American Indian and Alaska Native communities are facing increasing rates of suicide, with death by suicide now the second leading cause of death among non-Hispanic AI/AN individuals in the United States. In response, nearly all Health and Human Services agencies are working to address these high rates.
In 2024, the Indian Health Service (IHS) issued a policy requiring all federal IHS facilities to screen patients for suicide risk using the Ask Suicide-Screening Questions (ASQ) tool by September 2025. For some facilities, this meant replacing their current screening instrument; others needed to develop new processes, train providers, track screening results, and establish protocols for assessing and treating high-risk patients.
The Clinton IHS Health Center in Western Oklahoma serves members of the Cheyenne and Arapaho Tribes as well as other American Indian and Alaska Native communities in Oklahoma. Established in 1955 with a modern facility opening in 2007, it offers various ambulatory care services such as behavioral health, dental, orthopedics, pharmacy, and physical therapy.
Beginning in July 2025, staff at Clinton started administering both the ASQ and either the Patient Health Questionnaire-9 (PHQ-9) or its adolescent version every 90 days to all patients—including those not receiving behavioral health services. In its first month of implementation, 2,109 patients were screened with the ASQ.
To achieve this milestone, Clinton used three main strategies: customizing training by provider type; adapting the screening process to local needs; and scaling up through service-specific clinical pathway models.
The National Suicide Prevention office at IHS provided general training materials for implementing ASQ. However, because Clinton had not fully integrated behavioral and physical health services—a challenge shared by many IHS facilities—it adapted these materials so each provider type received information relevant to their roles. Behavioral health staff also met regularly with physical health staff to review progress and resolve challenges.
The ASQ toolkit was developed by the National Institute of Mental Health in 2008 and validated among adults in 2014. At Clinton Health Center, leadership added an extra step: after patients completed the ASQ on their own, providers reviewed responses verbally with them while cross-checking medical records. One provider said:
“I had an adolescent complete the suicide screening indicating that in the past few weeks, [the patient] had not wished [she] were dead. Yet, when I reviewed her record, she had had an emergency room visit for suicidal thoughts earlier in the month. When I asked her about the ER visit, she began to reflect on how she was doing honestly and we were able to obtain a more accurate screening.”
To clarify procedures further for documentation purposes, Clinton renamed “assessment” as “behavioral health evaluation,” ensuring only behavioral health providers could conduct follow-up evaluations or assessments if indicated by electronic records.
Clinical pathway models—visual guides outlining who is responsible at each stage of care—were tailored for each service unit within Clinton Health Center. Staff contributed feedback during development discussions led by behavioral health leadership.
As more IHS facilities adopt ASQ under federal policy requirements set for September 2025 implementation deadlines, lessons from centers like Clinton may inform broader efforts aimed at early identification of suicide risk and improved mental health support within American Indian/Alaska Native communities.
