With the ongoing stressors of the pandemic and media reports of apparent increases in suicidal behaviors, concerns about suicide and about suicidal and self–harm behaviors is an ongoing concern for which the medical and mental health community needs to retain front-of-mind. Even prior to the pandemic suicide was the second leading cause of death in adolescents, and now with the universal prevalence of higher stress because of the virus, active screening is of heightened importance. This week’s article provides a review of clinical considerations that can assist in incorporating interactive dialogue into the exam encounter to better screen for suicide risk and to providing referral for care when indicated.
Because of the prevalence of suicidal thoughts in adolescents (and other age groups), it is important for all medical and mental health providers to be comfortable asking questions related to suicide risk. The American Academy of Pediatrics 2016 guidelines on “Suicide and Suicide Attempts in Adolescents” urges pediatricians to screen patients for suicidal thoughts. The report identifies risk factors linked to teen suicide attempts, including:
- Family history of completed suicide and suicide attempts
- Personal history of suicide attempt and/or non-suicidal self-injury
- History of physical, sexual or emotional abuse or neglect
- Mood disorders and psychotic disorders
- Drug and alcohol use
- Sexual orientation
- Firearms in the home
- Strained parent-child relationship or living outside of the home
- Poor school attendance and/or performance
- Bullying, including cyber-bullying – highest risk in teens who are both bullies and victims of bullying
- Internet exposure – particularly concerning if using more than 5 hours/day.
- Male vs female: Girls more likely to make suicide attempts; boys more likely to have completed suicides.
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 may be concerned about. It is helpful to talk with a teen patient privately to increase their comfort in disclosing sensitive information. With the stressors of the pandemic an ongoing concern for virtually everyone, it may be helpful to start a dialogue with a comment such as “The virus situation has really been a challenge for so many people and I’m checking in with all my patients to see how they are doing with all the changes and restrictions from normal activities. How are you doing?” If needed, following up on this general inquiry by asking about how things are going for the teen at home, with schoolwork, and with friends can help keep the dialogue going. Clearly if the youth acknowledges any significant distress or depressive symptoms, a more specific inquiry such as “Have you ever thought about killing yourself or wished you were dead or never born?” would be appropriate, but given many teen’s reluctance to share emotionally sensitive concerns, it will always be appropriate to make the “ask”: “Have you ever done anything on purpose to hurt or kill yourself?”
Though for many this may feel like an emotionally charged inquiry, it is important to make the “ask” in a non-judgmental and matter of fact manner. If the answer to is yes, it is obviously important to obtain more details and it is particularly important to assess lethality and intent in determining the appropriate management. If the youth’s response is vague or otherwise unclear or seemingly uncomfortable, further dialogue is indicated. 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 relying on screening tools in the primary care setting to screen for depression in adolescents and adults, the evidence did not support using screening tools alone 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 and the Columbia Suicide Severity Rating Scale is likewise a useful 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.