Suicide is a difficult topic for our society to address. Frequently, our instinct is to not talk about it unless a parent or patient brings the topic up themselves, says Jenna Glover, PhD, Assistant Professor of Psychiatry at the University of Colorado. There are pervasive myths that persist that talking about suicide with youth will “plant” ideas in their mind and increase the likelihood that they will consider and attempt suicide. Despite these concerns, the research in this area is robust and clear that talking to youth about suicide decreases the likelihood that youth will make a suicide attempt1.
Understanding the power of having these conversations is essential for primary care providers because research indicates that 45% of patients who died by suicide visited a primary care provider in the month before their death2. Because primary care physicians are the most likely group of professionals to interact with youth on a regular basis, it is important that we use this setting to assess for suicidal ideation on a regular basis in all patients seen for annual wellness checks. This is particularly salient for the state of Colorado where suicide is the leading cause of death in youth and young adults.
Suicide in Colorado
One striking statistic is that Colorado is within the top 10 states in the U.S. for death by suicide. Often people have a conceptualization of Colorado as a place of health and wellness, which disrupts the notion that mental health problems exists among the youth in our state. Despite these notions, we know that 24% of youth experience a major depressive episode each year and that 14% of youth have seriously considered suicide within the past year. There are several ideas for why rates of depression and suicide are so high in Colorado. There is no one specific reason to explain this phenomenon; however, a conglomeration of factors is likely to explain the increased rates of depression and suicide and youth in Colorado.
First, access to mental healthcare is limited within Colorado so there are a variety of youth with mental illness who are not identified as having a mental disorder and if they are, there is difficulty connecting them with care. Second, states that have high gun ownership often have higher rates of suicide within the population, which speaks to the importance of step 6 in safety planning, which is addressed later in this article. Finally, there is some research that suggest that individuals living at a higher elevation have higher rates of depression3. Outside of these factors are other variables related to family history, social media use and resiliency factors available to youth.
Regardless of why, we know that suicide is an epidemic in the state of Colorado and primary care providers are best positioned to reduce the risk through systematic screening of suicide symptoms as part of sick and wellness visits.
Screening for suicide
There are several effective and nonproprietary measures for assessing suicide in youth available to primary care providers. These include the Columbia Suicide Severity Rating Scale (C-SSRS) and the Ask Suicide Screening Questions (ASQ). Both measures can be administered to youth within less than five minutes and are able to reliably and validly identify suicide risk. The C-SSRS and ASQ are both available in a variety of different languages.
There are many practices that also utilize the Patient Health Questionnaire 9 for Adolescents (PHQ-A) to identify depressive symptoms and suicide risk. Although the PHQ-A is an effective tool for assessing depressive symptoms, the C-SSRS and ASQ are more effective in flagging patients who are suicidal, and it is recommended that practices use these measures as an adjunct to the PHQ-A and not utilize the PHQ-A in isolation to screen youth for suicidal ideation.
Currently, Partners for Children’s Mental Health, a non-profit organization dedicated to improving systems of care for mental health services for youth in Colorado, is offering training and implementation support for integrating the ASQ screening tool into primary care practices. Please contact firstname.lastname@example.org for information on how to enroll your practice in this project.
In the event that primary care providers experience working with a suicidal patient, it is important to engage in supportive practices to stabilize the patient. For patients that are high risk, which means they are endorsing suicidal ideation with a plan and intent, providers are instructed to send the patient to an emergency department for crisis care. For patients who are medium to low risk, (ideation with or without a plan but no intent), it is recommended to engage the caregiver and patient in safety planning.
Safety planning consist of completing information in six core areas, which include:
- Identifying warning signs
- Listing coping strategies
- People and social settings to provide distraction
- People who I can ask for help
- Professional agencies I can contact during a crisis
- Making the environment safe (removing or locking away medications, guns, etc.)
The Stanley Brown Safety Plan is a well-established tool that providers can use. Additionally, there are a variety of apps that patients can download for safety planning that are free and easily accessible via their smartphones. These strategies can be helpful in best supporting patients with suicidal ideation without needing to escalate care to an emergency department. As primary care providers become more comfortable and adept at using these screenings and support tools, we can hope for a decrease in the rate of death by suicide in our youth in the state of Colorado.
- Gould MS, Marrocco FA, Klienman M., et al. Evaluating Iatrogenic Risk of Youth Suicide Screening Programs: A Randomized Controlled Trial. JAMA. 2005;293(13):1635-1643
- Association of Clinicians for the Underserved, Suicide Prevention in Primary Care A Toolkit for Primary Care Clinicians and Leaders
- News Now, Study Suggests that Suicide Rates Increase with Altitude