was
fundamental to the UVC development
process and allowed for the UVC to be designed according to
the priorities and preferences of
end users. Most students who had participated in the design
process for the UVC reported that
they felt “valued”, “helpful”, “involved”, and “respected”,
suggesting that being included in the
process was an empowering experience. Regardless of its
potential to improve effectiveness, and
encourage user acceptance and adoption of a programme, it has
been argued that a moral impera-
tive underlies participatory design to enable people to gain more
control over their health care and
quality of life (Frauenberger, Good, Fitzpatrick, & Iversen,
2015).
Engaging students in the design process allowed the
development team to consider the changing
needs of students and university environments, as well as
technological advances in web design and
development strategies for e-mental health services. Conducting
student surveys, engaging in
student consultations, and the creation of the Student
Leadership Group resulted in wide promotion
of the UVC across the ANU campus. This improved the
visibility of the UVC within the student com-
munity, and cultivated a positive attitude towards the UVC as
an e-mental health tool for students,
particularly due to the university community’s engagement and
consultation throughout the UVC
design and development process.

There were also challenges associated with using a participatory
design approach. Engaging end-
users in design and development is time-consuming and
resource intensive, and this impacted on
the time required for content creation and web development. It
was also difficult to determine
when user engagement in a particular development phase was
considered “complete”. In addition,
feasibility issues in the ability of the project team to implement
all of the recommendations of the
end users, either due to technical difficulty, or budgetary
constraints. Further, there was often
disagreement within and between end-user groups and other
stakeholders regarding UVC content
and functionality, which was challenging to harmonise in the
resulting programme. Additional
difficulties arose in engaging students in the participatory
design process itself, as students often
had limited availability throughout the semester, and many were
unavailable outside of semester
dates. Therefore, much of the design and development work for
the UVC was constrained by the aca-
demic calendar.
The UVC has the potential to assist universities to increase their
capacity to provide support to
students with mental health issues. Future directions for
research include a proof-of-concept trial
to assess engagement and uptake of the programme, satisfaction,
and mental health symptom

reduction, followed by a fully-powered, multi-site randomised
controlled trial (RCT). If shown to be
effective, the programme can be implemented in several ways
within a university setting. Given
that the programme targets all parts of the intervention
spectrum, it has the potential to be used
not only as a treatment tool, but for large scale prevention/early
intervention, or even relapse preven-
tion for students recovering from an acute episode of a mental
health problem. Within a university
counselling environment, the UVC could be used to screen and
triage students entering the service,
to provide resources to students while they are waiting for an
appointment, to augment face-to-face
counselling with homework exercises that students can complete
between sessions, or as a
step-down service to support students following counselling. It
could also have utility for groups
of students who find it difficult to engage with on-campus
services (e.g. remote students who
study predominantly off-campus).
University students experience high rates of mental health
problems, and face significant chal-
lenges in terms of help seeking barriers and treatment
accessibility. The UVC is a scalable, evi-
dence-informed intervention that has the potential to reduce
burden on campus mental health
services, and treat or prevent the development of mental health
problems in a high-risk group of
young people.
Acknowledgements
The authors would like to thank the following people for their
contributions to the project: Rebekah Anne-Smith, Annika

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