Identifying Suicide Risk in Adolescents: The Role of the Primary Care Physician

Can the Family Doctor Help Identify Suicide Risk and Prevent Teen Suicide?

Teen mental health is on the mind of every parent in the country right now.

And if it’s not, it’s our position that it should be.

We say that not only as professionals working in adolescent mental health, but also as concerned parents, uncles, aunts, and members of our various communities, all of which include teens we know and love.

We also say that based on the overwhelming amount of evidence published over the past several years indicating that teenagers in the U.S. are in the midst of a mental health crisis. Adolescent suicide risk has increased, suicidal ideation among teens has increased, and self-harming behavior among teens has increased. We see those risks alongside increases in adolescent depression, anxiety, and alcohol and substance use disorder (AUD/SUD).

The increase in risk and prevalence among teens prompted the Surgeon General of the United States to issue an advisory – called a Surgeon General’s Advisory, or SGA – on the state of teen mental health late last year called “Protecting Youth Mental Health.”

We weren’t surprised about the advisory, since we work with teens with mental health and addiction issues every day. Coming midway through the pandemic – which has exacerbated teen mental health issues – it should not have surprised parents, either. They all know the pandemic has increased stress levels across the board, and most understand teens with pre-existing mental health disorders and with significant risk factors have been particularly vulnerable.

What many parents don’t understand is that the teen mental health crisis – specifically the increase in suicidality and self-harm – is not new. The current crisis developed over the past twenty years – and a new paper published last year has important ideas about how primary care physicians – i.e. your family doctor – can play a key role in identifying suicide risk among adolescents.

The Current State of Teen Mental Health

Before we discuss the role of the primary care physician in identifying adolescent suicide risk, the presence of suicidal ideation in teens, or the risk of self-harming behaviors in teens, we’ll share the trends in the data that caused the Surgeon General to address the nation through the SGA about the current teen mental health crisis in the U.S.

First, the general mental health data.

Teen Mental Health: The Essential Facts

  • In 2019, 20% of children between age 3 and 17 reported an emotional, behavioral, developmental, or mental health disorder.
  • In 2016, only 50% of the children with a treatable mental health disorder received the treatment they needed.
  • The percentage of high school students with persistent feelings of sadness or hopelessness increased by 40% between 2009 and 2019
  • From 2011 to 2015, overall visits to hospital emergency rooms increased by 28% for:
    • Depression
    • Anxiety
    • Behavioral disorders

Those statistics are relevant to this article – which focuses on identifying teen suicide risk – because the presence of any mental health disorder in an adolescent increases suicide risk. That’s a critical fact for parents to understand. The data above give us a clear picture of the state of teen mental health in general.

Now let’s narrow in and look at the teen suicide statistics.

Trends in Teen Suicide: 2007-2019

  • Suicide rates among youth ages 10-24 in the US increased by 57% between 2007 and 2018
  • The percentage of high school students seriously considering suicide increase by 36% between 2009 and 2019
  • The percentage of high school students with a suicide plan increased by 44% between 2009 and 2019
  • In 2014, suicide surpassed homicide as the second leading cause of death for people age 10-24
  • An average of 3,703 adolescents in grades 9-12 attempt suicide every day
  • 80% of adolescents who attempt suicide give clear warning signs beforehand.

We’ll remind you that these statistics are pre-pandemic, as are the statistics included in the study on the role of the primary care physician we’re about to share. Before you read further, though, we encourage you to read this article on teen suicide:

A Parent’s Guide to Suicide Risk in Teens

In addition, to get an idea of the impact of the pandemic on teen mental health – which foregrounds the importance of identifying suicide risk in teens – we encourage you to read these articles:

Depression in the U.S. Before and After COVID: Risk of Increased Co-Occurring Disorders

The Impact of COVID-19 on LGBTQI+ Teen Mental Health

80% of Young Adults Report Depression During COVID-19, Study Says

Now let’s get to the paper we discussed in the introduction.

Primary Care Pediatricians, Teens, and Screening for Suicide Risk

We present the statistics above to inform parents about the current state of teen mental health in the U.S.

It’s precarious.

A majority of mental health professionals and their general physician colleagues, including the Surgeon General, agree one hundred percent. We understand how to identify and treat depression, anxiety, and various other mental health disorders. We also understand that various factors increase the risk of suicide among teens – including the presence of depressive and anxiety disorders. Currently, it’s standard practice to screen for a primary care physician to screen for depression, using one of several standardized assessment tools.

Each assessment tool includes suicide risk in its depression screening protocol, with follow up questions and protocols physicians ask if a child or teen answers “yes” to questions about suicide and suicidal ideation. “Yes” answers to these questions also trigger follow-up protocols.

Within a depression screen, suicide risk questions look like this:

Have you ever had thoughts that you would be better off dead or hurting yourself in some way?

Has there been a time in the past month when you had serious thoughts about ending your life?

Affirmative answers require follow-up questions like this:

Have you ever felt that life is not worth living?

Has this feeling occurred in the last week?

Affirmative answers trigger questions that gauge immediate risk, which, if identified, triggers suicide crisis protocols that typically involve emergency hospitalization for 24/7 monitoring until the crisis passes. Negative answers to these follow-up questions typically trigger a referral for a full psychiatric evaluation and plans to engage in some form of mental health treatment.

That’s the approach the pediatricians in this study took with their patients. The goal of the study was relatively simple: does this approach work? Does screening for suicide risk by pediatricians make sense?

Let’s see.

The Results: Pediatricians Can Identify Suicide Risk

When we ask the question “Does screening for suicide risk by pediatricians make sense?” what we really mean is “Can we find and help the teens who are at risk of suicide?” and further “Can we prevent a suicide attempt in a teen who shows signs of increased risk?”

To answer that last question we must speculate, since the researchers indicated that “data on actual suicide attempts were unavailable.” But we can answer the first two questions with a simple “yes.”

Here’s how the researchers found out:

  1. They examined electronic health records (EHR) from over 25,000 pediatrician well-visits made by teenagers between September 1, 2014, and August 31, 2016.
  2. They obtained complete depression assessment records for just under 7,000.
  3. Of those 7,000, 643 reported at least one suicide attempt in their life, serious suicidal ideation in the past month, or both.
  4. Those 643 were identified as at risk of suicide. Of those 643, pediatricians asked 472 (73%) five follow-up suicidality questions
  5. Of those 472 teens, 272 gave answers that indicated suicide risk.
  6. Those 272 were identified as at increased risk of suicide. Of those 272, pediatricians asked 236 (87%) – a total of eight mandatory follow up questions.

After collecting all that data from electronic records, researchers re-examined the data to identify any actions take to support the most at risk teens. They found three primary types of actions – and related steps – taken as a result of the pediatrician-delivered depression assessment:

Monitoring and Care Coordination

  • 17 received a suicide crisis line number
  • 15 received a safety plan
  • 3 received a crisis line and a safety plan

Referrals

  • 51 received a referral for behavioral health support the day of the assessment
  • 24 received a referral for behavioral health support within a year of the assessment

Interventions

  • 16 received professional psychotherapy
  • 28 received antidepressant medication
  • 10 went to the emergency room for a psychiatric emergency
  • 7 had a documented psychiatric hospitalization

When we read this data, we see positives and we see areas where this system needs improvement. The positives are easy to spot. First, the overall system works: pediatricians can identify suicide risk at a typical well-visit, using a tool designed to identify depression risk. Next, the data show that when they do identify risk, pediatricians can ask follow-up questions to identify increased risk. Once they identify increased risk, they can activate a system of care that supports teens. That support comes in three ways: monitoring care and coordination, referrals, and interventions.

That’s all good news.

However, the researchers think there is significant room for improvement.

Helping Pediatricians Identify Adolescent Suicide Risk: How the System Can Get Better

The main reason the researchers think the present system is inadequate is the small percentage of teens from the group identified as high-risk who received professional support and care. When we look at the data, we see what they mean. Of the 236 identified as high risk for suicide, only 51 received referrals for therapy (21%), 16 received therapy (8.5%), 17 received a crisis line number (7.2%), and only 3 received a crisis line number and a safety plan (1.7%).

In the researcher’s opinion – and we agree – those percentages simply aren’t large enough. Too many teens at risk of suicide are falling through the cracks.

Here’s how they think the system can improve. In the pediatric primary care environment, providers can:

1. Assessments

Providers can administer a suicide-specific suicide risk assessment in the pediatric primary care context to teens who display elevated risk on a depression screen

2. Care Navigators

Providers can employ a care navigator to help connect teens and families to behavioral health care providers and monitor treatment adherence and progress

3. Enhance Electronic Record Templates

Providers can ask software vendors to incorporate suicide-informed templates into the existing EHR system. Templates can include things like safety plans, suicide hotline numbers, or information for general support.

4. Integrate Follow Up Into Electronic Records

Providers can ask software vendors to add prepopulated text options into existing EHR note templates. These can include:

      • Documentation of when risk was first identified
      • Documentation of initial steps taken after risk was first identified
      • Reminders to follow up with family
      • Reminders to connect and collaborate with behavioral health providers to monitor progress and ensure best outcomes
      • Software that prohibits providers from closing a note on patient progress until actions related to suicide risk are documented

These recommendations appear logical and sound. While we know pediatric primary caregivers have a lot on their plate already, it’s critical that all providers, at all levels of care, respond to the trends in teen mental health identified by countless reliable studies over the past twenty years. The pandemic increases the urgency and necessity of this change in approach. Now that we know to treat mental health disorders – including those that may include suicidality – as chronic medical conditions that respond to evidence-based treatment, we need to demonstrate that awareness across the entire spectrum of care in ways that improve outcomes for our teenagers.

That means changing what, when, and how we do things. In the case of teen suicide, we can broaden the base of tools available to primary care pediatricians to include direct links to mental health resources that can be activated when needed. We’ll close this article with the words of the study authors themselves:

“Taken together, refinements in suicide assessment, documentation, and linkages to care guided by the current findings may make a meaningful difference in the lives of adolescents, their families, and the providers who care for them.”