ORLANDO — Primary care is a “ripe and rich environment” for youth suicide screening, and a new computer-based tool shows promise for identification of patients at risk, said Guy Diamond, Ph.D.
Dr. Diamond and his colleagues developed a Web-based behavioral health screen that adolescents and young adults can complete in about 10 minutes before seeing their doctor. The 55-item core questions also assess depression, anxiety, and trauma, as well as relevant behaviors, such as drug use and risky sexual behavior. “We put suicide into a bigger context,” he said.
The tool, which Dr. Diamond and his colleagues hope to launch in the fall, addresses everything the American Medical Association and the American Academy of Pediatrics recommend is covered during screening. Although all patients get the same questions asked in the same way, the time to take the screen varies from 9 to 14 minutes, depending on how many symptoms a patient endorses. Responses to the core items can trigger up to 41 additional questions.
The standardized format reduces provider bias, helps focus the clinical visit, and increases case identification, said Dr. Diamond, who is on the psychiatry and behavioral science faculty at Children's Hospital of Pittsburgh.
Sensitivity and specificity are 83% and 87%, respectively, for suicidal risk; 85% and 76% for depression; and 88% and 67% for anxiety, Dr. Diamond said.
When the patient has completed the screen, an automatically generated report prints out with scaled scoring and flagged critical items. On the plus side, the report also identifies individual patient strengths—such as “has a job” or “gets along well with parents.”
The screen's validity was demonstrated in a study of 1,547 primary care patients (Pediatrics 2010;125:945-52). A total of 209 (14%) of the 11- to 20-year-old respondents reported suicidal thoughts in the previous month. Girls, younger youths, substance users, depressed youths, youths who carried weapons, and those who had been in fights were at higher risk. Social workers were able to triage 205 (98%) of those identified, the majority on the same day. Most (152 patients or 74%) were recommended for a mental health evaluation.
Most other primary care screening tools inquire about symptoms that are current or from the previous 2 weeks, even though many physician visits are annual. “Kids who said no to 'current' but yes to 'past' are [still] very high risk,” Dr. Diamond said. “They have just as many risk factors as kids who say they are currently at risk.”
Dr. Diamond said primary care physicians are more likely, in general, to screen for suicide risk if it is part of a comprehensive screen. “When I ask a room of docs how many have seen suicide in their practice, four or five raise their hands. When I ask about depression, everyone raises their hands.”
Although most screening instruments are still paper-and-pencil format, a computerized instrument offers several advantages, Dr. Diamond said. Automated scoring is one example, and greater flexibility to tailor the screen with practice-specific items is another. “If a practice doesn't want to ask about child abuse, we can take it out. If another practice wants to add an STD [sexually transmitted disease] question, we can do that.”
The screen does not fully integrate with electronic medical record systems, Dr. Diamond said in response to a meeting attendee question. For now, the paper report is scanned as a pdf file and entered in the patient's EMR. He added that many doctors were initially nervous about using the tool, but that “many have now integrated it.”
Disclosures: Dr. Diamond will have a financial interest in the screening instrument when it is launched in the fall. At that time, physicians will be able to license the tool, he said.