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What if you reach Step 3 and determine that you need to screen for substance abuse, rather than for suicide risk? Your initial conversation might have revealed details about the patient's pattern of use of alcohol or other substances. If you think the patient may be at-risk, how do you determine his level of risk?

A variety of toolkits are available for use in conducting an alcohol screening, which can help determine whether patients are low-risk, increased-risk, high-risk for alcohol abuse, or high-risk for alcohol dependency. My preference is the RAPS 4 Q.F. Each letter of the acronym helps you remember a specific topic to cover in the screening.

R. Remorse. Sometimes after drinking, people may have feelings of guilt, remorse, or regret. Such feelings are associated with increased risk. Ask patients questions like, "During the last year, have you felt guilty or remorseful after drinking?"

A. Amnesia. Even one occasion of heaving drinking may cause lapses in memory referred to as "blackouts," and chronic heavy drinking can damage parts of the brain associated with long-term memory and the formation of new memories. In the screening, ask patients, "During the last year has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?"

P. Performance. Drinking may impede patients' ability to function and perform tasks or fulfill roles that are normally expected of them. You can ask, "During the last year have you failed to do what was normally expected from you because of drinking?"

S. Starter, or eye-opener. Individuals who are physically dependent on alcohol often need a drink upon awakening to feel "okay" and get them going through their day. Ask patients, "Do you sometimes take a drink in the morning when you first get up?"

Q. Quantity. Always ask patients specifically about quantity. Male patients are at higher-risk if they drink more than five drinks on one occasion, while women are at higher-risk if they drink more than four drinks on one occasion. You may also need to explain what constitutes a drink: one 12-ounce beer, one 5-ounce glass of wine, or one standard mixed drink, which includes a shot of spirits. During the screening, ask patients, "During the last year, have you had five or more drinks on at least one occasion?"

F. Frequency. Knowing how frequently patients drink and for how long they've been drinking is important in determining their level of risk. You can ask, "During the past year how often did you drink?"