Despite increased awareness of suicide as a major public health problem, many health care professionals who have frequent contact with high-risk patients lack adequate training in specialized assessment techniques and treatment approaches.1 Primary care providers (PCPs) are positioned to lead important public health interventions to prevent youth suicide because their practice setting provides opportunities for early identification of and intervention for common mental health disorders among adolescents, as well as for counseling, guidance, and care coordination.2 However, a PCP's ability to provide appropriate care depends on his or her knowledge, comfort, and skills.3 Accordingly, the American Academy of Child and Adolescent Psychiatry states, “[P]rimary care physicians … should be trained to recognize risk factors for suicide and suicidal behavior and, when necessary, refer to a mental health clinician.”4 (p28S) A goal of the U.S. government's National Strategy for Suicide Prevention involves increasing the proportion of residency programs that provide training in assessing and managing suicide risk and in identifying and promoting protective factors.1
Educating PCPs about the warning signs of adolescent suicide and equipping them with tools to identify and assess suicidal patients represent a promising approach to adolescent suicide prevention. In this article, we review the epidemiology of youth suicide, some risk and protective factors, and warning signs. We also present findings from prior research on physician education in this area, highlighting evidence of improved knowledge and skills among physicians following training. We conclude by offering recommendations for improving educational opportunities and suggestions for future research.
Epidemiology of Youth Suicide
Suicide is the third leading cause of death for Americans aged 15 to 24—after unintentional injuries/accidents and homicide—and accounts for more deaths among this age group than all natural causes combined.5 Suicide rates among this age group have decreased slightly, from 10.4 suicides per 100,000 individuals in 2004 to 9.7 per 100,000 in 2007. Still, in 2007, 4,225 Americans aged 5 to 24 died by suicide.5 Although adults older than age 65 have the highest suicide rates (14.3 per 100,000), suicide accounts for a much larger percentage of deaths among young people (12.2%) than among elderly adults (0.3%).6 The prevalence of nonlethal suicidal behavior heightens the public health significance of this problem: For every death by suicide, 100 to 200 adolescents attempted to take their own lives, compared with a rate of four attempts to one death among the elderly.6 In 2009, 13.8% of U.S. high school students seriously considered attempting suicide, 10.9% planned to attempt suicide, and 6.3% attempted suicide.7
Adolescent females contemplate and attempt suicide more often than males, but males are four times more likely to die by suicide than are females.8 Among youth, Native American and Hispanic females have the highest rates of suicide attempts, whereas Native American and white males have the highest rates of completed suicide.9 White youth have generally demonstrated higher suicide rates than their African American peers.10 However, a dramatic increase in the rate of suicide from 1981 to 1995 among African American male adolescents partially closed the gap in rates between African American and white males.9
From 1990 to 2004, females aged 10 to 24 and males aged 10 to 14 showed downward trends in firearm and poisoning suicides. By 2004, the most common method of suicide among these groups had become hanging/suffocation. Firearms remain the most common method among males aged 15 to 24.11
Risk factors, protective factors, and warning signs
Adolescent suicide represents a complex behavior associated with myriad interrelated biopsychosocial factors. However, about 90% of adolescents who die by suicide have a psychiatric disorder, among which depressive disorders remain most prevalent.12 Other risk factors include a previous suicide attempt, interpersonal losses, legal or disciplinary problems, family history of suicidal behavior or psychopathology, problematic parent–child relationships, physical and sexual abuse, exposure to suicidal behavior of others (peers or via media), difficulties in school, homosexual or bisexual orientation, and access to lethal means (particularly firearms).13 Some protective factors that promote resilience and reduce the potential for suicide include coping, problem-solving, and conflict-resolution skills; school and parent/family connectedness; academic achievement; help-seeking behavior; good peer relationships; emotional well-being; positive self-worth; and social integration.14,15
Many adolescents do not readily verbalize their feelings, yet their feelings will manifest in vague somatic symptoms or atypical behavior. Certain warning signs involve expressed suicidal thoughts or threats, which a young person may communicate directly (e.g., “I'm going to kill myself”) or indirectly (e.g., “It's no use,” “I won't be a burden anymore”). Some other warning signs include changes in eating or sleeping habits; withdrawing from friends, family, or regular activities; violent actions, rebellious behavior, or running away; drug and alcohol use; persistent boredom, difficulty concentrating, or a decline in the quality of schoolwork; and frequent complaints about physical symptoms related to emotions such as stomachaches, headaches, or fatigue (see List 1 for additional signs).16,17
Implications for provider education
Our brief review of the literature regarding factors associated with adolescent suicide and suicidal behavior identified some fundamental content areas that educational programs for PCPs should target. Changes in suicide methods demonstrate the potential mutability of youth suicidal behavior11 and suggest that PCPs need continuing education in adolescent suicide prevention. Knowing demographics associated with suicide among youth is also important: Research suggests that, compared to females, practitioners less often screen for emotional distress among adolescent males or talk with males about procuring help if they feel sad or depressed.18 Further, differences among ethnic groups extend beyond rates of suicidal behavior and may include the context in which suicidality occurs as well as clinical indicators of suicide risk.9,19
Associations between depressed mood and suicidal behavior among adolescents underscore the importance of training PCPs to identify and manage depression in this population. PCPs must become well versed in the warning signs of suicidality to ensure that they can recognize potentially high-risk patients who present with nonpsychological complaints. They need improved education initiatives across all levels of training and practice to gain the knowledge and skills they need to effectively elicit risk factors as well as reinforce and foster protective factors during clinical encounters.
PCPs' Role in and Preparation for Preventing Adolescent Suicide
Health care providers whose practice populations include young patients encounter distressed and suicidal adolescents and, thus, can play a major role in suicide prevention.14 One study found that 62% of persons aged 35 years and younger who died by suicide contacted a PCP in the year before their death, and 23% contacted a PCP in the month before their death.20 To our knowledge, no current data exist regarding the percentage of adolescents who visited their PCP before attempting or completing suicide. However, research shows that 20% to 41% of adolescents who present to PCPs have high levels of emotional distress and/or suicidal ideation, yet PCPs identify less than half (24%–45%) of these young people.18,21,22 This failure may reflect discomfort discussing sensitive issues,23 a focus on somatic complaints,24 or incomplete knowledge of relevant warning signs, risk factors, and demographics.25,26
We acknowledge that predicting and preventing youth suicide represent extremely difficult challenges for PCPs. Distressed adolescents often present with medical problems, not psychological symptoms,21,22 and they do not readily disclose their health-risk behaviors or psychosocial problems unless prompted.27 Yet adolescents and their parents want to discuss psychosocial problems with their PCPs,26,28 and adolescents will acknowledge suicidal thoughts when asked directly.3 Therefore, PCPs should consider all appointments with adolescents as opportunities to explore psychosocial issues beyond the presenting complaints.22 PCPs must become willing and able to inquire about adolescents' mental status, vigilantly screen for suicide risk factors, and proactively identify warning signs during routine medical and well visits.21,29,30
Unfortunately, PCPs may not receive adequate training to screen for suicide risk or mental health disorders. The Accreditation Council for Graduate Medical Education (ACGME) requires that pediatric residency programs include a one-month block rotation in developmental–behavioral pediatrics,31 which must involve training on internalizing behaviors such as suicidal behavior.32 However, a national survey of directors of pediatric residency training programs found that, on average, 64% did not consider instruction on suicide or depression in their program adequate or thorough.33 Boris and Fritz34 found that many pediatric residents receive clinical experience with suicidal patients, typically in emergency rooms, yet they do not feel competent to evaluate suicidal patients or assess a patient's state of mind. A recent survey of senior pediatric residents in a top-ranked training program supports this finding.35 Therefore, as expected, many PCPs working with adolescents report they need additional training in mental health care.18,26,34,36,37
Comprehensive training initiatives that address general competencies in mental health38 and specific competencies in suicide risk assessment and management should enhance PCPs' proficiency in identifying, evaluating, and assisting suicidal adolescents.39 After a systematic review of the literature, Mann et al40 concluded that physician education represents one of the most promising suicide prevention strategies. Research with adults demonstrated declines in suicide rates after PCPs participated in education programs targeting depression recognition and treatment. Kaplan et al41 found that residency training in assessing suicide risk was an especially important factor associated with PCPs' confidence in evaluating and managing suicidality.
Similarly, Frankenfield et al26 found that physicians who felt sufficiently trained and knew how to screen for suicide risk factors among adolescents were more than three times as likely as others to screen for these risk factors. Screening practices in this study constituted a physician's clinical assessment, a physician's review of a questionnaire completed by a patient or parent, or both methods. Pfaff et al22 found dramatic increases in physicians' detection rates of psychological distress and suicidal ideation in young patients after one day of training. They identified the increased rates through a physician-completed summary sheet describing patients' psychological states (i.e., presence of psychological distress and suicidal ideation, and estimate of suicide risk).
Even brief interventions may prove effective. A recent study found that a 90-minute training on youth suicide in primary care clinics resulted in a 219% increase in participating PCPs' rates of inquiry about suicide risk and a 392% increase in their case detection across three sites.42 Further, the rates of case detection remained elevated six months after the intervention. Trainers taught PCPs to screen for suicide risk by including two core questions in their standard psychosocial interview: “Have you ever felt that life is not worth living?” and “Have you ever felt like you wanted to kill yourself?” Patient endorsement of either question prompted PCPs to ask six additional questions regarding suicide planning, preparation, and attempts.
Opportunities for Improvement
We believe many opportunities exist to provide continuous and diverse learning experiences throughout medical school and residency, as well as in the practice setting. PCPs at all stages of their careers deserve opportunities to obtain requisite knowledge and hone their skills. Further, collaborative practice initiatives and other organizational changes that facilitate learning and support PCPs should be considered.
Opportunities during medical school and residency
The lack of adequate training in child and adolescent psychiatry during medical school demonstrates the devaluation of the field and minimization of mental health issues in medical education.43 U.S. medical students are only guaranteed exposure to psychiatry during the third-year clerkship.24 Yet, their psychiatry rotation may not include experience with adolescents, and some programs may not offer electives in child psychiatry. Medical schools should incorporate mental health education that takes a developmental approach and addresses mental health issues for people of all ages.
Although the ACGME requires training on adolescent suicide during pediatric residency, the time and exact content that residency programs should devote to identifying, assessing, and managing suicidality remain unclear. Residency programs need explicit guidelines to help them become more deliberate in their approach to training on this issue. Pediatric residents would benefit from an authoritative syllabus, standard curricula, and case material comprising exercises in interviewing, accessing resources, demonstrating empathy, and managing distressed youth.33 Also, residents should have opportunities to discuss their feelings of anxiety about engaging suicidal patients.33 Programs should implement curricula within a structured program offered in consecutive years, possibly within rotations in developmental–behavioral pediatrics, adolescent medicine, and/or ambulatory medicine.
Unfortunately, competing agendas and time constraints may reduce the likelihood that programs will develop or implement a comprehensive curriculum. Therefore, at a minimum, pediatric residency programs should provide trainees opportunities to participate in seminars and/or modules on identifying and assessing suicide risk during an adolescent medicine rotation or before their work in continuity clinics. For example, instructors could expand the Yale Primary Care Pediatrics Curriculum44 or related curricula to include a chapter on adolescent suicidality. Residents also would benefit from a collaborative training model in which mental health specialists coprecept in residency continuity clinics, partner with residents to conduct inpatient rounds, and codevelop educational programs with pediatric faculty.38
Ongoing training and collaborative practice
As noted above, PCPs require dynamic, ongoing education and training regarding adolescent suicide.25 In addition to workshops to enhance their knowledge, self-efficacy, and skills, PCPs would benefit from collaborating with mental health specialists during office rounds, comprehensive trainings focused on roles in collaborative practice, and quality improvement programs, as well as in assessing and managing youth in their mutual care.38 Further, PCPs report wanting self-instructional materials to increase their knowledge about pediatric mental health issues.37 Therefore, developing and implementing computerized tutorials45 or tool kits17 that address adolescent suicidality for PCPs may help close the gaps in their knowledge. Educators should identify and execute approaches that work within their organizations.
Incorporating interactive techniques
To reinforce learning, PCP training programs should incorporate interactive techniques such as role-playing with feedback, multiple sessions in a series, and tools that help PCPs implement knowledge and skills in the practice setting.46,47 Role-playing allows PCPs to practice identifying risk factors and warning signs, assessing suicide risk, strengthening protective factors, responding to reports of suicidality and self-injury, demonstrating empathy, facilitating access to mental health services, and using cognitive behavioral therapy techniques. Fallucco et al35 found that pediatric residents who participated in suicide risk assessment training that incorporated a lecture and practice with standardized patients showed greater objective knowledge of risk factors and confidence in screening for risk factors and assessing suicidal adolescents compared with residents trained via other methods. Role-playing exercises could help PCPs learn to incorporate relevant tools from sources such as the Suicide Prevention Toolkit for Rural Primary Care17 into their interactions with adolescents in the practice setting (e.g., suicide assessment pocket guide, safety planning guide, crisis support plan, suicidality treatment and tracking log, and patient/parent education materials). Other studies of programs for PCPs support the value of role-playing to prepare for addressing diverse adolescent health issues.48–51
Successful strategies to reduce adolescent suicidal behavior and suicide rates will likely involve multifaceted interventions that integrate physician education with other, organizational approaches.52 According to a national survey of pediatricians, organizational barriers to identifying and managing psychosocial issues among adolescents include lack of time to treat mental health problems, long waiting periods to see mental health providers, and lack of providers to whom to refer patients with mental health problems.53 Other issues involve the social stigma associated with mental illness, poor public education around mental health issues, cultural and language barriers, and financial barriers such as inadequate reimbursement for mental health services provided by PCPs.2,26,54 Systems and resources must exist that enable PCPs to remain confident that they can identify and respond to young people found to have thoughts of ending their lives.54
Organizational strategies that could supplement physician education initiatives include customized adolescent screening and provider charting forms,55 30-minute adolescent well visits,56 access to a health educator55 or health education materials,56 nurse case management,52 improved integration between primary and secondary care,52 and continuous monitoring and improvement measures.57 In addition, colocating mental health specialists in primary care settings may encourage collaboration in a variety of ways and increase the likelihood of consultation and referral.58 Gardner et al59 described an effective approach to screening and triaging potentially suicidal adolescents by capitalizing on colocated services and a coordinated team that included psychiatric social workers. Similarly, Asarnow et al60 showed the benefits of psychotherapists serving as mental health care managers supporting PCPs in improving access to depression treatment for adolescents through primary care. Combining strategies and implementing a team approach will likely produce synergistic effects and help overcome barriers to caring for suicidal adolescents in primary care settings.
Future Directions for Research and Education
High rates of emotional distress and suicidal ideation among many adolescents presenting to PCPs justify more robust training designed to empower physicians to identify these issues in the primary care setting.22 PCPs should have opportunities to become confident and competent in addressing adolescent suicidality during medical school and residency as well as through continuing education programs. The literature provides support for the effectiveness of physician education to improve identification and assessment skills, thereby helping prevent adolescent suicide. However, researchers rarely describe their training programs or assess components of educational sessions in their published articles. Further, limited evaluation data exist regarding the efficacy of established adolescent suicide prevention training programs for PCPs, such as the American Association of Suicidology's Recognizing and Responding to Suicide Risk in Primary Care.61 To advance the science in this area and assist educators, practitioners and researchers must rigorously evaluate their training programs, detail program components in published works, elucidate the most effective teaching methods and strategies, and ensure that evidence-based continuing medical education and other training programs become widely available at minimal cost.
Researchers also should conduct surveillance studies that capture the frequency and timing of adolescents' visits to PCPs before they attempt or complete suicide. In addition, this area of research needs sound longitudinal and controlled studies of physician education interventions that examine adolescent suicide attempts and rates as outcomes and identify the specific knowledge and skills required to affect suicidal behavior. The relatively low rate of adolescent suicide and many methodological constraints make such research challenging. However, educators, clinicians, and researchers must collaborate to ensure that research supports and propels this potentially lifesaving agenda.
Educators developing courses for medical students, residents, or PCPs in practice should include content on demographics, risk and protective factors, and warning signs of adolescent suicide. Courses should incorporate interactive techniques such as role-playing, provide opportunities for participants to discuss their feelings about engaging suicidal patients, and offer guidance on accessing resources and making referrals to specialists. Finally, individuals who develop educational interventions should evaluate their programs and share their findings. Until clearer guidelines, an authoritative syllabus, and comprehensive educational materials become available, a starting point may involve adapting the Suicide Prevention Toolkit for Rural Primary Care17 for PCPs working with adolescents. A tailored tool kit may provide a common information base from which educators could develop and expand medical education curricula and continuing education programs.
Often, suicide prevention becomes “a matter of a caring person with the right knowledge being available at the right place at the right time.”62 PCPs are known as caring individuals, and they are often in the right place at the right time. Therefore, educators must ensure that physicians possess the knowledge, skills, and supports to help prevent many tragic deaths.
This work, done during Dr. Taliaferro's fellowship training at the University of Minnesota, was supported in part through funds from the Healthy Youth Development • Prevention Research Center, University of Minnesota (Cooperative Agreement No. U48-DP001939, Centers for Disease Control and Prevention).
The findings and conclusions in this work are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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