Suicide Prevention, Screening and Intervention

Suicide is a leading cause of death among Colorado youth ages 10 to 24. A recent report from the CDC states that the rate of teens who have seriously considered attempting suicide rose from 13.8% to 18.8% from 2009 to 2019¹. Emerging data from the CDC also suggest that COVID-19 had serious impacts on youth mental health. One in three high school students reported experiencing poor mental health during the COVID-19 pandemic, and 44.2% of students experienced persistent feelings of sadness or hopelessness. Additionally, 20% reported seriously considering suicide with 9% attempting suicide within the 12 months prior to the survey².

One potential avenue for improving suicide prevention efforts is with primary care providers. Some studies estimate that up to 83% of suicide attempters were seen by their primary care provider in the months leading up to an attempt, with 45% of individuals who died by suicide visiting their primary care provider within a month of their death³. The American Academy of Pediatrics, in partnership with the American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association, declared a national emergency in child and adolescent mental health⁴. In turn, the American Academy of Pediatrics released a call to action for pediatricians and all adults working with youth. One point in the call to action specifies a need to strengthen efforts in primary care settings to reduce the risk of suicide.

Pathway to Suicide Prevention for Primary Care Providers

Partners for Children’s Mental Health is attempting to fulfill this need through the development of the Pathway to Suicide Prevention for Primary Care Providers program (PSP for PCPs). The PSP for PCPs project has been working to assist primary care providers and practices to implement suicide safer care using a process developed with consultation from national, state and local partners such as EDC, Zero Suicide, SAMHSA, NIMH, Colorado Office of Suicide Prevention and a variety of community based pediatric physicians and psychiatrists. Through this program, we train primary care clinics to utilize and implement the Youth Suicide Care Pathway. The Youth Suicide Care Pathway is roadmap of how to screen, assess and provide brief interventions that can be completed in the office for youth at risk for suicide.

Youth Suicide Care Pathway

The PSP for PCPs program trains providers on the use and implementation of the Youth Suicide Care Pathway. Through this program, we assist primary care providers in learning how to provide suicide screening using the Ask Suicide Screening Questions (ASQ) developed by Lisa Horowitz at the National Institute of Mental Health (NIMH). The screening tool is ideal for outpatient settings as it is a suicide-specific screening tool validated for youth ages 10 and up, as well as emergency room and primary care settings. It is free, available in 13 languages, and can be administered in under 20 seconds.

A positive screen will then lead to assessing the patient using the Brief Suicide Safety Assessment (BSSA). The BSSA is part of the ASQ toolkit developed by the NIMH. The BSSA provides suggested language on how to gather information about risk factors, protective factors and warning signs. With this information, providers are trained on how to assign a risk level and then complete the subsequent steps in the care planning phase. This involves:

• Safety planning using a modified version of the Stanley-Brown Safety Plan
• Conducting Means Safety Counseling
• Providing referrals
• How to complete a thorough follow-up call

Intervention for pediatric anxiety within primary care

The PSP for PCP program also supports clinics for a year after the training to assist in implementing the Youth Suicide Care Pathway. This provides the clinic with technical, evaluative and clinical support when adjusting workflows to include the changes that come with implementing the Youth Suicide Care Pathway. Preliminary results from participating clinics show that approximately 80% of adolescence are being screened at well visits with 6% screening positively for risk of suicide. Without the implementation of this program, that would be 6% of youth going undetected. 

The goal of the PSP for PCPs program is to give primary care providers and staff the tools and skills they need to provide suicide safer care for youth across Colorado and ultimately save lives.

Cited:

1. CDC. Youth Risk Behavior Survey: data summary and trends report 2009–2019. Atlanta, GA: US Department of Health and Human Services, CDC; 2021
2. Jones SE, Ethier KA, Hertz M, et al. Mental Health, Suicidality, and Connectedness Among High School Students During the COVID-19 Pandemic — Adolescent Behaviors and Experiences Survey, United States, January–June 2021. MMWR Suppl 2022;71(Suppl-3):16–21
3. Horowitz L., Snyder D., Ludi E., Rosenstein D., Kohn-Godbout J., Lee L., Cartledge T., Farrar A., Pao M. Ask Suicide-Screening Questions to Everyone in Medical Settings: The asQ’em Quality Improvement Project. Psychosomatics. 2013; 54:239-247
4. AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health. Aap.org. Accessed September 9, 2022