[NIMC] suicide assessment article in Medscape
Allen Ivey
Standardized Screening May Help Identify Suicidal Adolescents CME/CE
News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD
CME/CE Released: 04/15/2010; Valid for credit through 04/15/2011
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Authors and Disclosures
Freelance writer and reviewer, Medscape, LLC
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
CME Clinical Editor, Medscape, LLC
Disclosure: Brande Nicole Martin has disclosed no relevant financial relationships.
Associate Clinical Professor, Residency Program Director, Prime-LC, University of California-Irvine, Orange, California; Department of Family Medicine, University of California-Irvine, Orange, California
Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.
Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland
Disclosure: Laurie E. Scudder, MS, NP, has disclosed no relevant financial relationships.
Learning Objectives
- Describe the epidemiology of suicide and suicidal ideation among adolescents.
- Identify outcomes of a screening program for suicidal ideation among adolescents.
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CME/CE Released: 04/15/2010; Valid for credit through 04/15/2011
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April 15, 2010 — Standardized screening for suicide risk in primary care can detect adolescents with suicidal ideation, allowing referral to a behavioral healthcare center before a fatal or serious suicide attempt is made, according to the results of a study reported online April 12 and published in the May print issue of Pediatrics.
"Several associations and federal agencies have called for depression screening in pediatric primary care," writes Matthew B. Wintersteen, PhD, from Thomas Jefferson University in Philadelphia, Pennsylvania. "Screening for suicide risk is a natural adjunct to this call....To our knowledge, this is the first study to prospectively examine the impact of standardized screening for suicide risk on detection and referral rates in pediatric primary care."
The goals of the study were to evaluate whether brief standardized screening for suicide risk in pediatric primary care practices could improve detection of youth with suicidal ideation, maintain improved rates of detection and referral, and be duplicated in other practices.
Two primary care clinics (clinic A and clinic B) were selected as intervention clinics, and a third clinic (clinic C) asked about participating in the study and was offered the intervention. At these 3 clinics, physicians underwent brief training in detecting suicide risk, and 2 standardized questions for adolescents aged 12.0 to 17.9 years were added to their existing electronic medical chart psychosocial interview. Data without identifiers were extracted during intervention trials and for the same dates of the preceding year, and referral rates were determined from social work records.
The intervention was associated with doubling of the rates of inquiry about suicide risk, which resulted in a 219% increase overall (clinic A odds ratio [OR], 2.04; 95% confidence interval [CI], 1.56 - 2.51; clinic B OR, 3.20; 95% CI, 2.69 - 3.71; and clinic C OR, 1.85; 95% CI, 1.38 - 2.31).
In clinic A, the rate of case detection increased nearly 5-fold (OR, 4.99; 95% CI, 4.20 - 5.79), was maintained for a 6-month period after the intervention was implemented (OR, 4.38; 95% CI, 3.74 - 5.02), and was replicated in both clinic B (OR, 5.46; 95% CI, 3.36 - 7.56) and clinic C (OR, 3.42; 95% CI, 2.33 - 4.52). Across all 3 clinics, case detection rate increased by 392%. The rate of increase of referral rates of suicidal youth to outpatient behavioral healthcare centers was commensurate to that of the detection rates.
"Standardized screening for suicide risk in primary care can detect youth with suicidal ideation and prompt a referral to a behavioral health care center before a fatal or serious suicide attempt is made," Dr. Wintersteen writes.
Limitations of this study include suicidal ideation based on history, not necessarily on present thoughts; and inability to determine the impact of the brief training in suicide risk.
"The findings from this study are particularly timely after the recent recommendation of the US Preventive Services Task Force to routinely screen youth for a major depressive disorder," Dr. Wintersteen concludes. "In addition, the American Academy of Child and Adolescent Psychiatry along with the American Academy of Pediatrics Task Force on Mental Health also released a joint article in which routine behavioral health screening in primary care was recommended....Both reports cautioned against screening when psychotherapy followup was not readily available."
The American Foundation for Suicide Prevention supported this study. Dr. Wintersteen has disclosed no relevant financial relationships.
Pediatrics. Published online April 12, 2010. Abstract
Additional Resource
The American Foundation for Suicide Prevention offers information about several suicide prevention projects available online.
Clinical Context
Nearly 2000 US adolescents committed suicide in 2005, the first annual increase in this total in more than a decade. The authors of the current study review the epidemiology of suicide and suicidal behavior among teenagers. Every year, approximately 20% of adolescents contemplate suicide, and 5% to 8% attempt suicide. A past suicide attempt is the best predictor of attempting suicide, although many adolescents who commit suicide do not have a past psychiatric diagnosis.
Suicidal ideation usually precedes suicide attempts in adolescents. The current study examines the regular use of a screening tool for suicidal ideation among teenagers attending primary care clinics.
Study Highlights
- 3 urban primary care clinics in the United States participated in the study. More than half of the patients these clinics serve are female sex, and more three quarters are black.
- All providers at the 3 sites were invited to a 90-minute training on youth suicide, which detailed the screening procedures.
- The screening tool began with 2 questions regarding lifetime thoughts about morbid ideation (ie, "Have you ever felt that life is not worth living?") and suicidal ideation (ie, "Have you ever felt like you wanted to kill yourself?").
- A positive response to either of these 2 questions prompted 4 more questions focused on lifetime suicide planning and experiences with suicidal ideation and planning in the past week.
- The suicide questions were presented to patients by their providers as part of the normal flow of psychosocial questions, all of which were prompted by an electronic medical record.
- The main study outcomes were the difference in the number of adolescents screened for suicidal ideation before and after the study intervention, and the rates of detection and referral for suicidal ideation.
- The baseline rate of screening for suicidal ideation was slightly less than 40%.
- The study intervention was associated with a significantly higher OR for inquiry regarding suicidal ideation, ranging between 1.85 and 3.20 in the 3 clinics.
- The case-detection rate for suicidal ideation also increased significantly in all 3 clinics in the postintervention period vs the preintervention period. In the first clinic, the OR for a positive response increased by 4.99 with the study intervention and was maintained for 6 months. The ORs for case detection after the study intervention in the other 2 clinics were 5.46 and 3.42.
- The number of referrals for suicidal adolescents by clinic social workers increased in a manner commensurate with the higher detection rate associated with the screening tool. This postscreening referral rate was approximately 1 referral per week.
Clinical Implications
- The prevalence of suicide among adolescents climbed in 2005. Approximately 20% of adolescents contemplate suicide each year, and 5% to 8% attempt suicide. A past suicide attempt is the best predictor of attempting suicide, although many adolescents who commit suicide do not have a past psychiatric diagnosis.
- The current study demonstrates that a screening tool for suicidal adolescents increased the rate of inquiry regarding suicidal ideation as well as the number of adolescents with positive responses regarding suicidal ideation.
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