Suicide Risk Screening in Pediatric Primary Care

A recent study described the implementation of a suicide risk screening protocol in a pediatric primary care setting. The research aimed to determine the feasibility of implementation by measuring acceptability of the screening process to clinic staff, parents, and patients; disruption to workflow; and rates of suicide risk. A secondary study aim was to use the results to develop a clinical pathway (i.e., care pathway) for suicide risk screening in outpatient pediatric settings.

The study was carried out by leaders of a suburban pediatric primary care practice in collaboration with researchers from the National Institute of Mental Health. Participants were 271 patients ages 12 to 25 who were screened for suicidal thoughts and behaviors using the Ask Suicide-Screening Questions (ASQ) tool. Clinic staff received training in suicide epidemiology, risk factors, warning signs, and safety planning, as well as how to administer the ASQ, interpret results, and respond to a positive screen. Following the initial pilot, feedback from staff, parents, and patients was obtained through surveys.

Among the patients screened, 31 (11.4%) were positive for suicide risk with 1 at imminent risk. More than half of patients who screened positive reported a past suicide attempt. Overall, 64% of patients said they had never been asked about suicide before, including the one who was positive for imminent risk. Most parents (74%) were supportive of suicide risk screening at the doctor’s office and 80% indicated that they were somewhat or very comfortable with their child being screened.

All three pediatricians and 73% of nurses in the practice agreed that clinicians should ask patients about suicide risk in medical settings. All nurses reported experiencing discomfort asking direct questions about suicide but that after several patients reported suicidal thoughts, they better understood the importance of screening. After implementation, most clinic staff said that the screening protocol was not disruptive to workflow, were comfortable screening patients for suicide risk, and felt prepared to continue screening. 

This study has limitations that may limit the generalizability of its findings. Participants were not randomly selected and recruited from a single site and therefore may not be representative of the general population of pediatric outpatients and their families. The sample was mostly White and female. Because of the small sample size and relative homogeneity, cultural and ethnic differences in attitudes and beliefs about suicide could not be addressed. The authors also acknowledged that because of the focus on “wellness” visits, the patients may not be representative of those at highest risk. 

Despite its limitations, the results of this study are important and demonstrate that:

  • Suicide risk screening may be acceptable to young patients and their parents.
  • A standard suicide risk screening protocol can be successfully implemented in a pediatric primary care setting without any disruption to normal workflow.
  • Over time, staff may become more comfortable asking direct questions about suicide and realize the importance of screening.
  • Support from leadership, adequate planning and training, frequent feedback and self-monitoring, and willingness to make real time adjustments appear to be key to successfully implementing such a protocol.

The results of this study informed the development of a clinical pathway for youth suicide risk screening in outpatient settings.

Horowitz, L. M., Bridge, J. A., Tipton, M. V., Abernathy, T., Mournet, A. M., Snyder, D. J., Lanzillo, E. C., Powell, D., Schoenbaum, M., Brahmbhatt, K., & Pao, M. (2022). Implementing suicide risk screening in a pediatric primary care setting: From research to practice. Academic Pediatrics, 22(2), 217-226. https://doi.org/10.1016/j.acap.2021.10.012

Suicide and Known Mental Health Status among Males

In a new study, researchers examined suicide among males across the life span and its association with known mental health conditions.

Using data from the Centers for Disease Control and Prevention’s National Violent Death Reporting System, the researchers analyzed 70,376 suicide deaths from 2016 through 2018. They compared suicide characteristics with and without known mental health conditions among four groups of males (ages 10-17, 18-34, 35-64, and ≥ 65). Data was based on death certificates and coroner/medical examiner and law enforcement reports, and suicide was defined as deaths of persons ≥ 10 years old from intentional self-harm.

The analysis found 40% of all males had a history of known mental health conditions. Males with known mental health conditions were more likely to have a history of suicidal thoughts and/or suicide attempts. Among those recently released from an institution (10% of participants), those with a known mental health condition were more likely to have been released from a psychiatric hospital, while those without a known mental health condition were more likely to have been released from jail/prison.

Males without a history of known mental health conditions were more likely to have had a recent or impending crisis, such as eviction/home loss, relationship problems, or criminal/legal problems; live in a rural area; have disclosed suicidal thoughts or suicide attempts; used firearms as a suicide method; and have been recently released from jail/prison. 

Among males 65 and older, physical health problems also appeared to be a risk factor for suicide. Substance use was common in both groups but more likely in those with known mental health conditions.

This study helps shed light on risk factors for suicide among males across the life span with and without known mental health conditions. The findings highlight the importance of a comprehensive approach to suicide prevention, including strategies to reduce the impact of social stressors and provide supportive environments, especially in cases of substance misuse or access to firearms.

Unlike previous research of its kind, this study used medical records or other official documents to determine mental illness rather than interviews with family members, which may be less objective and subject to bias. However, it is possible that some individuals with mental health conditions were undiagnosed. The authors note that non-White, lower educated, and rural males were less likely to have had a known mental health condition, which may reflect disparities in access to mental health care.

As of 2018, data in the National Violent Death Reporting System was only available for 39 states, reflecting 72% of the U.S. population and Puerto Rico, so the data used in this study was not national in scope. Also, routine assessments of substance use are not standard across jurisdictions and not all substances are routinely screened for.

Fowler, K. A., Kaplan, M. S., Stone, D. M., Zhou, H., Stevens, M. R., Simon, T. R. (2022). Suicide among males across the lifespan: An analysis of differences by known mental health status. American Journal of Preventive Medicine, 63(3), 419–422.

Sexual Orientation Hate Crime Laws and Youth Suicide Risk

State laws that aim to prevent hate crimes related to sexual orientation may help reduce suicide among high-school-aged youth, suggests a recent study.

Using data from the Youth Risk Behavior Survey (YRBS), researchers examined suicide attempts among youth in states with hate crime laws that explicitly name sexual minorities as a protected population, states that do not include them as a protected group, and states without any hate crime laws. They found there were 62,274 past-year suicide attempts among youth in the study, with an overall prevalence of 8.6 %. The estimated prevalence of suicide attempts among youth who identified as gay or lesbian (25.7%), bisexual (27.1%), or questioning (18.5%) was considerably higher than among their heterosexual peers (6.3%).

The study found that including sexual minorities as a protected group in state-level hate crime laws reduced suicide attempt rates among youth by a small but significant percentage compared to state laws that did not include them as a protected group. The reduction in suicidal behaviors did not differ in magnitude between lesbian, gay, bisexual, or questioning and heterosexual respondents, suggesting that the passage of hate crime laws related to sexual orientation may benefit all youth. Reductions in suicide attempts were larger among questioning and bisexual youth compared to their gay or lesbian peers. Youth outcomes in states with hate crime laws that lacked specific protections for sexual minority populations did not differ from states without any hate crime legislation.

Experiencing social stigma, discrimination, and associated stress can increase suicide risk and mental health challenges among youth who identify as LGBTQIA+. This study highlights the potential benefit of state legislation that specifically names sexual minority populations as a protected group. Enactment of such legislation may be an indicator of a more supportive political environment which, in turn, may lessen actual or perceived stigma and victimization.

This study has some limitations. The identification of sexual and gender identity was based on a self-report survey, and it is likely that some respondents might have been reluctant to disclose this information. The authors noted that the validity of questions exploring sexual preferences have been questioned due to variability in the interpretation of the question. Also, the language and provisions of hate crime laws differ across states, making it difficult to establish a direct link between the legislation and behavioral outcomes.

Despite its limitations, the results of this study are intriguing. There have been few studies of the impact of legislation and public policy on individual suicide-related behavior. The results of this study highlight the need for further research on this topic.

Prairie, K., Kivisto, A. J., Gray, S. L., Taylor, N., & Anderson, A. M. (2022). The association between hate crime laws that enumerate sexual orientation and adolescent suicide attempts. Psychology, Public Policy, and Law. Advance online publication. https://doi.org/10.1037/law0000360

Evaluation of the REACH-VET Program

An evaluation found the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was associated with increased treatment engagement and quality of care and reduced suicide attempts among participants. Run by the Veterans Health Administration, the REACH VET program is designed to facilitate care enhancements for individuals identified by a validated algorithm as being in the top 0.1% for suicide risk.

The study sought to examine whether participation in REACH VET resulted in greater treatment engagement (i.e., more scheduled and completed appointments) and quality of care (e.g., suicide safety plan documentation), as well as reduced acute care needs (fewer inpatient mental health admissions and emergency department visits) and suicide-related behaviors (suicide attempts and deaths).

Researchers compared outcomes of individuals entering REACH VET between March 2017 and December 2018 to a group of individuals identified as high risk prior to the program’s start who would have met the eligibility criteria. They also included a second comparison group of people who would not have been eligible for the program to compare cause-specific mortality using death certificate data.

Participant data came from the Veterans Health Administration Corporate Data Warehouse on 173,313 individuals (93% men, 7% women) with a mean age of 51. 

Results indicated that participation in REACH VET was associated with more completed outpatient appointments, fewer missed appointments, having new suicide safety plans, reduced mental health admissions and emergency department visits, and fewer documented suicide attempts within six months. However, there was no difference between the groups in the proportion of deaths resulting from suicide or other causes within six months.

REACH VET is the first clinical implementation of a validated algorithm to support suicide risk identification in the U.S., carried out in the nation’s largest integrated health system. The findings from this study highlight the value of investment in suicide surveillance, data analytics, and clinical operations to improve health outcomes.

McCarthy, J. F., Cooper, S. A., Dent, K. R., Eagan, A. E., Matarazzo, B. B., Hannemann, C. M., Reger, M. A., Landes, S. J., Trafton, J. A., Schoenbaum, M., & Katz, I. R. (2021). Evaluation of the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment suicide risk modeling clinical program in the Veterans Health Administration. JAMA Network Open, 4(10), e2129900. doi:10.1001/jamanetworkopen.2021.29900

Treatment-Seeking and Suicidality by Suicide Method

A recent study looked at treatment-seeking and suicidality among people who died by firearm suicide compared to those who died by other suicide methods.

Using data from the National Violent Death Reporting System (NVDRS), researchers studied 234,652 people who died by suicide between 2003 and 2018. Comparing those who died by firearms to those who used other methods, the researchers examined history of mental health or substance use treatment, suicidal thoughts or plans, suicide attempts, and disclosure of suicidal thoughts or plans.

Study participants were mostly male (77.8%) and white (87.8%) with a mean age of 46. In this sample, firearms were the most frequently used suicide method (49.9%), followed by hanging, strangulation, or suffocation (26.7%), and poisoning (15.3%). Most participants were not receiving mental health or substance use treatment when they died, had not sought treatment in their lifetime, did not have a lifetime history of suicidal thoughts or plans or suicide attempts, and had not disclosed suicidal thoughts or plans in the month before they died. Those whose highest level of education was a high school diploma made up the largest percentage of deaths across all methods of suicide.

The analysis found that individuals with a history of mental health or substance use treatment or suicide attempts were significantly less likely to die by firearms than other methods. Those who recently disclosed suicidal thoughts or plans had higher odds of dying by firearms but were not more likely to have a previous history of suicidal thoughts or plans. These findings were consistent for both male and female participants ages 18 to 84. Compared to individuals who died by poisoning, those who died by firearms were significantly more likely to have a history of suicidal thoughts or plans and to have recently disclosed suicidal thoughts or plans. Compared to people who died by hanging, those who used firearms were more likely to have recently disclosed suicidal thoughts or plans.

Study participants who died by firearm suicide were less likely to seek mental health treatment or to have attempted suicide compared to those who died by other methods, suggesting many likely died on their first attempt. These individuals may be less likely to be identified through evidence-based suicide interventions that take place in mental health care settings. Those who died by firearms were also more likely to have disclosed suicidal thoughts or plans to someone in the month before their death, but they were not more likely to have a history of suicidal thoughts or plans. These findings highlight the need for more universal prevention strategies to raise awareness of suicide risk factors, warning signs, and prevention strategies in the general population. Among potential upstream interventions, the authors note safe storage of firearms is associated with decreased firearms suicide. To increase their effectiveness, they recommend programs that promote safe storage practices reflect the language and culture of firearms owners.

Limitations of this study include the homogeneity of the sample and the lack of specifics about the mental health services used and the nature and recipients of suicidal disclosure. Individuals who did disclose thoughts or plans represented a small subset of those who used firearms, an indication that disclosure is rare. During the study, the dataset expanded from 6 states in 2003 to 32 states in 2018. The earlier data account for a disproportionate number of deaths in this sample and may not represent more recent socio-demographic trends or changes.

Bond, A. E., Bandel, S. L., Rodriguez, T. R., Anestis, J. C., Anestis, M. D. (2022). Mental health treatment seeking and history of suicidal thoughts among suicide decedents by mechanism, 2003-2018. JAMA Network Open, 5(3): e222101. doi:10.1001/jamanetworkopen.2022.2101

Racial Differences in Suicide Risk among Adults in Criminal-Legal Systems

Research shows that adults in the criminal-legal system have higher rates of suicide and behavioral health disorders than the general population. There are also documented racial differences in experiences of criminal processing and access to behavioral health care. However, few studies have looked at whether this population’s suicide risk varies by race. To fill that gap, researchers conducted a study to identify risk factors for suicide among adults involved in the criminal-legal system and to find out if there were differences in suicide risk based on race.

The sample for this study was 16,849 adults with recent criminal-legal involvement who were enrolled in a statewide behavioral health treatment program, Indiana Recovery Works, between October 2015 and March 2018. Participants only included those who identified as either White or Black. The group was predominantly White and male with an average age of 35. Suicide risk was determined by clinicians using the Adult Needs and Strengths Assessment (ANSA) tool. Researchers carried out analyses to model suicide risk overall and within each of the racial groups and to identify differences between them. 

The initial analyses revealed that one in five individuals had suicide risk, a majority had a primary diagnosis of substance use disorder and a primary mental health diagnosis, and a small percentage had a history of self-harm. Black participants were significantly older, had lower suicide risk and higher criminal behavior risk, and were more likely to have mental health or substance use diagnoses. White participants were more likely to have a co-occurring diagnosis, evidence of self-harm, and prior substance use episodes, and were more likely to be female and have worse scores on the domains of life functioning, strengths, and behavioral health needs. The secondary analyses found no evidence of differences in suicide risk between the groups based on race alone.

It is important to note that the study participants had already been identified as needing behavioral health treatment and therefore may have had higher suicide risk than the general population and others in the criminal-legal system. Without a behavioral health diagnosis or participation in treatment, additional or different risk factors may have been found, particularly since Black and White disparities have been found in both access to treatment and the likelihood of incarceration. All study participants were referred to treatment based on clinical diagnosis, which may have been influenced by implicit clinician bias (i.e., an association outside conscious awareness that lead to a negative evaluation of a person or group on the bias of irrelevant characteristics such as race or gender1).

Nonetheless, these findings suggest that adults with behavioral health disorders and recent experience in the criminal-legal system experience risk factors for suicide similar to those in the general population. The association of substance use and co-occurring behavioral health disorders with suicide risk is particularly important given the current opioid epidemic. As the authors note, these findings highlight the need for more investigation on how criminal-legal involvement may worsen suicide risk.

Lawson, S. G., Lowder, E. M., & Ray, B. (2022). Correlates of suicide risk among Black and White adults with behavioral health disorders in criminal-legal systems. BMC Psychiatry, 22(163). doi: 10.1186/s12888-022-03803-8

  1. Fitzgerald, C., & Hurst, S. (2017.) Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(1). doi: 10.1186/s12910-017-0179-8

Outreach Programs vs. Usual Care for Self-Harm Prevention

In a recent clinical trial conducted in four U.S. health systems, researchers compared the effectiveness of two low-intensity outreach programs with usual care for preventing self-harm. Participants were 18,882 outpatients who reported recent frequent thoughts of death or self-harm on the nine-item Patient Health Questionnaire (PHQ-9) between March 2015 and September 2018.

Participants were randomly assigned to one of three groups: (1) usual care plus an online care management intervention, (2) usual care plus an online skills training intervention to learn four dialectical behavior therapy (DBT) skills, or (3) usual care only (no offer of additional services). The care management intervention included regular outreach for suicide risk screening and follow-up. The skills training intervention provided video instruction in mindfulness, mindfulness of current emotion, opposite action, and paced breathing, supported by a skills coach.

The two outreach programs lasted up to 12 months, delivered mostly through electronic health record messaging, and were designed to supplement ongoing mental health care. The primary outcome was first observed fatal or non-fatal self-harm within 18 months of randomization. Analyses compared groups according to randomized assessment, regardless of participation in the intervention.

This study tested the effectiveness of the two outreach programs under everyday practice conditions and found that neither program decreased risk of self-harm compared to usual care only. Compared to the group that was offered usual care only, the risk of self-harm was not statistically significantly different in the care management group. Compared to usual care only, the risk of self-harm was statistically significantly higher in the skills training group. The findings from the study do not support implementation of the outreach programs as they were tested.

While the findings of the study indicate that the two tested programs have no benefit over usual care in the participating health systems, the findings should not discourage systematic patient screening and intervention to prevent suicide in health care settings.

Study limitations include restrictive inclusion criteria and low participant engagement in the tested interventions. It should also be noted that all subjects had access to specialty mental health services and the comparative effectiveness of the two interventions tested might differ for patients without such services.

Simon, G. E., Shortreed, S. M., Rossom, R. C., Beck, A., Clarke, G. N., Whiteside, U., Richards, J. E., Penfold, R. B., Boggs, J. M., & Smith, J. (2022). Effect of offering care management or online dialectical behavior therapy skills training vs. usual care on self-harm among adult outpatients with suicidal ideation: A Randomized Clinical Trial. JAMA, 327(7), 630–638.

Ethical Issues in Suicide Prevention Research

A new consensus study summarizes key ethical considerations in suicide prevention research from multiple expert perspectives.

According to the study authors, research to understand and address suicide is critically important but must align with ethical guidelines and include safeguards for both participants and researchers. To identify the most important ethical issues to consider when designing such studies, they surveyed 34 suicide researchers and 32 people with lived experience (i.e., individuals who had attempted or considered suicide, lost a loved one to suicide, or cared for someone during a suicidal crisis). The study design was co-created by researchers with lived experience and used an online questionnaire that was based on previous findings.

The results showed strong agreement between respondents who were researchers and those who had lived experience. Researchers emphasized adherence to national guidelines, while people with lived experience focused on care and support for participants and researchers. In addition to concern about the availability of support and crisis intervention for study participants, respondents raised concern about the vulnerability of those conducting the research and the need to address potential vicarious trauma.

This study was conducted in Australia and although it provides important insights into ethical issues that need to be considered when designing and implementing suicide research, its generalizability to other cultural contexts and countries may be limited. Another limitation, acknowledged by the authors, is that because the design was a single-round consensus study, there was no opportunity for participants to reconsider ratings based on group scores. 

Dempster, G., Ozols, I., Krysinska, K., Reifels, L., Schlichthorst, M., Pirkis, J., & Andriessen, K. (2022). Ethical issues to consider in designing suicide prevention studies: An expert consensus study. Archives of Suicide Research, 1–17. https//doi.org/10.1080/1381118.2021.2022553

Association of the Song “1-800-273-8255” with Lifeline Calls and Suicides

In April 2017, hip-hop artist Logic released “1-800-273-8255,” a song featuring the phone number and services of the National Suicide Prevention Lifeline (Lifeline), highlighting the benefits of seeking help during a suicidal crisis. Findings from a recent study suggest the song was associated with an increase in calls to the Lifeline and a possible reduction in suicides during the study period.

Researchers conducted time series analyses looking at the number of Lifeline calls after three events: (1) the release of the song on April 28, 2017; (2) Logic’s performance of the song at the MTV Video Music Awards on August 27, 2017; and (3) his performance at the Grammy Awards on January 28, 2018.

To estimate public attention to the events, the researchers obtained Twitter data from data reseller Brandwatch, examining tweets that contained the search terms “Logic” and “1-800-273-8255” from March 1, 2017 to April 30, 2018. They also obtained call data from the Lifeline, as well as daily numbers of suicides from the National Center for Health Statistics, for the period January 31, 2010 to December 31, 2018. Sudden changes in Lifeline calls and suicides associated with each event were compared to trend data obtained from Brandwatch and the National Center for Health Statistics. 

In the 34 days after the three events, there was a statistically significant 6.9% increase in calls to Lifeline over the expected number, and a statistically significant decrease of 245 below the expected number of suicides. Twitter activity related to each event peaked rapidly and reached their maximum within one day. Activity was most pronounced following Logic’s performance at the 2017 MTV Video Music Awards, with an average of 1,324 posts daily over a 28-day period.

Previous research on the association between media messaging and suicide has focused on the negative effects of such publicity, such as increases in reported suicides or suicidal thoughts following media exposure. This is one of the few studies examining the positive impacts of media messaging. The results suggest media coverage focused on hope and recovery from suicide can be an effective prevention strategy.

It is important to note this is an observational study, and although it found a possible association between “1-800-273-8255” and help-seeking, it does not establish causality. Even so, this is a well-designed study that compares changes close in time to the presumed exposure (event) to longer data trends that reflect expected numbers of Lifeline calls and suicide deaths. The results suggest an innovative and potentially impactful approach to suicide prevention that needs to be explored further.

Niederkrotenthaler, T., Tran, U. S., Gould, M., Sinyor, M., Sumner, S., Strauss, M. J., Voracek, M., Till, B., Murphy, S., Gonzalez, F., Spittal, M. J., & Draper, J. (2021). Association of Logic’s hip-hop song “1-800-273-8255” with Lifeline calls and suicides in the United States: Interrupted time series analysis. BMJ, 375, e067726. https://doi.org/10.1136/bmj-2021-067726 

Update July 2022: 988 has been designated as the new three-digit dialing code that will route callers to the National Suicide Prevention Lifeline (now known as the 988 Suicide & Crisis Lifeline), and is now active across the United States. (Please note, the previous 1-800-273-TALK (8255) number will continue to function indefinitely.) Click here to learn more about 988.