Assessing the Validity of the Ask Suicide-Screening Questions in Black Youth

Temporal Patterns of Suicidality Among Adolescents Receiving Behavioral and Mental Health Services in the Community: A Survival Analysis

Adolescent suicide is a major public health concern, particularly among adolescents who have endured Adverse Childhood Experiences (ACEs). Adolescents who have been exposed to multiple ACEs are as much as three times more likely to present with suicidality compared to the general adolescent population. Adolescents who have been exposed to multiple ACEs are also more likely to receive behavioral and mental health services in the community. It is therefore important to understand patterns of suicidality among this sub-population of adolescents in order to provide the best clinical care. The present study examined the temporal patterns of suicidality among adolescents who have been exposed to multiple ACEs and are receiving behavioral and mental health services in the community. Using Electronic Health Record (EHR) data from a community-based behavioral and mental health care organization, an exploratory survival analysis was conducted on time to suicidal thoughts and behaviors (STBs) after suicidality risk screen at intake. Average time from suicidality risk screen at intake to STB was 185 days (6.2 months). Youth who screened negative for suicidality risk at intake had a longer survival time than youth who screened positive for suicidality risk, and the survival distributions between the two groups was significant. Predictors of STBs were also examined, with gender being a significant predictor of an STB occurring during the follow-up period. These findings may be used to guide suicidality screening and clinical practice at community-based behavioral and mental health care organizations serving adolescents who have been exposed to multiple ACEs.

Concordance Between the Ask Suicide Screening Questions (ASQ) and Self-Injurious Thoughts and Behaviors Interview-Self Report (SITBI-SR) Among Autistic and Non-Autistic Adults

OBJECTIVE

This study sought to examine concordance between two commonly used measures of suicidal thoughts and behaviors: the Ask Suicide-Screening Questions (ASQ) and the Self-Injurious Thoughts and Behaviors Interview-Self Report (SITBI-SR). Agreement was operationalized as the presence past month suicidal ideation and lifetime suicide attempts. To explore the utilization of these tools among neurodiverse samples, we also examined the concordance across autistic and non-autistic adults.

METHODS

The sample consisted of 200 individuals recruited online. Half of the sample self-reported a diagnosis of autism. A series of Cohen's kappas and confidence intervals were computed to assess agreement between the ASQ and SITBI-SR. Cohen's kappa was computed separately for each set of comparisons for the autistic and non-autistic samples.

RESULTS

Past month suicidal ideation had a kappa of 0.61 (95%CI = 0.48-0.73). The kappa for lifetime suicide attempts was 0.86 (95%CI = 0.78-0.94). There were no significant differences in agreement between the two measures for autistic versus non-autistic individuals.

CONCLUSIONS

Current findings suggest that the ASQ and SITBI-SR have high concordance with one another. Given that the ASQ and the SITBI-SR are both validated in the general population and that concordance was high and not significantly different based on autism status, the current study provides preliminary evidence that the ASQ and the SITBI-SR function similarly for autistic individuals.HIGHLIGHTSPeople do not always respond consistently to different STB assessment methods.Findings suggest that the ASQ and SITBI-SR have high concordance with one another.Evidence provided that these measures function similarly for autistic individuals.

A microcosting approach for planning and implementing community-based mental health prevention program: what does it cost?

BACKGROUND

Estimating program costs when planning community-based mental health programs can be burdensome. Our aim was to retrospectively document the cost for the first year of planning and implementing Healthy Minds Healthy Communities (HMHC), a mental health promotion and prevention multi-level intervention initiative. This Program is among the first to use the Community Initiated Care (CIC) model in the US and is aimed at building community resilience and the capacity for communities to provide mental health support, particularly among those disproportionately impacted by COVID-19. Our objective is to share our methods for costing a program targeting 10 zip codes that are ethnically and linguistically diverse and provide an example for estimating the cost of a mental health prevention and promotion programs consisting of multiple evidence-based interventions.

METHODS

We used a semi-structured interview process to collect cost data through the first year of program planning, start-up and initial implementation from key staff. We calculated costs for each activity, grouped them by major project categories, and identified the cost drivers of each category. We further validated cost estimates through extensive literature review. The cost analysis was done from the provider's perspective, which included the implementing agency and its community partners. We delineated costs that were in-kind contributions to the program by other agency, and community partners. Sensitivity analyses were conducted to estimate uncertainty around parameters.

RESULTS

For the first year of the development and implementation of the program, (funded through program and in-kind) is estimated at $1,382,669 (2022 US$). The costs for the three main activity domains for this project are: project management $135,822, community engagement $364,216 and design and execution $756,934. Overall, the cost drivers for the first year of this intervention were: hiring and onboarding staff, in-person community building/learning sessions, communications and marketing, and intervention delivery.

CONCLUSION

Implementation of community-based mental health promotion and prevention programs, when utilizing a participatory approach, requires a significant amount of upfront investment in program planning and development. A large proportion of this investment tends to be human capital input. Developing partnerships is a successful strategy for defraying costs.

A call to action: informing research and practice in suicide prevention among individuals with psychosis

Although it is well established that individuals living with psychosis are at increased risk for suicidal ideation, attempts, and death by suicide, several gaps in the literature need to be addressed to advance research and improve clinical practice. This Call-to-Action highlights three major gaps in our understanding of the intersection of psychosis and suicide as determined by expert consensus. The three gaps include research methods, suicide risk screening and assessment tools used with persons with psychosis, and psychosocial interventions and therapies. Specific action steps to address these gaps are outlined to inform research and practice, and thus, improve care and prognoses among persons with psychosis at risk for suicide.

Suicide Risk Screening Tools for Pediatric Patients: A Systematic Review of Test Accuracy

CONTEXT

Health care settings have increasingly adopted universal suicide risk screening tools into nonpsychiatric pediatric care; however, a systematic review examining the accuracy of these tools does not yet exist.

OBJECTIVE

Identify and review research on the test accuracy of suicide risk screening tools for pediatric patients in nonpsychiatric medical settings.

DATA SOURCES

PubMed and PsycINFO were searched to identify peer-reviewed articles published before March 23, 2023.

STUDY SELECTION

Articles that quantified the accuracy of a suicide risk screening tool (eg, sensitivity, specificity) in a nonpsychiatric medical setting (eg, primary care, specialty care, inpatient or surgical units, or the emergency department) were included.

DATA EXTRACTION

A total of 13 studies were included in this review. Screening tool psychometric properties and study risk of bias were evaluated.

RESULTS

Sensitivity among individual studies ranged from 50% to 100%, and specificity ranged from 58.8% to 96%. Methodological quality was relatively varied, and applicability concerns were low. When stratifying results by screening tool, the Ask Suicide-Screening Questions and Computerized Adaptive Screen for Suicidal Youth had the most robust evidence base.

LIMITATIONS

Because of considerable study heterogeneity, a meta-analytic approach was deemed inappropriate. This prevented us from statistically testing for differences between identified screening tools.

CONCLUSIONS

The Ask Suicide-Screening Questions and Computerized Adaptive Screen for Suicidal Youth exhibit satisfactory test accuracy and appear promising for integration into clinical practice. Although initial findings are promising, additional research targeted at examining the accuracy of screening tools among diverse populations is needed to ensure the equity of screening efforts.

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.

Validation of the Spanish ASQ translation: Screening pediatric patients for suicide-risk in Argentina

BACKGROUND

The high frequency of suicide risk in adolescents necessitates the development and validation of specific tools for systematic screening. To date, there are translated, but not validated suicide risk screening tools in Spanish.

OBJECTIVE

To validate the Spanish version of the Ask Suicide-Screening Questions (ASQ) for suicide risk screening in pediatric patients in Argentina.

METHOD

Using a cross-sectional multicenter design, a convenience sample of pediatric patients aged 10 to 18 years old were recruited from outpatient/inpatient medical settings and private psychiatric clinics. The Spanish version of the Suicidal Ideation Questionnaire (SIQ) assessment tool was used as a standard criterion to validate the ASQ.

RESULTS

A total of 301/380 pediatric patients were screened for suicide risk. Twentyeight percent of the entire sample (83/301) of youth screened positive on the ASQ, and 21% (62/301) screened positive on the SIQ/SIQ-JR and were considered "at risk" for suicide. Compared with the SIQ, the Spanish ASQ yielded a sensitivity of 96.8% (95% Confidence Interval [CI]: 88.8-99.6%), specificity of 90.4% (95% CI: 85.9-93.8%), positive predictive value of 72.3% (95 CI: 61.4-81.6%), and negative predictive value of 99.1% (95% CI: 96.7-99.9%). The positive Likelihood Ratio (LR) was 10.1 (95% CI: 6.1-14.0), and the negative LR was 0.03 (95% CI: -0.01-0.09). Kappa was 0.77 (95% CI: 0.69-0.86), and the Area Under the Curve was 0.94 (95% CI: 0.91-0.97).

CONCLUSION

The Spanish language ASQ demonstrated strong psychometric properties, providing initial evidence that it is a valid tool for identifying Spanish-speaking youth at risk for suicide.

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.

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.