Standardized Screening May Help Identify Suicidal Adolescents

Laurie Barclay, MD

April 15, 2010

April 15, 2010 — Standardized screening for suicide risk in primary care can detect adolescents with suicidal ideation, allowing referral to a behavioral healthcare center before a fatal or serious suicide attempt is made, according to the results of a study reported online April 12 and published in the May print issue of Pediatrics.

"Several associations and federal agencies have called for depression screening in pediatric primary care," writes Matthew B. Wintersteen, PhD, from Thomas Jefferson University in Philadelphia, Pennsylvania. "Screening for suicide risk is a natural adjunct to this call....To our knowledge, this is the first study to prospectively examine the impact of standardized screening for suicide risk on detection and referral rates in pediatric primary care."

The goals of the study were to evaluate whether brief standardized screening for suicide risk in pediatric primary care practices could improve detection of youth with suicidal ideation, maintain improved rates of detection and referral, and be duplicated in other practices.

Two primary care clinics (clinic A and clinic B) were selected as intervention clinics, and a third clinic (clinic C) asked about participating in the study and was offered the intervention. At these 3 clinics, physicians underwent brief training in detecting suicide risk, and 2 standardized questions for adolescents aged 12.0 to 17.9 years were added to their existing electronic medical chart psychosocial interview. Data without identifiers were extracted during intervention trials and for the same dates of the preceding year, and referral rates were determined from social work records.

The intervention was associated with doubling of the rates of inquiry about suicide risk, which resulted in a 219% increase overall (clinic A odds ratio [OR], 2.04; 95% confidence interval [CI], 1.56 - 2.51; clinic B OR, 3.20; 95% CI, 2.69 - 3.71; and clinic C OR, 1.85; 95% CI, 1.38 - 2.31).

In clinic A, the rate of case detection increased nearly 5-fold (OR, 4.99; 95% CI, 4.20 - 5.79), was maintained for a 6-month period after the intervention was implemented (OR, 4.38; 95% CI, 3.74 - 5.02), and was replicated in both clinic B (OR, 5.46; 95% CI, 3.36 - 7.56) and clinic C (OR, 3.42; 95% CI, 2.33 - 4.52). Across all 3 clinics, case detection rate increased by 392%. The rate of increase of referral rates of suicidal youth to outpatient behavioral healthcare centers was commensurate to that of the detection rates.

"Standardized screening for suicide risk in primary care can detect youth with suicidal ideation and prompt a referral to a behavioral health care center before a fatal or serious suicide attempt is made," Dr. Wintersteen writes.

Limitations of this study include suicidal ideation based on history, not necessarily on present thoughts; and inability to determine the impact of the brief training in suicide risk.

"The findings from this study are particularly timely after the recent recommendation of the US Preventive Services Task Force to routinely screen youth for a major depressive disorder," Dr. Wintersteen concludes. "In addition, the American Academy of Child and Adolescent Psychiatry along with the American Academy of Pediatrics Task Force on Mental Health also released a joint article in which routine behavioral health screening in primary care was recommended....Both reports cautioned against screening when psychotherapy followup was not readily available."

The American Foundation for Suicide Prevention supported this study. Dr. Wintersteen has disclosed no relevant financial relationships.

Pediatrics. Published online April 12, 2010. Abstract


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