Universal Suicide Risk Screening for Youths in the Emergency Department: A Systematic Review

Improving Universal Suicide Risk Screening Rates at a Children's Hospital

BACKGROUND AND OBJECTIVES

Suicide is a leading cause of death among US youth. In hospital settings, screening for suicide risk enables assessment, brief interventions, and linkage to treatment. Our objective was to increase compliance with universal suicide risk screening for patients aged 10 years or older during acute care visits (to the emergency department [ED] and/or inpatient medical units) of a children's hospital from 27% to greater than or equal to 60% over 13 months.

METHODS

Using quality improvement methodology, a multidisciplinary team implemented interventions to increase compliance with universal suicide risk screening for patients aged 10 years or older at an academic children's hospital from June 2022 to June 2023, followed by a 7-month sustainment period. Interventions included a clinical care guideline and clinical decision support tools embedded in the electronic health record (EHR). We measured compliance with administration of Ask Suicide-Screening Questions (ASQ) during eligible visits, overall and stratified by care area, and positivity rates.

RESULTS

During the intervention and sustainment periods, there were 18 435 and 10 257 acute care visits by patients aged 10 years or older, respectively. Screening compliance rates increased from 27% to 80% overall, from 17% to 80% in the ED, and from 55% to 76% in inpatient medical units. Of acute care visits with screening performed during the sustainment period, 8.6% had positive ASQ screening (6.9% nonimminent risk and 1.7% imminent risk).

CONCLUSIONS

Implementing a clinical care guideline, accompanied by EHR-integrated clinical decision support, increased compliance with suicide risk screening at a children's hospital. Screening positivity rates reflect mental health needs among children receiving acute care.

Evaluating the Prevalence of Suicide Risk Screening Practices in Accredited Hospitals

BACKGROUND

The Joint Commission's National Patient Safety Goal (NPSG) on suicide prevention (NPSG.15.01.01) requires accredited hospitals to screen all patients aged 12 years and older who are being evaluated or treated for behavioral health conditions as their primary reason for care for suicidal ideation using a validated screening tool. Some hospitals have expanded screening to include nonbehavioral health care patients.

METHODS

This cross-sectional observational study explored the prevalence and challenges of suicide risk screening practices among Joint Commission-accredited hospitals. An online questionnaire was sent to 859 general medical/surgical hospitals. Chi-square tests were used to evaluate differences in response rates, and responses were adjusted by hospital characteristics (bed capacity, location, system, and teaching status).

RESULTS

A total of 284 (33.1%) hospitals responded. The majority (n = 225 [79.2%]) reported screening all patients hospitalwide, and 185 (65.1%) had implemented a suicide prevention framework that includes protocols for positive screens and risk assessment. Challenges for implementing a comprehensive universal suicide risk screening and assessment protocol included insufficient staffing and lack of secure environments for at-risk patients. Of the 59 organizations not conducting hospitalwide screening, 94.9% indicated multiple reasons, including negative impact on workflow (30 [50.8%]), burden on providers (30 [50.8%]), not a requirement (29 [49.2%]), and workflow feasibility (28 [47.5%]).

CONCLUSION

Results suggest the majority of accredited hospitals have implemented suicide risk screening practices that exceed current Joint Commission requirements. The lack of sufficient resources to adequately address patients who screen positive for suicide risk remains a key challenge to universal screening.

Performance of an Electronic Universal Mental Health Screening Tool in Pediatric Emergency Departments

OBJECTIVE

Rates of suicide, anxiety, and depression have soared in US youth, and professional organizations strongly urge earlier identification, particularly in pediatric emergency departments (PEDs). However, there are few commonly used suicide screeners that also identify other mental health (MH) problems. A new, electronically administered instrument, the K-CAT, screens for suicide and multiple MH problems. We hypothesized that the K-CAT would enhance suicide identification compared with routine screening and identify significant anxiety and depression in youth presenting with non-MH chief complaints.

METHODS

This observational study was conducted in 2 PEDs. Eligible youth were 7 to 17 accompanied by a caregiver without: severe medical concerns, difficult behaviors, limited verbal language, or only a psychiatric complaint. Of the 341 eligible, 241 (70.7%) were screened, and 228 both presented with a non-MH problem and had complete K-CAT data. A Fisher exact test determined whether suicidal behaviors/ideation rates differed between the K-CAT and retrospective chart review data.

RESULTS

Seventy-four or 32.46% of youth scored positive for suicide, anxiety, and/or depression on the K-CAT. Females were more likely to screen positive (P<0.001). Compared with the retrospective data, more youth were identified with suicide risk by the K-CAT (3.95% vs. 0%; P=0.004). Youth identified by the K-CAT were 62.5% female and 33.3% 7 to 11 years.

CONCLUSIONS

The K-CAT increases the identification of suicidal ideation and behaviors overall and in younger children. It identifies significant rates of depression and anxiety in youth and could be an important first step in identifying MH problems in youth.

Suicide Risk Identified Among Transgender and Gender Diverse Youth in the Emergency Department (2019-2022)

OBJECTIVE

Suicide risk identified via universal screening in health care settings is associated with subsequent suicidal behavior and is an important prevention strategy. The prevalence of positive suicide risk screening among transgender and gender diverse (TGD) youth in the emergency department (ED) has not been described. The current study examined the association between gender identity and suicide risk screening results, adjusted for other demographic and clinical characteristics.

METHODS

Retrospective cross-sectional study of electronic medical record data from ED visits November 2019-August 2022 in an urban academic children's hospital. Participants were youth ages 8-25 who received the Ask Suicide-Screening Questions suicide risk screening tool.

RESULTS

Of 12,112 ED visits with suicide risk screening performed (42% male, median age 14 [12,16]), 24% had positive screens. Of 565 visits by TGD youth, 78.1% had positive screens, and 9.5% had active suicidal ideation. Compared to visits by cisgender females, the adjusted odds of positive screens were 5.35 times higher (95% CI 3.99, 7.18) among visits by TGD youth and 0.45 times lower (95% CI 0.40, 0.52) among visits by cisgender males. Compared to visits by cisgender females, the adjusted odds of active suicidal ideation were higher for cisgender males (aOR 1.34, 95% CI 1.07, 1.68) but did not significantly differ for TGD youth.

CONCLUSIONS

TGD youth have high rates of positive suicide risk screening in the ED, demonstrating substantial mental health needs. Opportunities may be available to improve detection, evidence-based brief interventions, and linkage to mental health services for this population.

Suicidal thoughts and behaviors among gender-minority adolescents in the emergency department

OBJECTIVE

Gender-minority youth, whose gender identity differs from their sex assigned at birth, have elevated suicide risk compared to cisgender youth, yet few studies examine their suicide risk in the emergency department (ED). Our objectives were to determine the prevalence of and assess risk and protective factors associated with prior suicide attempt (SA) and recent suicide ideation (SI) among gender-minority adolescents in the ED.

METHODS

We conducted a secondary analysis of gender-minority adolescents in the Emergency Department Screening for Teens at Risk for Suicide (ED-STARS) multicenter, random-series prospective cohort study. Prior SA and recent SI were based on the Columbia Suicide Severity Rating Scale and Ask Suicide-Screening Questions, respectively. We conducted Firth's logistic regressions to assess risk and protective factors associated with prior SA and recent SI.

RESULTS

Of 6641 adolescent participants in ED-STARS, 280 (4.2%) identified as gender minority. Of the gender minorities, 72% presented with a nonpsychiatric complaint, 37% admitted to a prior SA, and 25% reported recent SI. Prior SA was associated with the number of self-harm methods in the prior 12 months (adjusted odds ratio [aOR] 1.5, 95% confidence interval [CI] 1.3-1.9), sexual minority (aOR 5.0, 95% CI 2.5-10.6), and mother's history of prior SA (aOR 3.6, 95% CI 1.5-9.2). Recent SI was associated with hopelessness (aOR 4.2, 95% CI 1.5-13.9), lower positive affect (aOR 0.9, 95% CI 0.8-1.0), sexual minority (aOR 8.3, 95% CI 2.5-37.8), five or more self-harm events in the prior 12 months (aOR 4.9, 95% CI 2.1-11.6), and number of illicit drug classes (aOR 1.9, 95% CI 1.2-3.2).

CONCLUSIONS

Among gender-minority ED adolescent patients, one in three experienced a SA prior to the ED visit. One in four endorsed SI within 2 weeks of the ED visit. The identified risk and protective factors among gender-minority adolescents may inform future ED-based efforts to detect and reduce suicide risk.

Using Behavioral Measures to Assess Suicide Risk in the Psychiatric Emergency Department for Youth

Suicide screening is critical in pediatric emergency departments (EDs). Behavioral measures of suicide risk may complement self-report measures. The current study examines suicide-specific behavioral measures and tests their potential short-term within-person effects among respondents, ability to discriminate future suicide attempt from suicidal ideation, and translation into interpretable categorical composite scores. The sample included 167 youth (10-17 years), presenting for suicide-related reasons to a pediatric psychiatric ED. During their ED visit, participants completed the Death/Life Implicit Association Test (IAT) and the Suicide Stroop Task. Recurrent suicidal thoughts and attempts were assessed within 6 months of the ED visit via medical records and email surveys. Youth displayed a decrease in the levels of distress and self-injurious desires (negative mood, desire to hurt themselves, and desire to die) after completing the behavioral tasks. The Death/Life IAT prospectively differentiated with 68% accuracy between youth who attempted suicide after their ED visit and those who had suicidal ideation but no attempt, p = 0.04, OR = 5.65, although this effect became marginally significant after controlling for self-report and demographic covariates. Neither the Suicide Stroop Task, nor the categorical composite scores predicted suicide attempts, ps = 0.08-0.87, ORs = 0.96-3.95. Behavioral measures of suicide risk administered in the ED do not appear to increase distress or self-injurious desires. They may be able to distinguish those who go on to attempt suicide (vs. consider suicide) within six months after discharge.

Implementation Barriers Encountered During a Universal Suicide Screening Program in Pediatric Emergency Departments

OBJECTIVE

Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs.

METHODS

Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported.

RESULTS

Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening.

CONCLUSIONS

Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.

Pediatric Emergency Physicians' Knowledge, Attitudes, and Behaviors Regarding Confidential Adolescent Care

OBJECTIVES

More than 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians.

METHODS

We conducted a cross-sectional questionnaire of US physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes toward providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used χ 2 to compare subgroups.

RESULTS

Of 476 eligible physicians, 151 (32%) participated. Most (91. 4%) had completed pediatric emergency medicine fellowship. More participants reported familiarity with all sexual health-related laws compared with all mental health-related laws (64% vs 49%, P < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by the following: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%).

CONCLUSIONS

Respondents reported moderate familiarity with adolescent confidentiality laws. Although they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents' behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents.

Identification of suicide risk in a pediatric psychiatric emergency setting: Comparing the Ask Suicide-screening Questions and the Kiddie-Computerized Adaptive Test-Suicide Scale

While the emergency department (ED) is an important setting for identifying youth with psychiatric symptoms and connecting them to services, the demands of the ED make efficient and accurate measurement essential in the implementation of mental health screening. The Kiddie-Computerized Adaptive Test (K-CAT) scales, a new electronically administered measure that offers quick and comprehensive assessment across several mental health domains, may be particularly useful in this setting. Given current recommendations for youth suicide risk screening in EDs, this study compared the K-CAT-Suicide Scale (K-CAT-SS) and the Ask Suicide-screening Questions (ASQ), a widely used measure in EDs, in a sample of participants presenting to a pediatric, psychiatric emergency setting. The measures agreed on the presence of suicide risk in over 85% of cases (κ=0.59), and the characteristics of youth who screened at risk on both were similar. Cases of disagreement were more often male and more often had educational accommodations. They had lower symptom levels of and were less often diagnosed with internalizing disorders and were less often identified as high risk by ED psychiatrists and psychologists. Examination of item endorsement patterns in cases of disagreement revealed important areas of future study, including the role of caregiver report in suicide risk screening, item comprehension concerns, and the validity of assessing youth with neurodevelopmental disabilities. While additional research would be beneficial into its psychometrics when deployed in real-world settings, the K-CAT-SS should be considered a viable alternative for suicide risk screening in EDs.

Understanding Psychiatrists' Knowledge and Attitudes to Suicidality in Individuals with Autism Spectrum Disorder

Background

Several studies have demonstrated that individuals with autism spectrum disorder (ASD) are at a significantly higher risk of suicide, with over 7.5 times increased likelihood of dying by suicide and higher rates of suicidal ideation. The present study aimed to examine the perspectives and awareness of psychiatrists regarding suicidal behavior in individuals with ASD.

Methods

To achieve this, an online survey was developed to assess clinicians' practices in evaluating suicidal thoughts and behaviors in individuals with ASD.

Results

A total of 143 psychiatrists, including 55 general adult psychiatrists and 88 child and adolescent psychiatrists, completed the cross-sectional survey. The results of the study revealed that clinicians reported lower rates of suicidal ideation and behavior in individuals with ASD compared to those without ASD (P < .05). Furthermore, it was found that the usage of screening tools for assessing suicidal behavior was significantly lower in the ASD group (P < .05).

Conclusion

The study aimed to investigate psychiatrists' knowledge and screening practices regarding ASD and emphasize the importance of increasing knowledge and implementing effective screening and intervention practices to address the risk of suicidality in individuals with ASD.

Primary Care and Mental Health Staff Perspectives on Universal Suicide Risk Screening and Care Coordination

Little is known about staff or patient perspectives on suicide risk screening programs. The objectives of this study were to characterize Veterans Health Administration (VHA) primary care and mental health staff perspectives regarding the VHA Suicide Risk Identification Strategy screening and assessment program and to describe coordination of suicide prevention-related care following positive screening results. Qualitative interviews were conducted with 40 primary care and mental health staff at 12 VHA facilities. An inductive-deductive hybrid approach was used to conduct a thematic analysis. Several key themes were identified. Primary care and mental health staff participants accepted having a structured process for screening for suicidal ideation and conducting risk assessments, but both groups noted limitations and challenges with initial assessment and care coordination following screening. Mental health staff reported more concerns than primary care staff about negative impacts of the screening and assessment process on treatment. Both groups felt that better training was needed for primary care staff to effectively discuss and evaluate suicide risk. The results suggested that additional modifications of the screening and assessment process are needed for patients already known to have elevated risk of suicide or chronic suicidal ideation.

Suicidal ideation and intentional self-inflicted injury in autism spectrum disorder and intellectual disability: An examination of trends in youth emergency department visits in the United States from 2006 to 2014

LAY ABSTRACT

Youth suicide is a major problem in the United States and globally, but little is known about suicide risk in autistic youth and youth with intellectual disability specifically. Using data from the National Emergency Department Sample, which is the largest database of emergency department visits in the United States, we found that emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis were more common in autistic youth and youth with intellectual disability than in youth without these diagnoses (i.e. the comparison group). This was true when examining both suicidal ideation diagnoses and intentional self-inflicted injury diagnoses at emergency department visits. In addition, the number of emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis increased more from 2006 to 2014 in autistic youth and youth with intellectual disability compared with the comparison group. We also found both similarities and differences when examining factors, such as age, sex, and co-occurring mental health conditions, related to emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis across groups that may be helpful for understanding suicide risk. It is urgent that we improve our understanding, assessment, and treatment of suicidality and self-harm in these groups through more research and clinical efforts.

National estimates of emergency department visits for medication-related self-harm: United States, 2016-2019

BACKGROUND

Medication poisoning is a common form of self-harm injury, and increases in injuries due to self-harm, including suicide attempts, have been reported over the last two decades.

METHODS

Cross-sectional (2016-2019) data from 60 emergency departments (EDs) participating in an active, nationally representative public health surveillance system were analysed and US national estimates of ED visits for medication-related self-harm injuries were calculated.

RESULTS

Based on 18 074 surveillance cases, there were an estimated 269 198 (95% CI 222 059 to 316 337) ED visits for medication-related self-harm injuries annually in 2016-2019 compared with 1 404 090 visits annually from therapeutic use of medications. Population rates of medication-related self-harm ED visits were highest among persons aged 11-19 years (58.5 (95% CI 45.0 to 72.0) per 10 000) and lowest among those aged ≥65 years (6.6 (95% CI 4.4 to 8.8) per 10 000). Among persons aged 11-19 years, the ED visit rate for females was four times that for males (95.4 (95% CI 74.2 to 116.7) vs 23.0 (95% CI 16.4 to 29.6) per 10 000). Medical or psychiatric admission was required for three-quarters (75.1%; 95% CI 70.0% to 80.2%) of visits. Concurrent use of alcohol or illicit substances was documented in 40.2% (95% CI 36.8% to 43.7%) of visits, and multiple medication products were implicated in 38.6% (95% CI 36.8% to 40.4%). The most frequently implicated medication categories varied by patient age.

CONCLUSIONS

Medication-related self-harm injuries are an important contributor to the overall burden of ED visits and hospitalisations for medication-related harm, with the highest rates among adolescent and young adult females. These findings support continued prevention efforts targeting patients at risk of self-harm.

Disparities in Pediatric Mental and Behavioral Health Conditions

Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.

Assessing and Managing Suicide Risk in Autistic Youth: Findings from a Clinician Survey in a Pediatric Psychiatric Emergency Setting

Suicidal thoughts and behaviors (STB) and emergency department (ED) utilization are prevalent in autistic youth. The current study surveyed clinicians in a pediatric psychiatric ED to examine differences in attitudes on suicide-related care for autistic and non-autistic patient populations. While clinicians rated addressing STB in ASD as important and adaptations to care as necessary, less than half identified ASD as a suicide risk factor and confidence ratings were significantly lower for autistic patients. Previous ASD training predicted confidence and accounted for approximately 25% of the variance in confidence scores. Findings highlight the urgency to develop and disseminate ED clinician training, and address the lack of validated assessment tools, adapted suicide prevention practices, and evidence-based treatments for STB in autistic youth.