The reality of a busy primary care practice is that there never seems to be enough time to adequately assess patients' mental and psychosocial health concerns. And yet depression rates substantially increase between the ages of 13 and 18 years, with 11% experiencing a depressive disorder by 18 years of age.1,2 Depression carries significant developmental and mental health implications for adolescents and is also a risk factor for suicide.3,4 The burden of suicide extends far beyond the death of the individuals who take their lives. It has a major psychosocial impact on family and friends and places an economic burden on family, the workplace, and the healthcare system.5
Primary care providers have expressed perceptions of inadequate preparation to address mental health problems in their patients.6 Mental health assessment is an essential part of holistic healthcare and is particularly important in the adolescent population. The aim of this article is to increase primary healthcare providers' knowledge of suicide risk factors in adolescents and offer screening tools to better manage this important health issue.
Developmental stage of adolescence
Adolescents may physically look more like adults than children, but they still have many development phases ahead of them. A basic tenet of child development theory is that the teenage years are a time of figuring out their place in the world as they progress through stages of physical, cognitive, psychosocial, and emotional growth and development.
Neuroscientists have discovered that one of the most significant changes during adolescence is in brain structure and function.7,8 The human brain reaches 90% of its adult size by age 6; however, major changes in gray and white matter occur throughout adolescence.7 Gray matter is reduced through synaptic pruning, and white matter is increased, mostly due to a thickening of myelin sheaths and increased axon diameters, all of which lead to faster signal transmission among neurons and more efficient brain circuitry.7-9
During this same time period, changes in dopamine activity affect the limbic system, which is involved with emotions, and its connection with the prefrontal cortex, responsible for executive functioning skills such as reasoning, problem solving, and decision making.7,8 Increased emotional reactivity and impulsive, risky behaviors may ensue as a result of this process.7,10 Surges of dopamine increase adolescents' sensitivity to receiving rewards when they get something better than they expected.11 If it ends well, the reward for a risky behavior is worth the risk, in their view. As a result, they may seek out experiences that adults would not even consider.
Concurrently, during this process of brain growth and maturation, they may be exposed to factors that put them at risk for unhealthy outcomes, such as mental illness, substance abuse, issues with sexual orientation, and other stressors.12 The presence of protective factors, such as religious beliefs, successful school performance, school and neighborhood safety, caring friends, and connectivity with interested, caring adults in their lives, may moderate the risks of some, but may not for others.12,13
Depression is the most prevalent mental health disorder reported in adolescents.14 Survey data indicated that in 2013, nearly one-third of adolescents in the 9th through 12th grades reported feeling sad or hopeless for 2 or more weeks in a row.15 The National Institute of Mental Health reports that approximately 11.2% of teens have a depressive disorder, and girls suffer with depression three to four times more than boys, at 12.4% and 4.2%, respectively.2
The symptoms of depression can be easily overlooked as a normal part of puberty, and therefore, left untreated. Adolescents who have depression may seem moody, have increased sadness or crying, have a sense of hopelessness or helplessness, and have frequent headaches or body aches.16 Changes in appetite, sleep patterns, school attendance, and grades can occur. Unlike adults, depressed adolescents may demonstrate more anger and irritability.16
Approximately 40% of children and adolescents who have depression will have more than one mental health illness.17 The most common comorbidity is anxiety; others include behavioral disorders, mood disorders, eating disorders, and substance abuse.17,18 Management of depressed adolescents who have more than one psychiatric disorder is much more difficult. Most concerning is the rate of suicide in children and adolescents with these comorbidities. The higher the number of comorbidities affecting a child, the higher the risk of suicide is. For example, a child or adolescent with depression, anxiety, and attention-deficit hyperactivity disorder would have a six times higher likelihood of committing suicide when compared to adolescents without mental illness, and a child or adolescent having four psychiatric diagnoses would have an 18 times higher likelihood of committing suicide.19 Higher rates of suicidal ideations are seen when teens have both depression and anxiety.19,20
Mental health screening
Approximately 80% of all teens are seen in a primary care setting each year;12 however, healthcare providers fail to correctly identify those with a mental health condition 16% to 38% of the time.21 Approximately one in five adolescents have a diagnosable mental health disorder.22 Early identification and treatment of these disorders is important and necessary in order to keep them on a healthier track.23
Screening for mental health issues in children and adolescents has become a national healthcare priority. The American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force (USPSTF) recommend screening for mental health disorders in primary care settings in adolescents ages 12 to 18 years when services for accurate diagnosis, treatment, and psychotherapy are available.24,25 Early intervention, screening, and treatment can minimize the morbidity and mortality of mental illness.
Multiple mental health screening tools with adequate reliability and validity are available and can be easily administered in the primary care office.26 Most tools are free of charge and require little training to administer. Some tools screen for several disorders, while others focus on specific screening questions for one type of mental illness. For example, the Patient Health Questionnaire for Adolescents (PHQ-A) assesses for potential problems, such as anxiety, substance abuse, mood, or eating disorders.27 The Patient Health Questionnaire (PHQ-9) screens specifically for depressive symptoms; the score can indicate the level of severity of these symptoms.28 The Center for Epidemiological Studies Depression Scale for Children (CES-DC), a 20-item questionnaire, is another screening tool specifically for depression.29
This tool is free of charge and can be administered/scored in less than 5 minutes. The Strength and Difficulties Questionnaire (SDQ) is a 25-item questionnaire available in several versions for ages 4 to 17 years. It can be administered as a self-report tool or given to parents or teachers to gain additional insight.30 The Pediatric Symptom Checklist (PSC), or Pediatric Symptom Checklist - Youth Report (Y-PSQ), screens broadly for emotional and behavioral psychosocial concerns.31 This 35-item questionnaire has been validated in the primary care setting and is available in different languages (see Links to depression screening tools).31
Suicide risk factors
An important reason for mental health screening is to detect the presence of risk factors for suicide. Suicide is the 10th leading cause of death across all ages in the United States, with 40,600 reported suicides in 2012.4 According to the World Health Organization, it is the third leading cause of death among 10- to 19-year olds.32 Suicide rates increased 2.6% from 2011 to 2012, with a rate of 12.6 per 100,000 individuals. Approximately 16% of students in the 9th to 12th grades have had thoughts of suicide, and 7.8% reported one or more suicide attempts in the past year.33,34 Although girls are more likely to attempt suicide, boys are four times more likely to die by suicide.35
As adolescents progress through their developmental channels, critical risk factors may come in to play that promote suicidal ideation and transition to suicidal behaviors.12 Some of these risk factors include history of mental illness or mood disorders, such as depression, a previous suicide attempt, substance abuse, family history of a psychiatric diagnosis or suicide, and involvement in bullying, either as a victim or perpetrator (see Risk factors for suicide in adolescents).4,6,12,36 Family environment may also play a role; increased reports of suicidality in adolescents have been reported in families with high levels of conflict and low family cohesion.37 Access to lethal means to proceed with suicide, such as weapons or medication, is a risk factor.38
Adolescents who consider suicide may present to healthcare providers for reasons other than or in addition to depression, such as eating disorders, substance use, behavioral disorders, and physical health problems. Data from the National Comorbidity Survey—Adolescent Supplement revealed that between 50% and 75% of adolescents with suicidal thoughts had recent contact with a healthcare provider, although most did not receive specialized mental healthcare.39 It is important, therefore, to include suicide risk screening in routine health screening and to continue to screen—even if they are in treatment.39
While screening for depression in adolescents is recommended by the AAP and USPSTF, the most recent USPSTF recommendations based on a systematic review found insufficient evidence for suicide risk screening in all adolescents.24,25,40,41 These recommendations, however, did not address those who show symptoms of depression or other psychiatric disorders.42
The National Action Alliance for Suicide Prevention views suicide as an important public health issue and compiled a Suicide Prevention Research Prioritization Task Force to increase knowledge through research and decrease the burden of suicide in the United States.43 The overall goal is to reduce suicide deaths and attempts by 20% in 5 years.5 One of the “Aspirational Goals” developed by the task force is to “determine the degree of suicide risk among individuals in diverse populations and in diverse settings through feasible and effective screening assessment approaches.”43
Some health professionals and organizations have advocated for universal suicide screening; however, this has been met with resistance by some due to lack of evidence in the efficacy of suicide screening, time constraints, inadequate healthcare provider training in suicide screening, management of mental health problems once identified, and lack of mental health resources.6,12 Additionally, some still believe that inquiring about suicidal thoughts in adolescents may encourage them to think about suicide. In reality, this has not been shown to be the case; rather, asking about suicidal ideation may let the adolescent know that the provider cares and that they are not alone.38,44
Clarification about suicide risk assessment is essential. Adult and adolescent populations are different from each other; tools and techniques should be aimed at what fits within the specific population and setting. A fast-paced practice setting mandates screenings that are both effective and time-efficient.45 Providers must understand the difference between screening and assessment. Screening is done to eliminate those who are identified as having a low risk. Screening tools should be brief, easy to administer, and highly sensitive. Assessment is a more in-depth process that quantifies the severity of risk. Assessment tools should be highly specific, having the ability to identify those who are truly at high risk and in need of prompt management.45 Screening and assessment should be a collaborative process.
It is common to screen for depression and suicidality together because they are often linked together. The PHQ-9 contains an item that asks how often the patient is bothered by the thought that he would be better off dead, or how often he is bothered with the thought of hurting himself.28 This is often used as a suicide risk screening question; however, the information it elicits may be ambiguous and nonspecific.12 Thoughts of death are known to occur in patients who have chronic medical conditions and may have nothing to do with suicide. Additionally, adolescents who admit to thoughts of harming themselves may not relate this to thoughts of suicide. Specific questions about suicide are required to get the most accurate results.12
Suicide risk screening tools used with adolescents
Psychosocial assessment is a key component of adolescent healthcare assessment, but some adolescents do not reveal psychosocial problems and risk behaviors to primary care providers unless prompted.36 This process can be facilitated with the use of screening tools, such as the HEEADSSS, an acronym for key topics that should be addressed in questions related to Home environment, Education and employment, Eating habits, interest in Activities, Drug use, Sexuality, symptoms of Suicide risk factors and depression, and Safety practices.46 The concern about suicide risk should be approached directly. Wintersteen reported that including the following two questions in the psychosocial interview helped in identifying suicide risk in adolescents: “Have you ever felt that life is not worth living?” and “Have you ever felt like you wanted to kill yourself?”47
Several brief suicide risk screening tools have been developed and utilized with adolescents either in EDs or in primary care settings (see Links to brief suicide-risk screening tools). The full version of the Columbia Suicide Severity Scale (C-SSRS) screens for suicide ideation, intensity of ideation, and suicidal behaviors. It is one page (front and back) and takes only a few minutes to administer.48 It does not require specialized mental health training to administer, but individuals who administer the tool should receive the free training offered on the website. There is also a “screener” version of the C-SSRS that contains 3 to 6 questions intended for use in EDs or in triage by first responders (C-SSRS website). The Ask Suicide Screening Questions (ASQ), a 4-question tool that has been used in EDs, inquires about suicide ideation and behavior.49 Research is in progress related to its use in inpatient and outpatient settings. The Suicide Behaviors Questionnaire (SBQ-R) is another 4-item questionnaire that focuses on past suicidal thoughts and attempts.50
Other tools that have been used with the adolescent population include the Behavioral Health Screen.51 This is a web-based risk behavior screen completed by patients. The primary care version takes about 7 minutes to complete; the shorter version for EDs takes 3 to 6 minutes.52 The Suicidal Ideation Questionnaire (SIQ), a self-report tool focusing on suicide ideation, takes about 10 minutes to administer and 10 minutes to score.53 The SIQ is aimed at adolescents from 15 to 18 years of age; the SIQ-JR is for ages 12 to 14 years.54 It is available in paper/pencil or computer format.55
One of the major concerns about suicide risk screening is determining what action to take when positive suicide risk is identified. Horowitz and colleagues pointed out that what this means is that a symptom has been identified and requires further evaluation, just as if a patient had an elevated BP and required further evaluation.12 The patient would not automatically be placed on an antihypertensive. Similarly, a positive result on a suicide risk screen would indicate that there is a problem/symptom, and further evaluation is needed by a mental health professional. Avoiding suicide risk assessment because the provider does not want to uncover a risk of suicide is similar to avoiding a BP measurement because the provider does not want to expose a hypertension diagnosis.12
The Western Interstate Commission for Higher Education and the Suicide Prevention Resource Center developed a toolkit for primary care providers to address suicide prevention in their patient population.56 This toolkit contains information about developing office protocols for management of suicidal patients, training of office staff, provider and patient education, and developing mental health partnerships. One tool included in the toolkit is a decision tree for risk assessment of suicidal patients and initial management. Once a risk of suicide is identified, the next step is to assess the level of risk. A patient who has thoughts of death but no plans for suicide and no suicidal behavior is considered to be in the low-risk category.
A moderate risk patient has suicide ideation but no firm plans; he or she may have had a previous suicide attempt. Appropriate steps for the provider to take for the low- and moderate-risk category would include further assessment for psychiatric problems and other risk factors and enlisting the support of family, friends, and resources in the community as well as initiating contact with a therapist. A patient in the high-risk category has a detailed plan for suicide and has made preparation. The presence of factors, such as the presence of psychiatric symptoms, access to lethal means, poor social supports, and impaired judgment would necessitate hospitalization.6
One intervention that has been utilized in practice for patients not in imminent danger is the development of a safety plan.6,57 This brief plan, which may take approximately 20 to 45 minutes to complete, is individualized with input of the adolescent and parents. The safety plan includes six main elements:57
- Recognizing signs that symptoms are worsening
- Initiating coping strategies
- Make use of social contacts to help distract from thoughts of suicide
- Contacting family members to deal with the crisis
- Contacting mental health professionals
- Reduce access to lethal means
The safety plan is different from a no-suicide contract, in which the patient is asked to make pledge (verbal or written) to not kill him or herself and to call a mental health professional when in crisis.36,57 The no-suicide contract, while perhaps giving some reassurance to the healthcare provider, has not been found to reduce suicide or suicidal behavior.36
The safety plan, on the other hand, is developed to help them know what actions to take should a crisis occur.36,57 The process of creating a plan mandates a careful inventory of resources available and can focus not only on triggers to avoid and coping skills but also on protective factors that may help keep them safe. Parents play an important role in monitoring safety of their adolescent in such ways as contacting the primary care health provider and/or mental health professional as needed between visits and keeping the home environment as safe as possible.36,38
The adolescent and parents should be asked about the presence of weapons or firearms in the home; these should be removed from the home or locked away to make them completely inaccessible to the adolescent.36,38 Additionally, medications should be locked away to prevent overdosing in a suicide attempt.38 Follow-up visits can address the efficacy of the plan, and updates can be made based on the adolescent and parents' feedback. Safety plans are now available for smartphones, making it easily accessible for adolescents at all times.58 The healthcare provider must continue to monitor any adolescent who is at risk for suicide. This can be done with follow-up interviews that continue to address risk factors, determination of suicide risk, and suicidal ideation.
Documentation of these areas should include rationale for clinical decision making based on information from the patient, collaborative informants, consultants, and medical records.36,56 A tracking system is recommended to follow up on suicide ideation, current risk level, medications, and treatments.36,56 A flagging system for medical records of patients at risk for suicide can be developed so that clinic staff can be vigilant in assessing continued or escalating risk.36 In addition, ongoing communication (via phone or e-mail) between the primary healthcare provider, psychiatric clinicians, and designated mental health provider in the school (such as the school psychologist) is necessary for optimal management of the suicidal patient.36,59
Primary care providers are in a prime position to identify mental health problems in adolescent patients and initiate early referral for treatment and management of mental health problems. Assessing for the presence of suicidal thoughts and behaviors is a key component of psychosocial screening. Suicide risk screening tools are available and can be administered in a time-efficient manner. Advanced planning and preparation can lead to a systematic, effective way to manage patients at risk for suicide, whether it is immediate referral for hospitalization or referral to a therapist and initiation of a safety plan.
Links to depression screening tools
PHQ-9 modified for adolescents (PHQ-A): www.ncfhp.org/Data/Sites/1/phq-a.pdf
PSC and Y- PSC: www.massgeneral.org/psychiatry/services/psc_forms.aspx
Risk factors for suicide in adolescents4,6,12,36-38
- Previous suicide attempt
- History of suicidal ideation
- History of mental illness/mood disorders
- History of physical and sexual abuse
- Substance abuse
- Homosexual or bisexual orientation
- Impulsivity and risk-taking
- Social isolation
- Stressful life events (including school problems, bullying, legal, or disciplinary problems)
- Family history of suicidal behavior
- Problematic relationship between adolescent and parents
- Exposure to suicidal behavior of others
- Access to lethal means
Links to brief suicide-risk screening tools
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