Strategies for Clinical Settings for Youth Suicide Prevention

Suicide is the second leading cause of death in youth and young adults, ages 10-24 years

Medical settings are well-positioned to prevent and treat illness and save lives. Over a quarter of deaths in young people 10-24 years of age are from suicide, a potentially preventable outcome.

Data from the 2019 Youth Risk Behavior Survey indicate that:

• 8% of high school students reported “seriously considering” suicide
• 9% of high school students attempted suicide within the past year

Moreover, data from the 2019 CDC death reports reveal that in 2019:

• 6,488 children, adolescents, and young adults died by suicide
• Out of the 32,935 youth deaths, 20% were from suicide
• Every day, approximately 18 youth died by suicide

Clinical settings are well-positioned to identify and treat suicide risk

Many young people that die by suicide visit a healthcare provider in the months or weeks, prior to their death:

• 80% of adolescents visited a healthcare provider within the year prior to death by suicide
• 49% of youth had visited an emergency department (ED) within the year before their death
• 38% of adolescents had contact with a healthcare system within the 4 weeks before their death
• 34% of people ages 15+ years had contact with a healthcare provider in the week before their death

Most young people keep suicidal thoughts to themselves and do not bring up the topic on their own:

• Youth at risk for suicide may present to the clinic with somatic complaints; physical symptoms are often easier to talk about than mental health concerns
• Screening can open a potentially life-saving discussion about suicidal thoughts. Unfortunately, most youth who are thinking about suicide pass through the healthcare system with their suicide risk unrecognized because they were not asked directly about suicidal thoughts and behaviors

Protecting Youth Mental Health: The US Surgeon General’s Advisory

The 2021 US Surgeon General’s Advisory, Protecting Youth Mental Health highlights that mental health is inseparable from overall health. Therefore, suicide prevention is part of overall health promotion.

In clinical practice, efforts to promote health and prevent suicide can include encouraging physical activity, healthy sleeping/eating habits, positive communication, strong peer/family relationships, and developmentally appropriate problem-solving strategies. Importantly, building trusting relationships and providing trauma-informed care to patients and families can help to support healthy mental health development.

The Surgeon General’s Advisory notes that clinical treatment is a critical part of the broader public health approach to protecting mental health, and includes:

• Risk identification, screening, and assessment
• Indicated interventions (eg, safety planning and lethal means counseling for youth with suicidal ideation or behavior)
• Treatment (eg, use of medications, more frequent visits, or referral to cognitive behavioral therapy or other evidence-based suicide risk reducing treatment)
• Recovery (eg, supporting individuals to maintain progress, encouraging post-traumatic growth, facilitating individuals to find meaning and purpose)

Pediatric clinicians are encountering suicidal ideation, behavior, and death in their patient populations

Data from the 2019 AAP Periodic Survey of Fellows indicate:

• 92% of pediatricians have had a patient disclose suicidal ideation
• 80% of pediatricians have had a patient attempt or die by suicide
• 48% of pediatricians reported that they had a patient attempt or die by suicide in the past year

In 2021, AAP partnered with the American Academy of Child and Adolescent Psychiatry (AACAP) and Children’s Hospital Association (CHA) to declare a national emergency in child and adolescent mental health.

In a response to these concerning trends, this section of the Blueprint presents strategies for identifying youth at risk of suicide and providing appropriate supports in clinical practice settings. All you need to implement these strategies is the vision to save lives, a clinician champion, tools to identify suicide risk, guidelines to manage patients that screen positive, and motivation.

Efforts are needed to address disparities in youth suicide risk

Many populations have traditionally been underrepresented in suicide prevention and research efforts, yet these populations are experiencing rising rates of suicide and higher rates of suicidal thoughts and behavior.

Clinical suicide prevention efforts need to provide comprehensive, effective, and culturally appropriate care to youth populations, including (but not limited to):

• American Indian/Alaska Native youth
• Asian-American youth
• Black youth
• Latino youth
• Youth from other communities of color
• Youth who identify as lesbian, gay, bisexual, transgender, queer, or two-spirit (LGBTQ2S+)
• Youth in rural and medically underserved areas
• Youth involved with the child welfare system or those who have experienced family disruption
• Youth involved with the juvenile justice system
• Youth with special health care needs, including youth with developmental disabilities

Note: Suicide rates are not directly tied to race, gender, or any other social construct. Rather, youth may experience discrimination or long-standing health, social, or systemic inequities that may impact their development and risk for suicide.

Systemic inequities that impact youth mental health

• Racism
• Homophobia or transphobia
• Economic inequities
• Under-resourced schools
• Medically underserved communities

Pediatric health clinicians can promote health equity in clinical suicide prevention efforts

Pediatric health clinicians should be trained to understand and address the impact of systemic discrimination on health, and address these topics in practice:

• Youth and family experiences with systemic discrimination should be incorporated into clinical history taking and counseling discussions
• Pediatric health clinicians should discuss topics such as sexual orientation and gender identity in a way that is not stigmatizing or discriminatory, but promotes inclusion and non-judgmental listening

Universal suicide risk screening can help support equity in suicide prevention efforts:

• Universal screening helps ensure that specific questions to measure suicide risk are asked of all patients, not just those deemed by the pediatric health clinician to be high-risk (See Screening for Suicide Risk in Clinical Practice)
• Validated, evidence-based screening tools should be used to identify suicide risk
  • Importantly, more research is needed to establish whether existing suicide risk screening tools are effective in identifying risk in understudied populations
  • As the research progresses and because suicide is a pressing public health threat, the available evidence-based instruments can be utilized (See Conducting a Brief Suicide Safety Assessment)

Pediatric health clinicians can help address disparities by connecting youth and families to accessible and culturally appropriate behavioral health supports (See Two Critical Steps Before You Begin)

Pediatric clinicians can build a welcoming practice to serve all patients

• Encourage clinicians and staff to recognize and reflect on their own biases and work to prevent these biases from impacting care delivery
• Use inclusive language and imagery in signage, materials, and office art
• Ask patients about their names and pronouns and use them consistently during clinical visits
• Use respectful language and trauma-informed care principles when interacting with patients and families
• Utilize translation services, interpreters, and assistive technology to support accessible written, electronic, and verbal communication
• Engage families and community members in program development/evaluation and solicit feedback on the practice environment and care received
• For more information, see How to Prepare your Clinic or Health System for a Suicide Prevention Program
  
  

Integrating suicide prevention strategies into clinical settings is feasible. Health care settings across the country have successfully integrated suicide prevention initiatives into their clinical care without overtaxing or disrupting workflow in their health systems.

Addressing suicide and other mental health concerns early on can reduce strain on healthcare systems, by reducing the severity of symptoms for individual patients. Severe symptoms can take an emotional and financial toll on patients, families, providers, and health systems.

Consider the “asthma analogy”

Most pediatric primary care providers (PCPs) are not pulmonologists; however, PCPs regularly treat youth with asthma and support them in managing symptoms. If a PCP encounters a patient with a complicated case of asthma, they refer that patient to a pulmonologist.

Suicide prevention protocols can be straightforward and uncomplicated, just like asthma treatment:

• Screen for risk factors
• Provide standard resources and supports in practice
• Refer out for specialized care when needed
  
  

Any clinical setting can be a partner in suicide prevention.

Common settings include:

• Community practice settings
• Outpatient clinics
• Specialty clinics
• Emergency departments (ED)
• Federally qualified health centers
• Community health centers
• Urgent care settings
• Inpatient medical/surgical units
• Behavioral health settings
• School nurse offices
• School-based health centers
• Indian Health Service settings
• Tribal contract clinics
• Urban Indian health centers
• Juvenile detention centers
• Child abuse clinics
• College campus health centers
• Clinics serving youth in foster care.
  
  

1. Connect with mental and behavioral health resources in your community

Prior to implementing a suicide prevention protocol in your clinic, it is critical to establish a list of mental and behavioral health providers that you can refer patients and families to.

Ensure that the providers on your list are:

• Accessible to your patient community
• Affordable (eg, accepts public/private insurance or has a sliding-scale fee system)
• Multidisciplinary, diverse, and culturally and linguistically representative of your patient population
• Experience working with children and adolescents
• Able to assess for suicide risk and plan for safety

If possible, establish a connection with these providers prior to implementing the suicide prevention protocol in your clinic. Tell them you are going to start screening for suicide risk and ask if they can accommodate any of your patients that need further evaluation.  Building these connections will allow you to make a warm hand-off for patients in the future.

What to do when facing a lack of community resources

Many areas lack sufficient access to mental and behavioral health supports. This is a systemic challenge that requires long-term, appropriately resourced solutions.

When mental health care is unavailable, clinicians and office staff can help families consider alternative options such as telehealth services, school-based behavioral health services, or follow-up appointments with the pediatrician until mental health services can be arranged.

Alternative strategies include:

• Safety planning and lethal means safety counseling can be conducted in your practice during the visit to help ensure safety during long wait times for mental health intervention
• Telehealth can be used to increase youth access to mental and behavioral health care
  • Promote telehealth access to all families by using a modality that is mobile-friendly and using multiple languages, interpreters, and assistive technology to facilitate visits
  • Note: Accessibility of telehealth is dependent on the availability of reliable broadband and network access and state laws, which may vary by geographic region. For an overview of state telehealth laws, click here
• School, community, or tribal-based behavioral health services may be available
• Pediatric health clinicians can consider working with Pediatric Mental Health Care Access Programs (PMHCA), also called Child Psychiatry Access Programs (CPAP). These are collaborative programs that provide training and support to primary care providers related to addressing mental health conditions in practice. Please see the National Network of Child Psychiatry Access Programs to identify child psychiatry consultation programs across the country.

For more information, see How to Prepare your Clinic or Health System for a Suicide Prevention Program

2. Understand the difference between screening versus assessment – you need both!

Identifying youth at risk of suicide requires both screening and assessment. These are two distinct parts of the suicide prevention process. Both are necessary.

Suicide risk screening is a very rapid way to identify someone who needs further assessment for suicide risk. It can be completed through a variety of methods, including verbal asking, self-report paper/pencil forms, or computer questionnaires. Because we do not have tools that can predict who will die by suicide, anyone who is detected “at risk” by a suicide risk screening tool will require a brief suicide risk assessment to follow up on the tool.

Suicide risk assessment is a comprehensive evaluation to confirm suicide risk, assess risk and protective factors, and guide next steps. It may also assess other mental health symptoms and warning signs such as excessive alcohol or other substance use. Parents, families, and caregivers can be important corroborators when assessing a young person’s suicide risk and should be included, when appropriate and available.