Screening and Intervention for Youth Suicidality in Primary Care

For many years, the youth mental health crisis has been impacting more and more families.  Both local and national data show that suicide in youth has become more prevalent in recent decades.

Nationally, the Centers for Disease Control and Prevention (CDC) found that in youth and young adults 10 to 24 years old:

• Suicide rates have increased by 52.2% between 2000 and 2021
• The suicide rate was 11.0 per 100,000 in 2021
• Suicide was the second leading cause of death in 2021

Colorado faces a similar and unfortunate reality:

• In 2020, suicide was the second leading cause of death in youth and young adults age 10 to 24
• According to the American Foundation for Suicide Prevention (AFSP), in 2021, Colorado’s suicide rate was 5.21 per 100,000 people ages 10 to 14, 17.41 per 100,000 people ages 15 to 18, and combined, 10.82 per 100,000 people ages 10 to 18

In May of 2021, Jena Hausmann, CEO of Children’s Hospital Colorado, was one of the first children’s health system leaders to declare a ‘State of Emergency’ for pediatric mental health. Following this, many national entities announced a pediatric mental health state of emergency on a national level in the fall of 2021 and that year the U.S. Surgeon General released an advisory, Protecting Youth Mental Health.

Youth suicide prevention guidance

In the wake of this crisis, The American Academy of Pediatrics (AAP) partnered with the National Institute of Mental Health (NIMH) and the AFSP to create and publish the Blueprint for Youth Suicide Prevention. This free resource is specifically for pediatric providers and clinicians and outlines suicide prevention strategies and best practices.

This guide shares updated national suicide data and trends, outlines different screening prevention strategies and reviews suicide risk factors, protective factors and warning signs in youth. These organizations also make recommendations for best practices in suicide prevention and screening for clinical, school and community settings. We strongly urge primary care providers to visit this resource and explore it.

Resources for suicide screening and intervention for children in primary care practices

Current literature shows that most individuals who die by suicide have interacted with the medical system in the year preceding their death. Thus, primary care providers have an important role in identifying suicide risk.

While empirical studies are limited, successful interventions designed to identify and intervene with youth at risk for suicide in primary care and outpatient medical settings typically involve screening for suicide risk, referral to mental health treatment, brief family-based interventions and safety planning. Largely, the available literature suggests screening and brief intervention improves referral to ongoing mental health care.

Additionally, the Blueprint for Youth Suicide Prevention has a section on screening for suicide risk.

It makes the following age recommendations for screening

• Youth age 12 and older: Universal screening
• Youth ages 8 to 11: Screen when clinically indicated
• Youth younger than age 8: Screening not indicated. Assess for suicidal thoughts or behaviors if you see warning signs

The blueprint also offers the following evidenced-based screening tools:

• Ask Suicide-Screening Questions (ASQ) Toolkit
• Suicide Behavior Questionnaire-Revised (SBQ-R)
• Columbia Suicide Severity Rating Scale (C-SSRS)- Triage Version
• Patient Health Questionnaire-9 Adolescent Version (PHQ-9A)
• Patient Safety Screener-3 (PSS-S)

The blueprint goes on to highlight specific strategies for caring for patients at imminent risk of suicide, those who need further mental health evaluations and those at low risk for suicide. Primary care providers can use the ASQ Toolkit to briefly assess and triage suicide risk in youth.

In addition, numerous nonprofit and governmental organizations have come together to create a transformational framework for health care systems titled Zero Suicide. This framework offers extensive toolkits, including 4- or 5-question ASQ screeners, as well as the Brief Suicide Safety Assessment (BSSA), which is part of the ASQ and guides providers in asking patients questions related to suicide risk when they have a concern.

The BSSA includes verbiage providers can refer to when interviewing both patients and caregivers about suicide risk factors. It also assists providers with decision-making following patients’ responses to the ASQ, which includes recommendations on when to conduct the BSSA, when to refer a patient for a mental health evaluation and when to send a child to a crisis center or emergency room for further assessment.

Children’s Hospital Colorado has begun a multiyear project to incorporate the Zero Suicide framework across all clinical sites and levels of care, with the goal of incorporating suicide prevention within every single clinical encounter across the organization.

Pathway to Suicide Prevention for Primary Care Providers

These national resources are not the only way primary care providers can help prevent suicide in children. Partners for Children’s Mental Health is trying to make an impact through the development of the Pathway to Suicide Prevention for Primary Care Providers program (PSP for PCPs). The PSP for PCPs project looks to assist primary care providers and practices to implement safer care using a process developed with consultation from national, state and local partners.

Through this program, we train primary care clinics to utilize and implement the youth suicide care pathway. The youth suicide care pathway is a roadmap of how to screen, assess and provide brief interventions 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 teach primary care providers how to provide suicide screening using the ASQ. The screening tool is ideal for outpatient, emergency room and primary care settings. It’s free, available in 13 languages, and can be administered in under 20 seconds. In this program, we also help providers become more familiar with the BSSA.

Intervention for pediatric anxiety within primary care

The PSP for PCPs 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 based on the youth suicide care pathway. Preliminary results from participating clinics show they are screening approximately 80% of adolescents at well visits with 6% screening positively for risk of suicide when they otherwise wouldn’t have been.

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.