COMMENTARY

Suicide in Kids Continues to Rise: Strategies for Primary Care

William T. Basco, Jr, MD, MS

Disclosures

November 22, 2019

For at least the past decade, suicide has been recognized as the second leading cause of death in American preteens and teenagers. It's critical that we understand just how big an issue this is immediately, instead of—gruesomely—trying to measure the size of the problem by documenting the numbers of completed suicides.

Because suicide attempts and suicidal ideation are predictors of a later completed suicide, however, analyzing increases in these markers can provide a measurable proxy of the extent of suicidality. A recent analysis of data from the National Hospital Ambulatory Medical Care Survey sought to quantify just how much these markers have increased in children. The investigators examined emergency department (ED) evaluations for both suicide attempts and suicidal ideation in kids 5-18 years of age from a nationally representative sample of institutions.

Just under 5% of the almost 60,000 ED visits at participating hospitals during the 8 years of data collection were for a suicide attempt or suicidal ideation. The median age of these children was 13 years and the vast majority (97.9%) were not hospitalized.

Extrapolating these data to the entire nation, estimated annual ED visits for this indication almost doubled during the study period, rising from 580,000 in 2007 to 1.12 million in 2015. This compares to an increase in visits for all reasons of just under 20%.

Viewpoint

The conclusions from this study provide no solace for the typical primary care provider (PCP) who is "drowning" in mental health patients whom they feel underprepared or insufficiently skilled to manage. The findings do add more fuel to the argument that PCPs must hone their mental health evaluation and treatment skills, including the importance of clearly asking kids: Have you ever thought about suicide or tried to commit suicide?

For the near term, PCPs and their extended medical teams will need to try to fill the mental health care gaps their patients are facing. And there are tools to help. The Pediatric Mental Health Care Access Program, a federally funded program to promote integration of behavioral health into pediatric primary care using telehealth, is currently operating in 21 states. The American Academy of Pediatrics (AAP) Mental Health Initiatives offer a range of downloadable tools for primary care. AAP just released an updated policy statement on mental health competencies for pediatric practice in November 2019 along with a technical report which includes strategies for educating experienced clinicians.

While increased training for PCPs can help, it won't be enough, especially for kids with more challenging mental health issues, like suicidality. There are simply not enough mental health providers to meet the need in pediatrics. Lobbying to improve mental health financing and coverage is needed which likely means—for all of us—that we have to step out of our clinical silo and our comfort zones. Studies like this one, combined with our personal stories, may be the way to get the attention of the people who make the funding and coverage decisions.

William T. Basco, Jr, MD, MS, is a professor of pediatrics at the Medical University of South Carolina and director of the Division of General Pediatrics. He is an active health services researcher and has published more than 60 manuscripts in the peer-reviewed literature.

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