How Primary Care Providers Can Address Suicidal Youth and Self-Harming Behaviors

Pediatricians are often in an optimal position to see early warning signs of suicidal and self-harming behavior in their patients, to diagnose and recommend treatment, and to provide referrals depending on individual presentation and symptom severity.

To help providers who may not be comfortable in that position, the Department of Behavioral Health at Nationwide Children’s Hospital recently hosted a seminar about recognizing and responding to these behaviors. The seminar was part of the ongoing Behavioral Health CME Series for Primary Care Providers.

“Many adolescents report more comfort discussing risk-taking activities with primary care providers than with specialists,” says Ericka Bruns, M.S.Ed., LPCC-S, clinical director of Behavioral Health Crisis Services at Nationwide Children’s and a seminar leader. “In fact, more adolescents will disclose suicidal ideation when asked in a primary care setting.”

Suicide is the second leading cause of death for young people ages 10 to 24 years. Nearly 30 percent of high school students report feeling sad or hopeless for two or more weeks, while 17 percent seriously consider attempting suicide, 13.6 percent make a suicide plan and 8 percent actually attempt suicide. Young children are at risk as well: suicide is the 13th leading cause of death for children 12 and under, and 12 percent of children age 6 to 12 years have suicidal thoughts.

Uncovering at-risk patients in the pediatric setting takes vigilance.  But there are warning signs and risk factors that pediatricians should consider when evaluating patients.

Leading warning signs include suicide ideation, anxiety and mood changes. Risk factors include a history of suicide attempts, ideation or self-harming, as well as access to firearms. Depression seems an obvious warning sign, says Charles Glawe, MD, a member of the Section of Psychiatry at Nationwide Children’s and a seminar leader, but recognition of anxiety disorders is also important.

Dr. Glawe notes that other disorders can lead to suicidal ideation as well, including bipolar disorder, first-break psychotic disorders, autism and substance abuse. Medications to address these disorders include a broad range of selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and, to a lesser degree, tricyclics. Which to use and when varies by each patient and how they present.

According to Bruns, one tool has proven particularly helpful to pediatricians working with their patients. Short  and uncomplicated, the Ask Suicide-Screening Questions (ASQ) tool takes less than two minutes to administer and features four or five questions with simple check-box responses of Yes, No, and “No Response:”

• In the past few weeks, have you wished you were dead?
• In the past few weeks, have you felt that you or your family would be better off if you were dead?
• In the past few weeks, have you been having thoughts about killing yourself?
• Have you ever tried to kill yourself?

Any response other than “no” is considered a positive screen. If a patient answers “yes” to any of the questions, a fifth should be asked: “Are you having thoughts of killing yourself right now?”

When working with ASQ or other screening tools, health care providers need to know that how they ask questions is important, says Bruns. Avoid asking leading questions that suggest a “no” answer such as “You wouldn’t kill yourself, would you?” or “You don’t really want to die, right?”

Asking about suicidal ideation does not make a patient more likely to commit suicide, Bruns says. When working with patients, providers should be sure to validate their feelings and let them know they aren’t alone.

Once identified, patients at risk for self-harming behaviors or suicide need a safety plan. These plans should be developed collaboratively with patients, caregivers and family physicians or other health care professionals.

These resources may be helpful for patients and their families:

• 24/7 National Suicide Prevention Lifeline
  1-800-273-TALK (8255)
  En Espanol: 1-888-628-9454

• 24/7 Crisis Text Line
  Text ”HOME” to 741-741

• Franklin County Youth Psychiatric Crisis Line
  614-722-1800

• North Central Mental Health Text Line
  614-221-5445

Reference:

Bruns E, Glawe C. Responding to suicidal youth and self-injurious behaviors. Seminar presented at Nationwide Children’s Hospital. October 2017. Columbus, Ohio.