Suicide is now the second leading cause of death in adolescents, in the United States, surpassing homicide and second only behind unintentional injuries (motor vehicle accidents, accidental overdose). This switch occurred because of both a reduction in deaths from homicide and a modest increase in deaths from suicide. Deaths from suicide had been decreasing from 1990 to 2000; this seems partly related to better treatment options for depression in teens, including access to mental health services and antidepressant medications. The rate has been fluctuating in the last 18 years, partly because of increase in certain risk factors, and there is concern about the negative influence of the FDA Black Box warning on antidepressant medications on the prescribing practices of these medications in the primary care setting. Teen girls are more likely to make suicide attempts and teen boys are more likely to have completed suicides.
Because of the prevalence of suicidal thoughts in adolescents, it is important for all medical and mental health providers to be comfortable asking questions related to suicide risk. With these new findings, the American Academy of Pediatrics revised their 2007 guidelines on “Suicide and Suicide Attempts in Adolescents” in 2016 to urge pediatricians to screen patients for suicidal thoughts. The report identifies risk factors linked to teen suicide attempts, including:
1. Family history of completed suicide and suicide attempts
2. Personal history of suicide attempt and/or non-suicidal self injury
3. History of physical, sexual or emotional abuse or neglect
4. Mood disorders and psychotic disorders
5. Drug and alcohol use
6. Sexual orientation
7. Firearms in the home
8. Strained parent-child relationship or living outside of the home
9. Poor school attendance and/or performance
10. Bullying, including cyber-bullying – highest risk in teens who are both bullies and victims of bullying
11. Internet exposure – particularly concerning if using more than 5 hours/day
Screening for suicidal thoughts is important, and studies show that asking about suicide risk does not increase the risk of suicide attempts or “put the idea in the patient’s head” as some providers are concerned about. It is helpful to talk with a teen patient privately to increase their comfort in disclosing sensitive information, but it is also important to review mandated reporting with the teen. An example of an appropriate screening question is: “Have you ever thought about killing yourself or wished you were dead or never born?” It is best to embed a question like this in the middle of other questions about depressive symptoms, after asking more general questions about how things are going for the teen at home, at school, with friends, etc. The follow up question could be “Have you ever done anything on purpose to hurt or kill yourself?” If the answer to either question is yes, it is important to obtain more details. It is particularly important to assess lethality and intent in determining the appropriate management. In most cases, if there is a concern about acute risk, a provider should err on the side of caution and seek out emergency mental health services.
In 2015, the US Preventive Task Force concluded that while they recommend using screening tools in the primary care setting to screen for depression in adolescents and adults, they do not think the evidence supports using screening tools to screen for suicide risk in patients without a psychiatric disorder. When there is concern about depression, it is important to ask about suicide risk and there are questionnaires that can be useful. The PHQ9 has questions about thoughts of suicide and suicide attempts. The Columbia Suicide Severity Rating Scale is one such tool.
This report is relevant in that it highlights the importance for all providers to feel comfortable asking about suicide risk in patients. It is our hope that this article brings each of you closer to that goal.