Psychiatrists as Partners in Suicide Prevention for Pediatric Medical Settings
"The death rate among youth aged 10 to 24 years increased 52.2% from 6.9 per 100,000 in 2001 to 10.5 per 100,000 in 2020."
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SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY
Suicide remains a global public health crisis and is the third leading cause of death among US youth. Rates have also increased over the past 2 decades, with the death rate among youth aged 10 to 24 years increasing 52.2% from 6.9 per 100,000 in 2001 to 10.5 per 100,000 in 2020.1
Additionally, many populations are at elevated risk for suicide, including Black, Indigenous, Asian American and Pacific Islander, mixed race, Hispanic, LGBTQ+, and neurodiverse youth, as well as youth who are incarcerated or living with chronic illness or in the child welfare system.1-5 There are significant racial disparities in the rates of suicide and suicidal behavior in these understudied and underserved populations.
The COVID-19 pandemic has also exacerbated the pediatric mental health crisis. According to a report by the Centers for Disease Control and Prevention, emergency departments (EDs) showed a 39% increase in suicide-related visits among youth aged 12 to 17 years, with visits for females increasing 51% compared with a 4% increase for males.6 Although the pandemic’s full impact on pediatric mental health continues to be evaluated, early evidence suggests that minoritized populations experienced a disproportionate mental health decline.7
Calls to Action
In response to these alarming statistics, leading medical organizations have issued additional calls to action. For example, the US Surgeon General issued a 2021 advisory titled “Protecting Youth Mental Health,” which called for the expansion of suicide prevention practices and resources in medical settings.8 In the same year, the American Academy of Pediatrics (AAP), the Children’s Hospital Association, and the American Academy of Child and Adolescent Psychiatry (AACAP) jointly declared a national emergency in pediatric mental health.9
The report emphasized the importance of early detection in screening programs in community, school, and clinical settings, especially for underserved youth. In addition, the AAP and the American Foundation for Suicide Prevention, in collaboration with the National Institute of Mental Health, released the Blueprint for Youth Suicide Prevention (aap.org/suicideprevention).10
This online resource outlines clinical pathways for suicide risk screening, assessment, and triage care; it also highlights the role community settings can play in suicide prevention. Lastly, the AAP added suicide risk screening to its Bright Futures periodicity schedule, recommending that pediatricians annually screen all patients 12 years and older.11
With this upsurge in calls to action and revised practice recommendations, child and adolescent psychiatrists serve an essential role in suicide prevention efforts. According to death registry studies, 77.4% of youth suicide decedents had visited a health care provider in the year before their death, compared with only 31.8% who had visited a mental health provider.12
This critical gap positions medical settings as ideal venues for identifying youth at risk and referring them to further specialty psychiatric care. Psychiatrists, along with other mental health clinicians, are invaluable partners in these medical settings.
Clinical Pathways for Suicide Risk Screening
Psychiatrists and other licensed mental health clinicians can help nonpsychiatric clinicians on the front lines enact brief interventions to effectively identify and triage patients at risk for suicide. Specifically, the Blueprint for Youth Suicide Prevention outlines a 3-tiered pathway for youth suicide risk screening.10
In the first tier, all youth 12 years and older are screened for suicide risk using a brief, validated tool. There are many available tools for suicide risk screening. Thom et al conducted a review of validated tools to describe their strengths and limitations.13
The tools discussed included the Ask Suicide-Screening Questions (ASQ), the Columbia-Suicide Severity Rating Scale (C-SSRS; triage version), and the Patient Safety Screener (PSS-3), which are all approved by The Joint Commission.13 The authors note that the ASQ and PSS-3 are the only tools specifically developed for use among medical patients.
In the second tier, all youth who screen positive receive a brief suicide safety assessment (BSSA) to further inquire about the extent of suicidal ideation, the presence of a suicide plan, and other risk and protective factors. There are several tools available to conduct a brief suicide safety assessment, such as the ASQ Brief Suicide Safety Assessment14 and the C-SSRS.15
These tools should be used to determine risk level and operationalize next steps: what should happen next with the patient, which is the third tier, disposition. This includes disposition for (1) acute suicidal ideation that requires emergency intervention, (2) a nonurgent full mental health evaluation, (3) minimal routine psychiatric care, or (4) no further action needed.
Suicide risk screening programs have demonstrated feasibility using this clinical pathway. For example, a hospital system in Dallas, Texas conducted more than 90,000 screenings, with less than 3% of patients screening positive for suicide risk. Rates were slightly higher for EDs and among psychiatric patients, but emergency interventions were only necessary in 0.3% of all encounters, indicating that screening did not overburden hospital workflows.16 Smaller implementation studies have yielded similar results in pediatric primary care networks.17,18
Collaborative Care
As clinicians without extensive mental health specialization launch suicide risk screening programs, it is important for them to have connections with child psychiatrists, who can offer support and resources for patients identified with elevated risk. Before implementing a screening program, providers may establish partnerships with local mental health clinicians to triage care for those requiring further evaluation. Other forms of long-term support include child psychiatry access programs.
These collaborative initiatives can empower primary care providers to better address mental health concerns when specialty care is unavailable.19 These partnerships can also limit the need for emergency interventions in nonacute cases, reducing burden on both patients and limited ED resources.
In cases where referrals are unavailable due to high patient demand, mental health clinicians can train those on the front lines in brief, evidence-based interventions to mitigate risk, such as safety planning and lethal means safety counseling.20,21 These interventions have a demonstrated ability to reduce morbidity and mortality.
In a landmark study that included young adult patients, patients who received universal suicide risk screening paired with a brief intervention demonstrated a 30% reduction in suicide attempts compared with those receiving the standard of care.22 Lastly, psychiatrists can provide nonmental health providers and their patients with educational resources and training materials, such as those offered in the AACAP Suicide Resource Center.23
Culturally Responsive Care
Importantly, psychiatrists can also help with cultural responsiveness. Given the significant disparities in the suicide rates among BIPOC youth, LGBTQ+ youth, and other understudied/underserved populations, it is important that youth suicide prevention strategies be culturally responsive to the specific needs of the patient populations that are targeted.
As novel interventions are developed and implemented, it will be important to obtain feedback and insights from community members, especially those with lived experience who can provide invaluable input. Efficacy as well as effectiveness of each intervention should be tested in diverse health care settings that provide care to underserved communities.
Concluding Thoughts
Psychiatrists and other mental health clinicians are uniquely positioned to bolster novel suicide prevention efforts in medical settings. Youth with suicidal ideation can be identified in pediatric primary care, EDs, and inpatient medical units and connected with psychiatrists who can administer much needed mental health care. As pediatricians and other medical providers increase suicide risk screening in response to new practice recommendations, psychiatrists are essential partners in providing vital support to help save young lives.
Dr Horowitz is the director of patient safety and quality, a senior associate scientist, and a clinical psychologist at the National Institute of Mental Health (NIMH) Intramural Research Program at the National Institutes of Health in Bethesda, Maryland. Mr Ryan is an Intramural Research Training Award Fellow at the NIMH. Dr Pao is the clinical and deputy scientific director of the Intramural Research Program at the NIMH.
Acknowledgements: This research was supported by the Intramural Research Programs of the National Institute of Mental Health (ZIAMH002922).
References
1. WISQARS – Web-based inquiry statistics query and reporting system. CDC. Updated February 9, 2023. Accessed March 28, 2023. https://www.cdc.gov/injury/wisqars/
2. Youth risk behavior survey (YRBSS). CDC. Updated November 22, 2022. Accessed March 28, 2023. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm
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15. The Columbia Protocol (C-SSRS). The Columbia Lighthouse Project. Accessed March 28, 2023. https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/
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19. National Network of Child Psychiatry Access Programs. Accessed March 28, 2023. https://www.nncpap.org/
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