ATLANTA – The potential utility of the medical emergency department as a key venue in which to conduct youth suicide screening is now well established, and a federally funded effort to develop and validate an optimal screening tool designed specifically for this purpose is underway.
Suicide is the second-leading cause of death among 12- to 17-year-olds in the United States. Routine screening for suicide risk in medical EDs would solve a major challenge in preventing these deaths: namely, that adolescents – especially older male teens, who are at highest suicide risk – seldom seek mental health care. Yet, roughly one-third of adolescents visit the ED per year, Cheryl A. King, Ph.D., explained at the annual conference of the American Association of Suicidology.
Cheryl A. King, Ph.D.
“They come in for exacerbation of common medical illnesses and sports injuries, but they’re also coming in for things like alcohol poisoning, car accidents, and fistfights,” noted Dr. King, professor of psychology and psychiatry at the University of Michigan, Ann Arbor.
These ED visits offer a particularly good opportunity to screen for suicide risk in adolescent males, who account for 80% of all youth suicides in the United States. Yet, because they are so much less likely than teen girls to share thoughts of suicide, males comprise only 25%-35% of teens hospitalized for suicide risk, she continued.
Dr. King has been a leader in the exploration of the medical ED as a venue for routine screening for high risk for suicidal behavior in adolescents. She and others have shown that such screening is productive. But there’s a problem: ED personnel already feel plenty busy and time crushed without taking on a huge new responsibility. And screening instruments designed to miss few teens at risk will have a high false-positive rate. “I don’t want to set the screen-positive threshold so low that 40% of all youth who come in with a broken thumb that was jammed in a car door screen positive, because then what will the ED physicians say to me? They may not even want to talk to me,” she said.
In an early proof-of-concept study, she and her colleagues developed and tested a high-bar screen, one in which a positive result required self-reported serious suicidal ideation within the past 2 weeks, a suicide attempt within the past month, or co-occurring depression plus alcohol/substance misuse. Applying the screen to 298 adolescents who presented to an ED, the investigators found a 16% screen-positive rate (Acad. Emerg. Med. 2009;16:1234-41).
The investigators went on to survey pools of adolescents and parents as to the acceptability of routine ED screening for suicide risk, and got a thumbs-up from both groups (Ped. Emerg. Care 2012;28:626-32).
Next, Dr. King and her colleagues established that their screening tool actually predicted a high near-term risk for suicidal behavior. In a separate study of 81 adolescents aged 14-19 who were screen positive, 15 (18.5%) engaged in some type of suicidal behavior in the 2 months following their ED visit (J. Child Adolesc. Psychopharmacol. 2015;25:100-8).
Another promising screening tool for use in youths presenting to EDs is the ASQ (Ask Suicide-Screening Questions), a four-question test developed at the National Institute of Mental Health (NIMH). It assesses current thoughts of wishing to die, being better off dead, suicidal ideation, and past attempts (Arch. Pediatr. Adolesc. Med. 2012;166:1170-16); however, the predictive validity of this scale in terms of future suicide attempts has yet to be validated, according to Dr. King.
The clinician-administered Columbia–Suicide Severity Rating Scale has demonstrated predictive validity, but it is likely to prove too comprehensive and time consuming for routine use as a screening tool in the ED. However, several specific items incorporated in the scale – namely, the duration element of the intensity scale score and a lifetime history of nonsuicidal self-injury – showed predictive validity as a streamlined screening tool in a study by Dr. King and her colleagues (Pediatr. Emerg. Care 2015;31:88-94).
The most recent development in ED screening is the National Institute of Mental Health–funded ED-STARS (Emergency Department Screening for Teens at Risk for Suicide) project. Dr. King is a codirector of this multicenter effort to develop the optimal suicide risk screening tool for adolescents in the ED, along with a triage algorithm ED physicians can follow.
The tool being developed is a computerized adaptive screen. Rather than answering a fixed list of screening questions, patients will take a very brief, personalized test administered via computer. The adaptive aspect involves an algorithm in which the next question posed depends upon the individual’s response to the question before. This screening instrument is being paired with the Implicit Association Test developed by investigators at Harvard University, Cambridge, Mass.