Identification of At-Risk Youth by Suicide Screening in a Pediatric Emergency Department

Factors associated with repeat emergency department visits for mental health care in adolescents: A scoping review

OBJECTIVES

The aim of this review was to identify factors associated with multiple visits to emergency department (ED) services for mental health care in adolescents.

METHODS

Electronic databases (MEDLINE, PsycINFO, Embase, CINAHL, Web of Science and ProQuest Dissertations & Thesis Global) were searched for evidence that presented an association between risk factors or correlates of multiple visits to the emergency departmental for mental health care by 10-24 year olds. High impact use was defined as at least one return ED visit for mental health care. Primary studies of any quantitative design were included, with no exclusions based on language or country and all possible risk factors were considered. Data were extracted and synthesised using quantitative methods; frequencies of positive, negative and null associations were summarised for categories of potential risk factors.

RESULTS

Sixty-five studies were included in the review. Most studies were from North America and reported a wide range of measures of high impact ED use, the most common being a binary indicator of multiple ED visits. Sex/gender and age were the most frequently reported risk factors. Measure of previous or concurrent access to mental health care was consistently positively associated with high impact use. Having private health insurance, compared with public or no insurance, was generally negatively associated with high impact use. Proxy measures of socioeconomic position (SEP) showed associations between lower SEP and more high impact use in a small number of studies. No other factors were consistently or uniformly associated with high impact use.

CONCLUSIONS

The review identified a substantial evidence base but due to the variability in study design and measurement of both risk factors and outcomes, no consistent risk factors emerged. More research is needed, particularly outside North America, using robust methods and high quality routinely collected data.

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis

Background

Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway.

Aims

To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment.

Objectives

To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK.

Data sources

Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites.

Review methods

A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines.

Results

From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan.

Limitations

Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment.

Conclusions

No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement.

Study registration

This study is registered as PROSPERO CRD42021276671.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

Worsening Symptoms of Anxiety, Depression, and Sleep Problems in Caregivers Following Youth's Suicide-Related Emergency Department Visit

OBJECTIVE

Although families assume considerable responsibility in caring for their child after a suicidal crisis, little is known about caregiver well-being following a suicide-related pediatric Emergency Department (ED) visit. This study aimed to (1) describe the course of caregiver distress symptoms (e.g., anxiety, depression, and negative affect) and sleep problems following their child's suicide-related ED visit and to (2) identify factors (e.g., parents' mental health history, youth suicide risk chronicity, and perception of feeling supported by the mental health system) hypothesized to be related to caregiver distress symptoms and sleep problems at follow-up using a diathesis-stress model framework.

METHOD

Participants included 118 caregiver/youth (ages 11-17) dyads presenting to a psychiatric ED due to youths' suicide-related concerns. Caregivers and youth were assessed during index ED visit and 2-weeks following discharge.

RESULTS

Caregivers' anxiety and depressive symptoms and sleep problems increased significantly from the time of the ED visit to 2-week follow-up. There was no significant change in caregiver negative affect. Caregivers with their own history of mental illness and those whose children had a previous ED visit due to a psychiatric concern, suggestive of chronic suicide risk, reported higher anxiety and depressive symptoms at follow-up.

CONCLUSION

In the 2 weeks following an ED visit for their child's suicidal crisis, caregivers reported significant increases in anxiety and depressive symptoms and sleep problems. Findings highlight the need to consider the mental health of caregivers whose children are at elevated risk for suicide.HighlightsCaregivers report increases in distress symptoms following youth's suicidal crisis.Caregiver mental health history and youth suicide chronicity impacted distress.Caregiver mental health should be considered when planning youth interventions.

Measurement Choices for Youth Suicidality

Suicide is among the leading causes of death among individuals ages 10-24, making suicidal thoughts and behaviors (STBs) a serious public health crisis among youth. Suicide risk screening and assessment are vital to addressing this public health crisis. In fact, many youths that screen positive for suicidal ideation do not have known mental health concerns and would have been missed if not asked directly. Medical settings are an optimal setting to detect suicidality early and provide appropriate follow-up monitoring and care as needed. To support effective and efficient screening and assessment of suicidal thoughts and behaviors, providers must choose measures with both strong psychometric properties and clinical utility. While measurement of STBs can vary across health settings, suicide risk screening and assessment typically involves gathering information about current suicidal ideation, suicidal behaviors, and suicidal plans via self-report questionnaires, clinical interviews, and/or computerized adaptive screens. In alignment with measurement-based care efforts, the current manuscript will provide a scoping review of measures of youth suicidal ideation, behavior, plans, and their risk factors. Specifically, the psychometric properties, clinical utility, and other key considerations for screening and assessment of adolescent suicide risk are discussed.

Suicide Prevention in Pediatric Health Care Settings

Given recent trends demonstrating increased suicide risk among youth, particularly those from minoritized populations, youth suicide is a major public health concern. Evidence-based practices for the identification and management of youth suicide risk have been developed, yet many challenges exist to implementing them routinely in health care settings. Suggestions for leveraging publicly available resources, gathering input from a range of stakeholders to inform implementation, and enhancing multidisciplinary collaboration are provided with the aim of offering tangible steps toward addressing the youth suicide crisis.

Suicides among Children and Adolescents in Paraguay: An 18-year National Exploratory Study (2004-2022)

BACKGROUND

Suicide and suicide attempts are impacting events for patients and their relatives, and these behaviors are still taboo among adults and may be even more traumatic when involving children and adolescents.

AIM

In this study we aimed to describe suicide rates among children and adolescents in Paraguay over the last decades as well as associated factors such as sociodemographic characteristics and methods used for suicide.

METHODS

This was an observational and exploratory study describing the frequency and characteristics of suicide among children and adolescents in Paraguay between 2004 and 2022. Official records of all deaths by suicide were reviewed, and statistical analyses were performed. In addition, an attempt was made to predict the number of suicides in the next 5 years using a mathematical model based on simple linear regression.

RESULTS

In the 18-year period observed, 940 suicides among children and adolescents were recorded. The mean age was 15.05 ± 1.8 years old. Of these, 51.17% were male, 74.6% were from urban areas, and 22.2% were from the Greater Asunción and Central Department of Paraguay. The most frequently used method of suicide was intentional self-inflicted injury by hanging, strangulation, or suffocation, which all represented 75.3% of the cases. Our mathematical modeling based on simple linear regression determined that the expected yearly number of national suicides in the pediatric population for the following years, from 2023 to 2027, will range between 72 and 81.

CONCLUSION

This study is the first large national epidemiological report on the emerging issue of suicide among children and adolescents in Paraguay. It may be a relevant source of information for mental health professionals, health authorities, and decision makers to develop national prevention strategies and actions against suicide among youths.

Comparing the Acceptability and Quality of Intervention Modalities for Suicidality in the Emergency Department: Randomized Feasibility Trial

BACKGROUND

Emergency departments (EDs) manage many patients with suicide risk, but effective interventions for suicidality are challenging to implement in this setting. ReachCare is a technology-facilitated version of an evidence-based intervention for suicidal ED patients. Here, we present findings on the acceptability and quality of ReachCare in the ED, as well as a comparison of these measures across 3 potential delivery modalities.

OBJECTIVE

Our aim was to test the feasibility of the ReachCare intervention in its entirety through conducting a pilot study with patients presenting with suicidality to the ED. We tested three different ways of receiving the ED-based components of ReachCare: (1) self-administered on the tablet app using a chatbot interface, (2) administered by an in-person clinician, or (3) administered by a telehealth clinician.

METHODS

In total, 47 ED patients who screened positive for suicide risk were randomly allocated to receive one of three delivery modalities of ReachCare in the ED: (1) self-administered on the patient-facing tablet app with a chatbot interface, (2) delivered by an in-person clinician, or (3) delivered by a telehealth clinician, with the latter two using a clinician-facing web app. We measured demographic and clinical characteristics, acceptability and appropriateness of the intervention, and quality and completeness of the resulting safety plans.

RESULTS

Patients assigned high ratings for the acceptability (median 4.00/5, IQR 4.00-4.50) and appropriateness (median 4.00/5, IQR 4.00-4.25) of ReachCare's ED components, and there were no substantial differences across the 3 delivery modalities [H(acceptability)=3.90, P=.14; H(appropriateness)=1.05, P=.59]. The self-administered modality took significantly less time than the 2 clinician modalities (H=27.91, P<.001), and the usability of the self-administered version was in the "very high" range (median 93.75/100, IQR 80.00-97.50). The safety plans created across all 3 modalities were high-quality (H=0.60, P=.74).

CONCLUSIONS

Patients rated ReachCare in the ED as highly acceptable and appropriate regardless of modality. Self-administration may be a feasible way to ensure patients with suicide risk receive an intervention in resource constrained EDs. Limitations include small sample size and demographic differences between those enrolled versus not enrolled. Further research will examine the clinical outcomes of patients receiving both the in-ED and post-ED components of ReachCare.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04720911; https://clinicaltrials.gov/ct2/show/NCT04720911.

The Cost of Universal Suicide Risk Screening for Adolescents in Emergency Departments

Suicide is the second leading cause of death among adolescents. As nearly 20% of adolescents visit emergency departments (EDs) each year, EDs have an opportunity to identify previously unrecognized suicide risk. A novel Computerized Adaptive Screen for Suicidal Youth (CASSY) was shown in a multisite study to be predictive for suicide attempts within 3 months. This study uses site-specific data to estimate the cost of CASSY implementation with adolescents in general EDs. When used universally with all adolescents who are present and able to participate in the screening, the average cost was USD 5.77 per adolescent. For adolescents presenting with non-behavioral complaints, the average cost was USD 2.60 per adolescent. Costs were driven primarily by time and personnel required for the further evaluation of suicide risk for those screening positive. Thus, universal screening using the CASSY, at very low costs relative to the cost of an ED visit, can facilitate services needed for at-risk adolescents.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

Evaluation of the Risk Identification for Suicide and Enhanced Care Model in a Native American Community

Importance

There are many prognostic models of suicide risk, but few have been prospectively evaluated, and none has been developed specifically for Native American populations.

Objective

To prospectively validate a statistical risk model implemented in a community setting and evaluate whether use of this model was associated with improved reach of evidence-based care and reduced subsequent suicide-related behavior among high-risk individuals.

Design, Setting, and Participants

This prognostic study, done in partnership with the White Mountain Apache Tribe, used data collected by the Apache Celebrating Life program for adults aged 25 years or older identified as at risk for suicide and/or self-harm from January 1, 2017, through August 31, 2022. Data were divided into 2 cohorts: (1) individuals and suicide-related events from the period prior to suicide risk alerts being active (February 29, 2020) and (2) individuals and events from the time after alerts were activated.

Main Outcomes and Measures

Aim 1 focused on a prospective validation of the risk model in cohort 1. Aim 2 compared the odds of repeated suicide-related events and the reach of brief contact interventions among high-risk cases between cohort 2 and cohort 1.

Results

Across both cohorts, a total of 400 individuals identified as at risk for suicide and/or self-harm (mean [SD] age, 36.5 [10.3] years; 210 females [52.5%]) had 781 suicide-related events. Cohort 1 included 256 individuals with index events prior to active notifications. Most index events (134 [52.5%]) were for binge substance use, followed by 101 (39.6%) for suicidal ideation, 28 (11.0%) for a suicide attempt, and 10 (3.9%) for self-injury. Among these individuals, 102 (39.5%) had subsequent suicidal behaviors. In cohort 1, the majority (220 [86.3%]) were classified as low risk, and 35 individuals (13.3%) were classified as high risk for suicidal attempt or death in the 12 months after their index event. Cohort 2 included 144 individuals with index events after notifications were activated. For aim 1, those classified as high risk had a greater odds of subsequent suicide-related events compared with those classified as low risk (odds ratio [OR], 3.47; 95% CI, 1.53-7.86; P = .003; area under the receiver operating characteristic curve, 0.65). For aim 2, which included 57 individuals classified as high risk across both cohorts, during the time when alerts were inactive, high-risk individuals were more likely to have subsequent suicidal behaviors compared with when alerts were active (OR, 9.14; 95% CI, 1.85-45.29; P = .007). Before the active alerts, only 1 of 35 (2.9%) individuals classified as high risk received a wellness check; after the alerts were activated, 11 of 22 (50.0%) individuals classified as high risk received 1 or more wellness checks.

Conclusions and Relevance

This study showed that a statistical model and associated care system developed in partnership with the White Mountain Apache Tribe enhanced identification of individuals at high risk for suicide and was associated with a reduced risk for subsequent suicidal behaviors and increased reach of care.

"Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors

OBJECTIVES

Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018.

RESULTS

After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies).

CONCLUSIONS

The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).

Health Diagnoses and Service Utilization in the Year Before Youth and Young Adult Suicide

OBJECTIVE

Suicide rates among young people are rising. Health care visits provide opportunities for identification and intervention, yet studies have been limited by small or circumscribed samples. This study sought to expand the knowledge base by examining health care encounters and diagnoses among young people who later died by suicide.

METHODS

This case-control study examined diagnoses of mental and general medical disorders and health care utilization in the 30 and 365 days before suicide death in nine large U.S. health care systems. Data (years 2000-2015) from 445 suicide decedents ages 10-24 years were matched with data from 4,450 control group patients.

RESULTS

Suicide decedents were more likely to have at least one mental disorder diagnosis (51% vs. 16%; adjusted OR [AOR]=5.74, 95% CI=4.60-7.18) and had higher rates of nearly all mental health conditions. Substance use disorders were common (12%) and more likely (AOR=8.50, 95% CI=5.53-13.06) among suicide decedents. More than one in three (42%) suicide decedents had a health care visit in the month before death, and nearly all (88%) had a visit in the previous year.

CONCLUSIONS

Despite the greater likelihood of suicide associated with mental disorder diagnoses, such disorders were present among only 51% of suicide decedents. High rates of health care utilization among suicide decedents indicate a need for improving identification of mental health conditions and suicide risk across the health care system. Increased substance use screening may help identify youths at high risk because substance use disorders were significantly more prevalent and likely among suicide decedents.

Healthcare utilization, psychiatric disorders, and physical illnesses shortly before suicide mortality in adolescents in Taiwan

BACKGROUND

This study examined the pattern of medical utilization and the distribution of comorbidities shortly before death among adolescents who died from suicide and compared these data with those of living controls.

METHODS

From Taiwan's National Health Insurance Research Database, this study identified adolescents aged 10-19 years who died from suicide (n = 935) between 1 January 2000, and 31 December 2016, by linking each patient with the national mortality database. The researchers conducted a nested case-control study through risk set sampling, and for each case, 20 age- and sex-matched controls (n = 18 700) were selected from the general population. The researchers applied conditional logistic regression to investigate differences in medical utilization and physical and psychiatric comorbidities between cases and controls.

RESULTS

Cases had a higher proportion of contact with the psychiatric department but a similar proportion of contact with any non-psychiatric medical department within 1 year before suicide compared with controls. There were 18.6% of adolescent suicide victims who only had contacted with a psychiatric department 3 months before suicide. Moreover, cases had a higher proportion of contact with non-psychiatric services within 3 months before suicide, particularly with emergency, surgery, and internal medicine departments. Cases had higher risks of several psychiatric disorders and physical illnesses, including heart diseases, pneumonia, and ulcer disease, than did controls.

CONCLUSIONS

The findings of increased medical utilization and higher risks of physical and psychiatric comorbidities in adolescent suicide victims are crucial for developing specific interventions to prevent suicide in this population.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

Importance

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes.

Objective

To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes.

Design Setting and Participants

In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition).

Exposure

Positive ASQ screen at baseline ED visit.

Main Outcomes and Measures

The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk.

Results

The complete sample was 15003 youths (7044 47.0%] male; 10209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]).

Conclusions and Relevance

Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.Appeared originally in JAMA Netw Open 2019; 2:e1914070.

Rates of Positive Suicide Screens in the Emergency Department and Outpatient Clinics at a Tertiary Care Children's Hospital

PURPOSE

To provide guidance to hospitals that are developing suicide screening programs, we identified rates of positive screens across outpatient visits within a tertiary care children's hospital.

METHODS

Suicide screening results from healthcare encounters occurring between February 2019 and January 2020 were estimated for ambulatory clinics (OP), urgent care (UC) clinics, and the emergency department (ED).

RESULTS

Positive screens (95% confidence interval [CI]) occurred in 10.8% (10.6, 11.0)%) of visits overall. Rates of positive screens were 14.5 (14.1, 14.9)%, 9.9 (9.7, 10.1)%, and 9.3 (8.9, 9.7)% in the ED, OP, and UC, respectively. Rates of positive screens in outpatient clinics were highest in child abuse (33.4 (28.0, 39.2) %) and adolescent specialty (19.2 (17.3, 21.1) %).

DISCUSSION

Some outpatient clinics had rates of positive suicide screens that surpass those seen in the ED. These findings could inform targeted suicide screening in hospital systems with limited resources to do universal screening.

Screening and Assessing Suicide Risk in Medical Settings: Feasible Strategies for Early Detection

Early detection of risk is a key suicide prevention strategy. Given that most individuals who die by suicide visit a health care provider in the year leading up to their death, medical settings are ideal venues for identifying those at elevated risk and bridging them to life-saving care. Clinicians are presented with an opportunity to engage in proactive suicide prevention efforts through practical and adaptable suicide risk screening, assessment, and management processes. Psychiatrists and mental health clinicians are well positioned to assist nonpsychiatric clinicians on the frontlines of this public health problem. This article discusses the importance of identifying people at elevated suicide risk through screening, differentiates screening from assessment procedures, and presents practical strategies for implementing evidence-based screening and assessment tools into practice as part of a three-tiered clinical pathway. Specifically, this article discusses key components that guide embedding suicide prevention strategies into the workflows of busy medical settings.

Reliability and Validity of the Korean Version of the Ask Suicide-Screening Questions (ASQ)

BACKGROUND

The Ask Suicide-Screening Questions (ASQ) tool is a simple suicide screening tool developed to screen patient suicide risk (SR). The purpose of this study was to verify the reliability and validity of the ASQ tool in hospitalized patients.

METHODS

The internal consistency and test-retest reliability of the South Korean version of the ASQ tool were verified in 99 hospitalized patients admitted to a tertiary medical institution in Seoul. To verify the correlations and validity of each convergence with other scales, the Mini-International Neuropsychiatric Interview (MINI), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Satisfaction with Life Scale (SWLS) were also conducted to determine convergent and discriminant validity. Then, the receiver operating characteristic (ROC) curve diagnosis values for suicide and depression levels with the highest correlations were analyzed.

RESULTS

As a result, Cronbach's alpha was 0.826, and when each item was removed sequentially, Cronbach's alpha ranged from 0.736-0.840, showing stable internal consistency. Most of the corrected item-total correlation were over 0.500; however, a relatively low correlation was shown for the fourth and fifth questions, which had values of 0.429 and 0.410, respectively. The test-retest reliability was 0.830, and the MINI and PHQ-9 showed high values of 0.872 and 0.672, respectively. The area under the curve (AUC) according to the ASQ diagnosis value was also the highest for the MINI (0.936).

CONCLUSION

The validity and reliability of the South Korean version of the ASQ tool were demonstrated. Through this validation, the ASQ tool can be used for simple suicide risk screening (SRS) in hospitalized patients.

Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments

IMPORTANCE

Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool.

OBJECTIVE

To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata.

DESIGN, SETTING, AND PARTICIPANTS

The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023.

MAIN OUTCOMES AND MEASURES

This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA.

RESULTS

Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively).

CONCLUSIONS AND RELEVANCE

This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.

Assessing the Healthcare Utilization of Youth Who Died by Suicide: A Case-Control Study

OBJECTIVE

Suicide is the second leading cause of death in youth ten years old or older. Healthcare utilization prior to death by suicide is high in adults, but there is conflicting evidence in youth. The objective of this study was to compare healthcare utilization in youth who died by suicide to youth who died in a motor vehicle accident (MVC) to determine whether healthcare utilization is associated with death by suicide in youth.

METHODS

This retrospective case-control study used death records from Coroners/Medical Examiners (C/MEs) for children 11-17 years old who died by suicide (case) and MVC (control) between October 2013 and October 2018 were obtained. Data from the electronic medical record (EMR) at a healthcare system was reviewed. The primary outcome was healthcare utilization. Secondary outcomes included mental health diagnosis. Data was analyzed using Fisher's Exact Test and considered significant if p < 0.05.

RESULTS

The analysis included 60 youth who died by suicide and 14 youth who died by MVC. Most decedents were male (68%) and white (80%). Mean age at death was 16 years old. Only 25 decedents had a corresponding record in the EMR, with no significant difference based on manner of death (35% suicide vs 29% MVC, p = 0.8). Fourteen decedents had a known mental health diagnosis in their EMR with no difference based on manner of death (p = 0.5).

CONCLUSIONS

There was no difference in healthcare utilization or mental health diagnosis in youth who died by suicide compared to youth who died by MVC. Strict reliance on both of these factors when considering youth who may be at risk of suicide is inadequate. Expanding universal suicide screening to other settings, including schools or primary care, can help identify youth at risk for suicide and may prevent unnecessary deaths.HIGHLIGHTSLittle is known regarding the healthcare utilization of youth who died by suicide prior to their death.This study uses a case-control design to investigation healthcare utilization of youth who died by suicide versus youth who died in a motor vehicle crash.We did not find a significant difference in healthcare utilization between cases and controls. These findings suggest that non-clinical interventions would be useful in detecting suicide risk.

A randomized controlled trial evaluating the effect of an internet-based cognitive-behavioral program on anxiety symptoms in a community-based sample of adolescents

Adolescents' use of online resources to self-manage anxiety is growing. The objective of the current trial was to assess the effectiveness of an online, primarily self-led cognitive behavioral therapy (CBT) program in reducing anxiety symptoms compared to an active comparator, access to anxiety resources on a static website. A total of 563 adolescents (13-19 years) with self-identified anxiety concerns were enrolled. Self-reported anxiety symptoms were assessed pre- and post-intervention (6 weeks). Adolescents were further assessed 3 months post-intervention. Other outcomes assessed at the three time-points were quality of life (QOL) and healthcare utilization. Both interventions reduced anxiety symptoms after use. Group differences in symptom change were not significant post-intervention (p = 0.16), but were at 3 months (favouring online CBT; p = 0.04) with male participants reporting more symptom change (p = 0.03). Across time-points, as anxiety symptoms decreased, QOL increased (p < 0.001). Among participants that provided healthcare utilization before and after intervention use, the greatest changes in use were among online CBT users particularly for mental health provider visits (psychiatrist, -41.0 % vs. +18.5 %; social worker, -42.5 % vs. -22.1 %), hospital-based care (emergency department visits, -80.0 % vs. +79.4 %; hospital admissions, -76.1 % vs. +42.9 %), and use of self-help or alternative treatments (-60.0 % vs. +6.6 %). Results suggest that, over time, use of online CBT by adolescents can result in improved anxiety symptoms and fewer use of other healthcare resources compared to traditional online information seeking.

Electronic Screening for Adolescent Risk Behaviors in the Emergency Department: A Randomized Controlled Trial

Introduction: In this study we aimed to assess the impact of an electronic health assessment with individualized feedback for risk behaviors in adolescents seeking care in a pediatric emergency department (ED). Methods: We conducted a randomized control trial using a tablet-based screening program with a study population of adolescents in a busy pediatric ED. The intervention group received the screening program with individualized feedback. The control group received the screening program without feedback. All participants received one-day and three-month follow-up surveys to assess behaviors and attitudes toward health behaviors. Results: A total of 296 subjects were enrolled and randomized. There was no difference in changes in risky behaviors between the control and experimental groups. A higher proportion of participants in the intervention groups reported that the screener changed the way they thought about their health at one-day follow-up (27.0%, 36/133) compared to the control group (15.5%, 20/129, P = .02). Conclusion: This study successfully tested a multivariable electronic health screener in a real-world setting of a busy pediatric ED. The tool did not significantly change risky health behaviors in the adolescent population screened. However, our finding that the intervention changed adolescents’ perceptions of their health opens a door to the continued development of electronic interventions to screen for and target risk behaviors in adolescents in the ED setting.

Child Sexual Abuse and Suicide: Essentials for the Forensic Nurse

Sexual abuse can result in significant negative sequelae for victims. One particularly harmful consequence is suicidal ideation, which can lead to suicide attempts and even death. It is essential to screen children and adolescents for suicidal ideation when providing medical forensic care after disclosure of acute or nonacute sexual abuse/assault. Forensic nurses must feel confident in their abilities to assess suicide risk and provide appropriate intervention and referrals. A thorough understanding of the relationship between sexual abuse and suicidal ideation and behaviors can assist the forensic nurse in the development of practice behaviors to better identify, intervene, and prevent suicidal ideation and behaviors among youth experiencing sexual abuse.

Provider opinions of the acceptability of Ask Suicide-Screening Questions (ASQ) Tool and the ASQ Brief Suicide Safety Assessment (BSSA) for universal suicide risk screening in community healthcare: Potential barriers and necessary elements for future implementation

A convenience sample of community health care providers (N = 19) was asked to preview and rate the acceptability of the Ask Suicide-Screening Questions (ASQ) tool and the ASQ Brief Suicide Safety Assessment (BSSA) guide. Providers were also asked about potential barriers to implementation. The majority of participants stated they would be comfortable screening for suicide with the ASQ tool (78.9%; N = 15), that they would recommend the ASQ tool and the BSSA to colleagues (84.2%; N = 16), and that they were "satisfied" or "highly satisfied" with the ASQ and BSSA (88.2%; N = 13). Barriers to implementation reported included a lack of knowledge regarding suicide risk screening and lack of access to behavioral health resources. Education regarding the ASQ, the BSSA, and suicide risk screening are highlighted as crucial elements for future implementation.

Assessing Suicide Risk in a Pediatric Outpatient Behavioral Health System: A Quality Improvement Report

Introduction

Standardized suicide risk assessment improves the detection of individuals at risk of suicide. We conducted a quality improvement initiative in a system of outpatient behavioral health practices affiliated with a free-standing children's hospital to implement standardized suicide risk assessment for new patients.

Methods

Clinicians received education in suicide risk assessment and were trained to use an evidence-based suicide risk assessment tool, the Columbia Suicide Severity Rating Scale (C-SSRS). We standardized workflow processes and integrated the C-SSRS in the electronic health record with a feature to communicate instances of elevated risk across care teams through a problem list. We analyzed C-SSRS responses and adherence to standardized processes and compared the percentage of patients with a suicide-related item on the problem list before and after implementation. We assessed clinician knowledge through a survey. All patients with identified suicide risk received treatment to reduce their risk of suicide in the context of usual care.

Results

For 3,972 new patient visits occurring postimplementation (November 2016-December 2018), the average monthly adherence to the standardized process was 97.7%. The mean monthly incidence of nonspecific active suicidal thoughts was 16%, aborted suicide attempts were 2%, and actual suicide attempts were 3%. The mean monthly incidence of a suicide-related item documented on the problem list was 5.66% in the postimplementation period compared with 1.47% in the 1-year preimplementation. Clinicians demonstrated statistically significant increases in knowledge about suicide risk factors and assessment.

Conclusions

Standardization of suicide risk assessment processes improved detection and documentation of suicide risk in a pediatric outpatient behavioral health setting.

Identifying Suicide Risk in Adolescents and Young Adults With Type 1 Diabetes: Are Depression Screeners Sufficient?

OBJECTIVE

Examine the utility of suicide-risk items embedded within depression screeners for identifying the presence of suicide risk in adolescents and young adults (AYA) with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Sensitivity, specificity, and predictive value of self-report of suicide risk on the Patient Health Questionniaire-9 (PHQ-9) were compared with the pediatric psychologist-administered Columbia-Suicide Severity Rating Scale (C-SSRS) as the reference standard for AYA with type 1 diabetes seen in a multidisciplinary AYA Diabetes Program clinic.

RESULTS

Of 133 participants, 9.8% and 11.3% reported suicide risk on the PHQ-9 and C-SSRS, respectively. Sensitivity of the PHQ-9 risk item was 53.3% (95% CI 27.4%-77.7%), specificity was 95.7% (95% CI 89.9%-98.4%), positive predictive value was 61.5% (95% CI 32.3%-84.9%), and negative predictive value was 94.2% (95% CI 87.9-97.4%).

CONCLUSIONS

Depression screeners appear to under-identify AYA with type 1 diabetes who may otherwise be at risk for suicide.

Suicide Risk Screening in Pediatric Outpatient Neurodevelopmental Disabilities Clinics

OBJECTIVE

The purpose of this study was to describe the implementation of universal suicide risk screening in pediatric neurodevelopmental disabilities (NDD) medical clinics, analyze demographic and clinical characteristics of eligible patients, describe outcomes of positive screenings, and describe factors that influenced participation in screenings.

METHODS

A suicide risk screening protocol was developed and implemented for medical clinic patients aged 8 to 18 years. Registered nurses screened patients using the "Ask Suicide-Screening Questions" tool during triage. Positive screenings were referred for further assessment and mental health management. Demographics and clinical data were extracted from medical records using retrospective chart reviews.

RESULTS

During the 6-month study period, 2961 individual patients presented for 5260 screening eligible patient visits. In total, 3854 (73.3%) screenings were completed with 261 (6.8%) positive screenings noted. Screenings were declined in 1406 (26.7%) visits. Parents of children with cognitive impairments were more likely to decline screening. Clinics serving children with autism spectrum disorder had higher rates of positive screenings compared with all other clinic attendees. Seventy-two of 187 children (38.5%) with positive screenings were identified and referred to outpatient mental health referrals. Seven (2.5%) of these children required acute psychiatric treatment.

CONCLUSION

Routine screening, identification of increased suicide risk, and referral to mental health care among children with NDD are feasible. It remains unclear whether variation in rates among youth with and without NDD may indicate true differences in suicide risk or cognitive impairments or reflect psychiatric comorbidities. High rates of declined participation may have influenced identification of children with NDD and suicide risk. Preliminary findings identified groups of children with NDD at heightened risk for suicidal ideation and behavior. Further research is needed to assess the validity of suicide risk screening tools in children with neurodevelopmental disorders.

Suicide Screening in a Large Pediatric Emergency Department: Results, Feasibility, and Lessons Learned

OBJECTIVE

This study examined the feasibility of screening all patients entering the ED using the Columbia-Suicide Severity Rating Scale as well as examining the rates of suicide ideation and attempts endorsed by adolescents who present at the ED.

METHODS

This study used a sample of 12,113 patients between the ages of 11 and 19 years.

RESULTS

Results revealed that 13.5% of the participants endorsed passive suicide ideation in the month leading up to their ED visit and 11.3% of the participants reported active ideation in the prior month. Results also revealed that patients whose chief complaints were coded as psychiatric or medical trauma were more likely to endorse either active or passive suicidal ideation than other presenting problems. Patients with a psychiatric or medical trauma chief complaint were also more likely to report lifetime suicidal behavior and suicidal behavior 3 months before the ED visit.

CONCLUSIONS

In addition to findings, implications, feasibility, and lessons learned are discussed for other institutions or departments considering implementation of a widespread screening.Highlights:• Suicide screenings were implemented in a large pediatric emergency department.• One in 5 endorsed suicidal ideation or behavior regardless of presenting problem.• Feasibility and lessons learned are discussed for others hoping to implement a widespread screening.

Emergency Department Adolescent Suicidality: A Pilot Study to Determine How Common Actual Attempts Are

OBJECTIVE

Adolescent mental health is a rapidly escalating presentation to emergency departments in the United States with depression and suicidal thoughts being the most prevalent condition. Much of the research and focus has been on preventing future attempts. However, one outcome that may be very important in addition to focus on is the impact of presentations for thoughts without self-injury. The aim was to evaluate outcomes of interest for a larger prospective observational adolescent suicidal trial including frequency of suicide attempts versus thoughts and factors associated with each outcome.

METHODS

This is a prospective pilot study of adolescents at a single pediatric emergency department between December 2016 and September 2017 with acute suicidality. We used descriptive statistics to compare chief complaint, medical history, Patient Health Questionnaire-9 (PHQ-9), and outcomes including final disposition and total emergency department length of stay (LOS). We used t tests for continuous outcomes, χ2 test for categorical data, and Fisher exact tests for categorical and sparse data (20% of cell sizes of <5).

RESULTS

Forty-one patients were enrolled, with 43.9% having an attempt; 72.2% of attempts were the result of an ingestion, and approximately 54% were over-the-counter medications. The average (SD) LOS was 30.8 (31.2) hours, and 63% were discharged home to outpatient services. There were no significant differences in age, chief complaint (except overdose), medical history, final disposition, total LOS in the ED, and the PHQ-9. Scores of the PHQ-9 were, on average (SD), 18.51 (4.7) across the entire cohort, 18.06 (5.75) in patients with an attempt, and 18.87 (3.77) in patients without an attempt (P = 0.59).

CONCLUSIONS

Adolescent mental health is a growing issue for pediatric emergency departments nationally. Prospective research to identify factors associated with worsening outcomes is important to identify and potentially modify if possible. This study did not find any specific factors associated with a suicide attempt, but found that less than half of patients presenting with suicidality actual made an attempt. Future research should focus on not only limiting suicide attempts but also using decreased emergency department visits for worsening thoughts as an outcome of interest.

Opportunities for Early Identification: Implementing Universal Depression Screening with a Pathway to Suicide Risk Screening in a Pediatric Health Care System

OBJECTIVES

To describe the implementation process and assess results of a large-scale universal depression screening program with pathways to suicide risk screening in a pediatric integrated delivery network.

STUDY DESIGN

This retrospective study analyzes depression and suicide risk screening data for 95 613 patients ages 12-17 years.

RESULTS

Of the 95 613 adolescent patients who were screened for depression, 2.4% (2266) screened positive for risk for moderate-severe depression (>10 Patient Health Questionnaire; 9-item version) and 4.1% (3942) endorsed elevated suicide risk (≥1 Columbia Suicide Severity Rating Scale). Overall, 51% of screened patients who present with a primary psychiatric concern screened positive for elevated risk of suicide (2132). Two percent of screened patients who presented with a primary medical concern screened positive for elevated risk of suicide. Nearly one-half (45.9%) of all elevated suicide risk screenings were from patients with a primary medical concern.

CONCLUSIONS

A large-scale universal depression screening program with a pathway to identify elevated suicide risk was implemented in a pediatric health care system using the Patient Health Questionnaire and the Columbia Suicide Severity Rating Scale. This screening program identified youth with moderate-severe depression and elevated risk for suicide with and without presenting psychiatric concerns across service settings.

Self-reported Symptoms of Anxiety Predict Positive Suicide Risk Screening in Adolescents Presenting to the Emergency Department

OBJECTIVE

The objective of this study was to assess whether patient-reported anxiety symptoms are associated with suicide risk in pediatric emergency department (ED) patients. An additional objective was to examine differences between patients presenting for medical/surgical or psychiatric complaints.

METHODS

Pediatric patients aged 10 to 21 years were recruited from 3 pediatric EDs. Participants completed self-report questionnaires assessing for suicidal ideation and behavior, in addition to questions of interest about recent feelings of unbearable anxiety and depression. Adjusted odds ratios were calculated to assess the relationship between endorsement of recent anxiety and screening positive for suicide risk.

RESULTS

Data were analyzed from 522 participants, including 344 presenting with medical/surgical chief complaints and 178 presenting with psychiatric complaints. Overall, 28.9% of participants screened positive for suicide risk, 29.9% endorsed recent feelings of anxiety, and 24.3% endorsed recent feelings of depression. Patients who self-reported recent anxiety symptoms were 5 times more likely to screen positive for suicide risk (adjusted odds ratios = 5.18, 95% confidence interval = 3.06-8.76). Analysis of the 344 medical/surgical patients revealed that this subsample was also 5 times more likely to screen positive for suicide risk if they endorsed recent anxiety (adjusted odds ratios = 4.87, 95% confidence interval = 2.09-11.36).

CONCLUSIONS

Self-reported suicidal ideation and feelings of unbearable anxiety are prevalent among patients presenting to pediatric EDs. Patients who self-report recent feelings of unbearable anxiety are significantly more likely to screen positive for suicide risk, regardless of whether their presenting complaint is medical/surgical or psychiatric in nature.

Suicide Screening Tools for Pediatric Emergency Department Patients: A Systematic Review

BACKGROUND

According to the Centers for Disease Control and Prevention, suicidality and suicidal behavior among youth continues to increase significantly each year. Many of those who die by suicide interact with health services in the year before death. This systematic review sought to identify and describe empirically tested screening tools for suicidality in youth presenting to Emergency Departments (ED).

OBJECTIVE

(1) To identify and compare existing tools used to screen for suicidality in children and adolescents who present to the ED and (2) to ascertain the prevalence of suicidality in pediatric populations found with these tools.

METHODS

We searched Ovid Medline, CINAHL, Scopus, and Cochrane databases for primary research studies that identified and evaluated screening tools for suicide risk in pediatric ED patients. A total of 7,597 publications published before August 25, 2021 met search criteria and were screened by two independent reviewers based on our inclusion and exclusion criteria, with any conflicts resolved via consensus meetings or an independent reviewer. A total of 110 papers were selected for full text review, of which 67 were excluded upon further inspection. Covidence was used to extract and synthesize results.

RESULTS

43 articles were eligible for inclusion. Most studies (n = 33) took place in general pediatric EDs; the quality was generally high. Patients ranged from 4-24 years old, with most screening tested in patients 12 years and older. The most researched tools were the Ask-Suicide Screening Questions (ASQ) (n = 15), Columbia-Suicide Severity Rating Scale (C-SSRS) (n = 12), Suicidal Ideation Questionnaire (SIQ) (n = 11), and the Risk of Suicide Questionnaire (RSQ) (n = 7). Where screening was applied to all patients, about one-fifth of pediatric ED patients screened positive; where suicide screening was applied to psychiatric patients only, over half screened positive. Positive screens were more likely to be female and older than negative screens and they were more likely to be assessed and admitted.

CONCLUSION

Several validated screening tools exist for the purpose of screening pediatric populations in EDs for suicidality. Such tools may help to support early detection and appropriate intervention for youth at risk of suicide.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=276328, identifier: 276328.

Interventions to change clinicians' behavior related to suicide-prevention care in the emergency department: a scoping review

OBJECTIVE

The objective of this scoping review was to explore, characterize, and map the literature on interventions and intervention components implemented to change emergency department clinicians' behavior related to suicide prevention using the Behaviour Change Wheel as a guiding theoretical framework.

INTRODUCTION

An emergency department is a critical place for suicide prevention, yet patients are often discharged without proper suicide risk assessments and/or referrals. In response, we must support emergency department clinicians' behavior change to follow evidence-based suicide prevention strategies. However, reviews to date have yet to systematically and theoretically examine interventions' functional characteristics and how they can influence emergency department clinicians' behaviors related to suicide-prevention care.

INCLUSION CRITERIA

This review considered interventions that targeted emergency department clinicians' behavior change related to suicide prevention. Behavior change referred to observable practice changes as well as proxy measures of behavior change, including changes in knowledge and attitude.

METHODS

This review followed JBI methodology for scoping reviews. Searches included PubMed, PsycINFO, CINAHL, Embase, and gray literature, including targeted Google searches for relevant organizations/websites, ProQuest Dissertations and Theses Global, and Scopus conference papers (using a specific filter). This review did not apply any date limits, but our search was limited to the English language. Data extraction was undertaken using a charting table developed specifically for the review objective. Narrative descriptions of interventions were coded using the Behavior Change Wheel's intervention functions. Reported outcome measures were categorized. Findings are tabulated and synthesized narratively.

RESULTS

Forty-one studies were included from the database searches, representing a mixture of experimental (n = 2), quasi-experimental (n = 24), non-experimental (n = 12), qualitative (n = 1), and mixed methods (n = 2) approaches. An additional 29 citations were included from gray literature searches. One was a pilot mixed methods study, and the rest were interventions. In summary, this review included a total of 70 citations, describing 66 different interventions. Identified interventions comprised a wide range of Behaviour Change Wheel intervention functions to change clinicians' behavior: education (n = 48), training (n = 40), enablement (n = 36), persuasion (n = 21), environmental restructuring (n = 18), modeling (n = 7), and incentivisation (n = 2). Based on the Behaviour Change Wheel analysis, many interventions targeted more than one determinant of behavior change, often employing education and training to improve clinicians' knowledge and skills simultaneously. Among the 42 studies that reported outcome measures, effectiveness was measured at clinician (n = 38), patient (n = 4), and/or organization levels (n = 6). Few studies reported implementation outcomes, such as measures of reach (n = 4), adoption (n = 5), or fidelity (n = 1). There were no evaluation data reported on the interventions identified through Google searches.

CONCLUSIONS

Interventions included in this review were diverse and leveraged a range of mechanisms to change emergency department clinicians' behavior. However, most interventions relied solely on education and/or training to improve clinicians' knowledge and/or skills. Future research should consider diverse intervention functions to target both individual- and/or organization-level barriers for a given context. Secondly, the ultimate goal for changing emergency department clinicians' behavior is to improve patient health outcomes related to suicide-related thoughts and behaviors, but current research has most commonly evaluated clinicians' behavior in isolation of patient outcomes. Future studies should consider reporting patient-level outcomes alongside clinician-level outcomes.

Comparing the predictive value of screening to the use of electronic health record data for detecting future suicidal thoughts and behavior in an urban pediatric emergency department: A preliminary analysis

AIM

Brief screening and predictive modeling have garnered attention for utility at identifying individuals at risk of suicide. Although previous research has investigated these methods, little is known about how these methods compare against each other or work in combination in the pediatric population.

METHODS

Patients were aged 8-18 years old who presented from January 1, 2017, to June 30, 2019, to a Pediatric Emergency Department (PED). All patients were screened with the Ask Suicide Questionnaire (ASQ) as part of a universal screening approach. For all models, we used 5-fold cross-validation. We compared four models: Model 1 only included the ASQ; Model 2 included the ASQ and EHR data gathered at the time of ED visit (EHR data); Model 3 only included EHR data; and Model 4 included EHR data and a single item from the ASQ that asked about a lifetime history of suicide attempt. The main outcome was subsequent PED visit with suicide-related presenting problem within a 3-month follow-up period.

RESULTS

Of the N = 13,420 individuals, n = 141 had a subsequent suicide-related PED visit. Approximately 63% identified as Black. Results showed that a model based only on EHR data (Model 3) had an area under the curve (AUC) of 0.775 compared to the ASQ alone (Model 1), which had an AUC of 0.754. Combining screening and EHR data (Model 4) resulted in a 17.4% (absolute difference = 3.6%) improvement in sensitivity and 13.4% increase in AUC (absolute difference = 6.6%) compared to screening alone (Model 1).

CONCLUSION

Our findings show that predictive modeling based on EHR data is helpful either in the absence or as an addition to brief suicide screening. This is the first study to compare brief suicide screening to EHR-based predictive modeling and adds to our understanding of how best to identify youth at risk of suicidal thoughts and behaviors in clinical care settings.

Suicide in African American Adolescents: Understanding Risk by Studying Resilience

Historically, suicide rates for African American adolescents have been low,relative to rates for youth of other racial-ethnic backgrounds. Since 2001, however, suicide rates among African American adolescents have escalated: Suicide is now the third leading cause of death for African American adolescents. This disturbing trend warrants focused research on suicide etiology and manifestation in African American adolescents, along with culturally sensitive and effective prevention efforts. First, we revisit leading suicide theories and their relevance for African American adolescents. Next, we discuss health promotive and protective factors within the context of African American youth development. We also critique the current status of suicide risk assessment and prevention for African American adolescents. Then, we present a heuristic model of suicide risk and resilience for African American adolescents that considers their development within a hegemonic society. Finally, we recommend future directions for African American adolescent suicidology. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Validation and Feasibility of the ASQ Among Pediatric Medical and Surgical Inpatients

OBJECTIVES

To validate the use of a brief suicide risk screening tool, the Ask Suicide-Screening Questions (ASQ) instrument, in pediatric inpatient medical and surgical settings.

METHODS

Pediatric patients (10-21 years) hospitalized on inpatient medical and surgical units were recruited through convenience sampling for participation in a cross-sectional instrument validation study. The Suicidal Ideation Questionnaire was used as a standard criterion to validate the ASQ. Patient opinions about screening and parent consent to enroll in a suicide risk screening study were assessed to determine the feasibility of administering the ASQ in this venue.

RESULTS

A total of 600 pediatric medical inpatients were screened. Compared with the gold standard, the ASQ had strong psychometric properties, with a sensitivity of 96.67% (95% confidence interval [CI]: 82.78 to 99.92), a specificity of 91.05% (95% CI: 88.40 to 93.27), a negative predictive value of 99.81% (95% CI: 98.93 to 99.99), and an area under curve of 0.94 (95% CI: 0.90 to 0.97). Only 3 participants (0.5%) had acute positive screen results on the ASQ, endorsing current suicidal ideation, whereas 77 participants (12.8%) screened nonacute positive, and 48 participants (8.0%) reported a past suicide attempt.

CONCLUSIONS

The brief 4-item ASQ is a valid tool to detect elevated suicide risk in pediatric medical and surgical inpatients. Our findings also reveal that screening is feasible in terms of detection of suicidal thoughts and behaviors and is acceptable to parents and patients.

Pediatric Suicide Screening: A Review of the Evidence

BACKGROUND

Suicide rates are increasing for youths and suicide is the second leading cause of death for 10-24 year olds. This evidence-based practice project critically reviews literature regarding the effectiveness of pediatric suicide screening.

METHODS

A literature search was guided by the following question: In pediatric patients, does suicide screening at every health encounter compared to an annual screen increase clinician identification of patients at-risk. Ten articles met inclusion criteria and were critically appraised and synthesized.

FINDINGS

Youths had high rates of suicidal ideation (SI), anxiety, and depression. Pediatric universal suicide screening identified SI in youths with both psychiatric and non-psychiatric medical complaints. Patients with chronic health conditions reported higher rates of mental health symptoms and SI. A specific suicide screening instrument should be used as general mental health screens likely miss youths at-risk for SI. The Ask Suicide-Screening Questions tool is an easy to use and highly sensitive instrument for detecting suicide risk in youths.

DISCUSSION

Many youths that screen positive for SI do not have known mental health concerns and would have been missed if not asked directly. Universal screening for SI identifies at-risk youth and allows nurses and other providers to intervene. The need for universal screening across pediatric health care settings using brief, validated screening tools is paramount.

APPLICATION TO PRACTICE

Nurses working in pediatric settings should champion universal screening for SI. Unit-based quality improvement projects using the Plan-Do-Study-Act change cycle provides a model for instituting universal screening for SI.

Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults

Pediatricians are often the first physicians to encounter adolescents and young adults presenting with psychotic symptoms. Although pediatricians would ideally be able to refer these patients immediately into psychiatric care, the shortage of child and adolescent psychiatry services may sometimes require pediatricians to make an initial assessment or continue care after recommendations are made by a specialist. Knowing how to identify and further evaluate these symptoms in pediatric patients and how to collaborate with and refer to specialty care is critical in helping to minimize the duration of untreated psychosis and to optimize outcomes. Because not all patients presenting with psychotic-like symptoms will convert to a psychotic disorder, pediatricians should avoid prematurely assigning a diagnosis when possible. Other contributing factors, such as co-occurring substance abuse or trauma, should also be considered. This clinical report describes psychotic and psychotic-like symptoms in the pediatric age group as well as etiology, risk factors, and recommendations for pediatricians, who may be among the first health care providers to identify youth at risk.

Lowering the Age Limit in Suicide Risk Screening: Clinical Differences and Screening Form Predictive Ability

Our research provides preliminary evidence that suicide risk screening is warranted in patients as young as 8-9 years old presenting to the emergency department (ED) with behavioral and mental health symptoms. The goal of this retrospective cohort study (N = 2,466 unique patient visits) was to assess the value of suicide risk screening in children younger than 10 years old who present to the ED with behavioral and mental health concerns. The Johns Hopkins Hospital pediatric ED began screening with the Ask Suicide-Screening Questions (ASQ) for patients 8-21 years old who presented with a behavioral or mental health concern in March 2013 as ED standard of care. We examined the demographic and clinical differences between younger (8-9 years old; n = 270) and older (10-21 years old; n = 2,196) youths who were screened for suicide risk with the ASQ (from March 13, 2013 through December 31, 2016). In summary, 36% of 8- and 9-year-old patients who came to the ED for behavioral and mental health concerns screened positive for suicide risk on the ASQ. The younger patients who screened positive were more likely to present with externalizing symptoms and hallucinations and less likely to present with suicidal ideation or an attempt than their older counterparts. Importantly, 71.1% of 8- to 9-year-old patients who screened positive did not present to the ED for suicidal ideation or attempt vs 50.1% (614/1,226) of patients older than age 10 years.

Health Services Use by Children in the Welfare System Who Died by Suicide

OBJECTIVES

To examine characteristics and health service use patterns of suicide decedents with a history of child welfare system involvement to inform prevention strategies and reduce suicide in this vulnerable population.

METHODS

A retrospective matched case-control design (120 suicide decedents and 1200 matched controls) was implemented. Suicide decedents included youth aged 5 to 21 who died by suicide and had an open case in Ohio's Statewide Automated Child Welfare Information System between 2010 and 2017. Controls were matched to suicide decedents on sex, race, and ethnicity. Comparisons were analyzed by using conditional logistic regressions to control for matching between the suicide and control groups.

RESULTS

Youth in the child welfare system who died by suicide were significantly more likely to experience out-of-home placements and be diagnosed with mental and physical health conditions compared with controls. Suicide decedents were twice as likely to access mental health services in the 1 and 6 months before death, regardless of the health care setting. A significantly higher percentage of suicide decedents used physical health services 6 months before their death or index date. Emergency department visits for both physical and mental health conditions were significantly more likely to occur among suicide decedents.

CONCLUSIONS

Suicide decedents involved in the child welfare system were more likely to use both mental and physical health care services in the months before their death or index date. Findings suggest that youth involved in the child welfare system may benefit from suicide prevention strategies in health care settings.

Confidential Screening for Sex Trafficking Among Minors in a Pediatric Emergency Department

OBJECTIVES

Child sex trafficking is a global health problem, with a prevalence of 4% to 11% among high-risk adolescents. The objective of this study was to confidentially administer a validated screening tool in a pediatric emergency department by using an electronic tablet to identify minors at risk for sex trafficking. Our hypothesis was that this modality of administration would adequately identify high-risk patients.

METHODS

English- and Spanish-speaking patients from the ages of 12 to 17 years presenting to a large urban pediatric emergency department with high-risk chief complaints were enrolled in a prospective cohort over 13 months. Subjects completed a previously validated 6-item screening tool on an electronic tablet. The screening tool's sensitivity, specificity, and positive and negative predictive values were calculated. Multivariable logistic regression was performed to identify additional risk factors.

RESULTS

A total of 212 subjects were enrolled (72.6% female; median age: 15 years; interquartile range 13-16), of which 26 patients were subjected to child sex trafficking (prevalence: 12.3%). The sensitivity and specificity of the electronic screening tool were 84.6% (95% confidence interval [CI] 70.8%-98.5%) and 53.2% (95% CI 46.1%-60.4%), respectively. The positive predictive value and negative predictive value were 20.2% (95% CI 12.7%-27.7%) and 96.1% (95% CI 92.4%-99.9%), respectively. A previous suicide attempt and history of child abuse increased the odds of trafficking independent of those who screened positive but did not improve sensitivity of the tool.

CONCLUSIONS

A confidentially administered, previously validated, electronic screening tool was used to accurately identify sex trafficking among minors, suggesting that this modality of screening may be useful in busy clinical environments.

Saving Lives: Recognizing and Intervening with Youth at Risk for Suicide

Suicide is the second leading cause of death for youth in the United States. Fortunately, substantial advances have been achieved in identifying and intervening with youth at risk. In this review, we first focus on advances in proactive suicide risk screening and psychoeducation aimed at improving the recognition of suicide risk. These strategies have the potential to improve our ability to recognize and triage youth at risk who may otherwise be missed. We then review recent research on interventions for youth at risk. We consider a broad range of psychotherapeutic interventions, including crisis interventions in emergency care settings. Though empirical support remains limited for interventions targeting suicide risk in youth, effective and promising approaches continue to be identified. We highlight evidence-based screening and intervention approaches as well as challenges in these areas and recommendations for further investigation.

Introducing an innovative model of acute paediatric mental health and addictions care to paediatric emergency departments: a protocol for a multicentre prospective cohort study

INTRODUCTION

Children and youth with mental health and addiction crises are a vulnerable patient group that often are brought to the hospital for emergency department care. We propose to evaluate the effect of a novel, acute care bundle that standardises a patient-centred approach to care.

METHODS AND ANALYSIS

Two paediatric emergency departments in Alberta, Canada are involved in this prospective, pragmatic, 29-month interventional quasi-experimental study. The acute care bundle comprises three components, applied when appropriate: (1) assessing self-harm risk at triage using the Ask Suicide-Screening Questionnaire (ASQ) to standardise the questions administered, enabling risk stratification; (2) use of the HEADS-ED (Home, Education, Activities/peers, Drug/alcohol, Suicidality, Emotions and behaviour, Discharge Resources) to focus mental health evaluations for those who screen high risk on the ASQ; and (3) implementation of a Choice And Partnership Approach to enable shared decision making in care following the emergency department visit. The overarching goal is to deliver the right care at the right place and time for the patients. The study design involves a longitudinal collection of data 12 months before and after the introduction of the bundle and the use of quality improvement strategies such as Plan-Do-Study-Act cycles during a 5-month run-in period to test and implement changes. The primary study end-point is child/youth well-being 1 month after the emergency department visit. Secondary outcomes include family functioning, child/youth well-being at 3 and 6 months, satisfaction with emergency department care, and health system outcomes (hospital admissions, length of emergency department stays, emergency department revisits).

ETHICS AND DISSEMINATION

The study is registered at www.ClinicalTrials.gov and has received ethics and operational approvals from study sites. The results of the study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results will be shared broadly with key policy and decision makers and disseminated in peer-reviewed academic journals and presentations at conferences.

TRIAL REGISTRATION NUMBER

NCT04292379.

PCP Opinions of Universal Suicide Risk Screening in Rural Primary Care: Current Challenges and Strategies for Successful Implementation

PURPOSE

Universal suicide risk screening has the potential to address the disproportionately high rates of suicide in the rural United States, as 83% of people who have died by suicide have visited a health care provider in the year prior to their deaths, and rural patients are more likely to visit medical professionals than behavioral health professionals for mental health concerns. This study describes the opinions of primary care providers (PCPs) practicing in a primarily rural state regarding universal suicide risk screening, barriers to implementation, and strategies to increase the feasibility of screening in their practices.

METHODS

In-depth, individual semistructured qualitative interviews were conducted with a sample of PCPs practicing in West Virginia (N = 15). Applied thematic analysis of the data was completed by a team of 3 coders using a consensus-coding methodology.

FINDINGS

The majority of PCPs supported the practice of screening, but they identified multiple barriers, including a lack of access to mental health and crisis support services, concerns about clinic flow and follow-up with suicidal patients, cultural beliefs specific to rural Appalachia, and provider discomfort with screening. Strategies suggested to address these barriers included the use of technology for screening, a multidisciplinary team approach, streamlined methods for screening and risk assessment, co-located behavioral health, and additional trainings for PCPs on the topic of suicide.

CONCLUSION

Future research should examine the efficacy of universal suicide risk screening programs in rural adult primary care that utilize these strategies in diverse samples with longitudinal data.

Hormonal contraceptives and the risk of suicide: a systematic review and meta-analysis

OBJECTIVE

To assess the effect of hormonal contraceptive use over the risk of suicide.

METHOD

Systematic review and meta-analysis of observational studies retrieved from five search engines until September 2019, comparing the use of any hormonal contraceptive versus non-hormonal contraceptive use or no use. Primary outcome was consumed suicide, and secondary outcomes were suicidal attempt and ideation. Random effects meta-analyses with the inverse variance method were used to evaluate the effects of exposure over outcomes. Effect was calculated as risk ratio (RR) with their corresponding 95% confidence interval (CI). Risk of bias was assessed with the Newcastle-Otawa Scale.

RESULTS

There were no randomized controlled trials concerning suicide and hormonal contraceptive use. Only three cohort studies (n = 184,721 women), that evaluated the primary outcome (consumed suicide), were included in the meta-analysis. Hormonal contraceptive use was associated to a higher risk of consumed suicide (RR = 1.36, 95% CI 1.06 to 1.75, P =  0.015, I² = 0%). There were no secondary outcomes in at least two cohorts.

CONCLUSION

This meta-analysis found a positive association between hormonal contraceptive use and consumed suicides. Prior to their use, populations at suicidal risk should be properly evaluated.

The Feasibility and Impact of a Suicide Risk Screening Program in Rural Adult Primary Care: A Pilot Test of the Ask Suicide-Screening Questions Toolkit

OBJECTIVE

The purpose of this study was to evaluate the feasibility and impact of a suicide risk screening program in a rural West Virginia primary care practice.

METHODS

Patients presenting for routine and sick visits were asked to participate in electronic suicide risk screening using the Ask Suicide-Screening Questions tool; screen positive individuals were assessed with the Ask Suicide-Screening Questions Brief Suicide Safety Assessment. Screening program feasibility was evaluated by the proportion of patients consenting to participate, participant Ask Suicide-Screening Questions and Brief Suicide Safety Assessment completion rates, and response to a question asking whether primary care providers should ask about suicide. Screening impact was evaluated quasi-experimentally by comparing electronic medical record documentation of suicide risk screening, assessment, and risk determination in practice patients before and after implementing the screening program.

RESULTS

Over half of the patients approached agreed to participate in a research study about suicide (N = 196; 57.7%). Feasibility of the screening program was demonstrated by the high completion rates for the Ask Suicide-Screening Questions (99.0%) and the Brief Suicide Safety Assessment (100.0%) among study participants. Additionally, 95.4% (N = 187) of participants agreed primary care providers should screen patients for suicide. Suicide screening rates rose significantly between the baseline and intervention phases (5.8% to 61.0%; X² = 200.61, P < 0.001), as did suicide risk detection rates (0.7% to 6.2%; X² = 12.58, P < 0.001).

CONCLUSION

Suicide risk screening was feasible and well accepted by adult patients in rural primary care and has potential to improve suicide risk detection in this setting.