Implementing Digital Suicide Risk Screening in Behavioral Health: a Mixed-methods Study of Organizational Adaptation

Digital behavioral health platforms extend clinical capabilities beyond traditional appointment-based care, but implementation challenges limit their routine use. Although validated suicide risk screening instruments exist and evidence suggests individuals provide honest responses in digital contexts, how behavioral health organizations implement asynchronous screening remains poorly understood. This exploratory study examined implementation experiences from nine behavioral health organizations that adopted digital suicide screening. Nine behavioral health organizations that implemented remote, asynchronous Columbia Suicide Severity Rating Scale (C-SSRS) screening completed post-implementation surveys. Using a mixed-methods approach combining Interpretative Phenomenological Analysis and VADER sentiment analysis, we identified implementation patterns, organizational adaptations, and provider attitudes across diverse service settings. Implementation challenges clustered into operational, technical, clinical, and systemic domains. Operational challenges involved workflow integration, staff training, and protocol development, while technical challenges included EHR integration, digital divide concerns, and alert volume management. Clinical challenges centered on screening quality, therapeutic rapport, and risk factor evaluation, while systemic challenges reflected resource constraints, crisis response protocols, and staff capacity. Provider attitudes evolved from initial anxiety and role uncertainty in early-stages to strong support among advanced-stage organizations, where 48% expressed very supportive and 32% expressed moderately supportive sentiments. Sentiment analysis of alert-workflow responses indicated generally positive attitudes across organizations (mean score = 0.24 on a scale of -1 to 1). Two preliminary frameworks emerged from analysis: the Service Delivery Ecosystem Framework describes context-specific adaptation patterns observed in this sample, and the Implementation Stage Framework characterizes common progression from initial rollout to mature implementation. These findings offer preliminary considerations for organizations planning digital suicide screening integration.