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