Adolescent Suicide Risk Screening in the Emergency Department

Abstract

Objectives Many adolescents who die by suicide have never obtained mental health services. In response to this, the National Strategy for Suicide Prevention recommends screening for elevated suicide risk in emergency departments (EDs). This cross-sectional study was designed to examine 1) the concurrent validity and utility of an adolescent suicide risk screen for use in general medical EDs and 2) the prevalence of positive screens for adolescent males and females using two different sets of screening criteria. Methods Participants were 298 adolescents seeking pediatric or psychiatric emergency services (50% male; 83% white, 16% black or African American, 5.4% Hispanic). The inclusion criterion was age 13 to 17 years. Exclusion criteria were severe cognitive impairment, no parent or legal guardian present to provide consent, or abnormal vital signs. Parent or guardian consent and adolescent assent were obtained for 61% of consecutively eligible adolescents. Elevated risk was defined as 1) Suicidal Ideation Questionnaire-Junior [SIQ-JR] score of ≥31 or suicide attempt in the past 3 months or 2) alcohol abuse plus depression (Alcohol Use Disorders Identification Test-3 [AUDIT-3] score of ≥3, Reynolds Adolescent Depression Scale-2 [RADS-2] score of ≥76). The Beck Hopelessness Scale (BHS) and Problem Oriented Screening Instrument for Teenagers (POSIT) were used to ascertain concurrent validity. Results Sixteen percent (n = 48) of adolescents screened positive for elevated suicide risk. Within this group, 98% reported severe suicide ideation or a recent suicide attempt (46% attempt and ideation, 10% attempt only, 42% ideation only) and 27% reported alcohol abuse and depression. Nineteen percent of adolescents who screened positive presented for nonpsychiatric reasons. One-third of adolescents with positive screens were not receiving any mental health or substance use treatment. Demonstrating concurrent validity, the BHS scores of adolescents with positive screens and the POSIT scores of those with positive screens due to alcohol abuse and depression indicated substantial impairment. The addition of alcohol abuse with co-occurring depression as a positive screen criterion did not result in improved case identification. Among the subgroup screening positive due to depression plus alcohol abuse, all but one (>90%) also reported severe suicide ideation and/or a recent suicide attempt. This subgroup (approximately 17% of adolescents who screened positive) also reported significantly more impulsivity than other adolescents who screened positive. Conclusions The suicide risk screen showed evidence of concurrent validity. It also demonstrated utility in identifying 1) adolescents at elevated risk for suicide who presented to the ED with unrelated medical concerns and 2) a subgroup of adolescents who may be at highly elevated risk for suicide due to the combination of depression, alcohol abuse, suicidality, and impulsivity.

Adolescent and Parent Attitudes Toward Screening for Suicide Risk and Mental Health Problems in the Pediatric Emergency Department

“…In the first published study of screening for suicide risk among adolescents who presented to the ED with both psychiatric and nonpsychiatric chief complaints, 13 adolescents were screened for depression, alcohol abuse, and suicidal thoughts and behaviors. A positive screen for elevated suicide risk was defined as being at or above the clinical cutoff score for suicidal ideation, a suicide attempt in the past 3 months, or being at or above the clinical cutoff point for both depression and alcohol abuse.…”

Life is Precious: A Community-Based Program to Reduce Suicidal Behavior in Latina Adolescents

“…All our assessments are self-reported by the adolescents, and we did not assess parents' perceptions of change. However, the measures have been found reliable and valid in populations of adolescents, including Latinas (Reynolds & Mizza, 1999, King et al, 2009, Osman et al, 2010; Stockings et al, 2015, Nilsson et al, 2008, Martinez et al, 2014, Olsen et al, 2011). Data on assessments were collected by the LIP program at intake and during participation, but attendance data were not consistently collected at the time of this study.…”

“…Suicidal ideation, depressive symptoms, trauma exposure, and family cohesion were assessed every four months. Suicidal ideation was measured by the Suicidal Ideation Questionnaire, a 30-item assessment of suicidal thoughts that is reliable and valid in adolescents, including Latinas (Reynolds & Mizza, 1999, King et al, 2009). Scores range from 0 to 180; higher scores indicate greater suicidal ideation.…”

“…Small studies of Cognitive-Behavioral Therapy (CBT) (N=36) (Esposito-Smythers et al, 2011) and Dialectical Behavior Therapy (N=29) (Rathus and Miller, 2002) found reductions in suicidal ideation among adolescents. Other studies of CBT (Donaldson et al, 2005), multi-systemic therapy (Huey et al 2004), home-based family therapy (Harrington et al, 1998), and psychoeducation (King et al, 2009) did not find changes in suicidal ideation. We know of no interventions providing a comprehensive set of services specifically designed or culturally adapted to address the unique risk factors for suicidal ideation and attempts faced by Latinas, including challenges regarding mental health, academic achievement, family relationships, and peer networks.…”

Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms

“…155 Suicide screening has been found to be acceptable to 60% to 66% of patients and parents, with 96% of participants agreeing that suicide screening is appropriate in the ED. 149,150,156 What do ED clinicians think about mental health screening in the ED? Is such screening acceptable to them?…”