Screening and Follow-Up Treatment Practices for Suicide Risk in Adolescent Primary Care: A Retrospective Chart Review

Abstract

Universal depression screening in adolescent primary care often encompasses questions about suicide risk. We conducted a retrospective chart review of well-child visits where adolescents (ages 13-17.9) had endorsed self-injurious thoughts and behaviors or suicidal ideation. The goal was to investigate primary care providers’ follow-up actions, including documentation, further assessment, and referrals. Over 3-quarters of the progress notes showed evidence of further assessment, and two-thirds documented same-day actions, including mental health referrals, emergency department referrals, safety plans, medication changes, primary-care follow-up, and talking to parents. Actions varied by depression severity. Cases without interventions often had justifications. Owing to the variety of possible meanings and severity underlying positive screens, providers implemented an array of interventions, using clinical judgment to tailor actions to patients’ individual needs and preferences. From these observations, we propose that standardized guidelines for suicide risk screening and follow-up should involve a clinical assessment and individualized treatment planning.

Keywords

primary-care pediatrics screening suicide risk adolescent mental health

Introduction

Self-injurious thoughts and behaviors (SITB), including suicidal ideation (SI), are common among adolescents in the United States, with 22% of adolescents reporting SI on the Center for Disease Control and Prevention’s (CDC) most recent Youth Risk Behavior Survey.¹ Across age groups, most individuals who die by suicide have contact with a primary health care provider the year before death.² In addition, suicide decedents are more likely to see a primary care physician in the year before death than any other type of provider.³ The American Academy of Pediatrics (AAP) recommends universal suicide risk screening at all health supervision visits for adolescents aged 12 and older who are medically and developmentally able to complete them.⁴ In contrast, following a comprehensive review of the research evidence, the United States Preventive Services Task Force (USPSTF) most recently concluded that there was insufficient evidence on the benefits and harms of screening in children and adolescents to recommend universal screening.⁵ Thus, there remains a lack of consensus on whether universal screening of adolescents for suicide risk in primary care improves outcomes.

Despite inconclusive recommendations regarding suicide risk screening, the USPSTF does support and recommend universal depression screening for ages 12 to 18.⁵ As such, adolescent suicide risk screening in primary care has become a widespread practice in the context of screening for depression. Pediatricians are likely to see patients who endorse SITB or SI in the context of both depression screening and specific suicide risk screening. One of the most common depression screening tools, the Patient Health Questionnaire-9 Modified for Teenagers (PHQ-9M), contains several questions assessing SITB within the past 2 weeks, SI within the past month, and lifetime history of a suicide attempt. Based on a nationally representative survey of pediatricians, Green and colleagues found that 93% of pediatricians reported having a patient with SI, and 61% reported that they always screened for SI.⁶ Past studies in primary care settings showed that between 4.9% and 15.6% of adolescents screened positive for suicide risk, depending on the measure and sample used.^7-13 Accordingly, pediatricians must be equipped with the training, guidelines, and resources necessary to respond to positive screens.

In qualitative studies, primary care pediatricians report a number of barriers to conducting suicide risk screening in their adolescent patients. These challenges include a lack of time, patients’ reluctance to discuss or report mental health issues, inadequate compensation, insufficient training, lack of treatment options for positive screens, the need for parental involvement for adolescents to follow through on mental health referrals, and lack of communication from behavioral health providers after making a referral.^6,14-17 Several health care practices and researchers have implemented automated screening systems with standardized pathways for following up on positive suicide risk screens.^9,10,16,18 In a qualitative study by Radovic and colleagues, parents, adolescents, and providers perceived some benefits to these automated tools, but also expressed concerns that an automated screening process might replace trusted discussions about mental health with the provider and that a decision algorithm could interfere with provider autonomy in treatment decisions.¹⁶ These findings suggested that standardized tools are only one piece of the suicide risk assessment process and must be followed up by clinical assessment and individualized treatment planning using shared decision-making strategies.¹⁶

A handful of studies have examined the outcomes of suicide risk screening using a single metric, such as how many adolescents who screen positive for SI during health supervision visits go on to engage in mental health treatment. Gardner and colleagues found that about 65% of adolescents who reported SI at a primary care visit subsequently received mental health services within 6 months,¹¹ while other studies found that only 28% to 46% of these patients went on to obtain behavioral health services.^9,18,19 However, patients who endorsed SI on questionnaires are found to be at widely varying levels of risk: In 2 prior studies, 71% and 79.5% of positively screened adolescents were deemed “not actively suicidal” or “no suicidal concern” by their providers, respectively, after follow-up assessment.^10,18 Owing to the high-risk nature of these patients, suicide risk screening tools are designed to prioritize sensitivity to identify situations before they are necessarily imminent. The identified cases often benefit from closer primary care and psychiatric follow-up for symptom monitoring and further risk stratification. Given that patients who endorse SITB or SI on a screening measure will require further assessment, and that clinical judgment is needed to determine the most appropriate intervention, examining referral rates or treatment engagement as the primary outcome of screening may not fully capture the success of a screening program.

In this study, we investigate a wide range of outcomes of suicide risk screening in a network of pediatric primary care clinics. These clinics began screening adolescents ages 13 and older with the PHQ-9M, including its SITB and SI-related questions, for the first time in January 2022. Through a retrospective chart review of patients who screened positive for SITB on the PHQ-9M, we aim to assess: (a) the extent and variety of ways pediatricians documented and addressed suicide risk in practice during the first 6 months of the new screening protocol (how many patients were further assessed, given same-day referrals/interventions, and what these referrals/interventions were), (b) discernable reasons a pediatrician did not intervene when a patient endorsed SITB or SI, and (c) how many patients who endorsed SITB or SI remained at risk approximately 1 year later.

Method

Screening Measure

In January 2022, the pediatric clinics included in this study began universally screening all patients with a battery of 3 psychosocial screening measures, which included the PHQ-9M. The PHQ-9M is a youth-report measure of depressive symptoms adapted from the original PHQ-9 to contain language more appropriate to adolescents. The PHQ-9M also contains several supplemental questions assessing SI, lifetime suicide attempts, persistent sadness, and impairment.^20,21 Prior to the battery’s introduction, the pediatricians in these clinics were already accustomed to screening all adolescents for a range of psychosocial concerns using the Pediatric Symptom Checklist-17 (PSC-17). However, the initial use of the PHQ-9M in 2022 marked the first time that the pediatricians were systematically screening for SITB and SI because unlike the PSC-17, the PHQ-9M contains items that ask about SITB and SI.

The PHQ-9M contains 13 total items, including 9 initial items and 4 supplemental items.^20,21 The 9 initial questions assess the frequency of various depressive symptoms in the past 2 weeks, with the following possible responses: 0 (“not at all”), 1 (“several days”), 2 (“more than half the days”), and 3 (“nearly every day”). The total score on the first 9 items is used as an indicator of the severity of depression risk, as described in Table 1. Item 9 assesses past 2-week SITB (“thoughts that you would be better off dead, or of hurting yourself in some way?”). We defined past 2-week SITB as endorsing item 9 at least “several days” (Table 1). The remaining 4 supplemental questions assess past-month SI, lifetime suicide attempts, persistent sadness, and impairment. We defined past-month SI as a response of “Yes” to the supplemental item: “Has there been a time in the past month when you have had serious thoughts about ending your life?” (Table 1). We defined a lifetime suicide attempt as a response of “Yes” to the supplemental item: “Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?.”

Table 1.

Definitions of Study Constructs Based on PHQ-9M Items.^a

Construct	Definition
Mild depression risk	Total score on first 9 items: 5-9
Moderate depression risk	Total score on first 9 items: 10-14
Moderate-to-severe depression risk	Total score on first 9 items: 15-19
Severe depression risk	Total score on first 9 items: 20+
Past 2-week self-injurious thoughts or behaviors (SITB)	Response of at least “several days” to item 9: “. . .thoughts that you would be better off dead, or of hurting yourself in some way?”
Past-month suicidal ideation (SI)	Response of “yes” to supplemental item: “Has there been a time in the past month when you have had serious thoughts about ending your life?”
Lifetime suicide attempt	Response of “yes” to supplemental item: “Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?”

Abbreviations: SITB, self-injurious thoughts and behaviors; SI, suicidal ideation.

Construct scores are based on the scoring guidelines for the PHQ-9M.²¹

Coding Manual and Training

A coding manual for extracting dependent variables from patient charts was developed by the authors. Systematic retrospective case analysis was conducted by 3 of the authors who had been trained in the coding protocol. One coder reviewed each case, and a subsample of cases was reviewed by 2 coders to establish interrater reliability. The following dependent variables were recorded from the progress notes and other areas of the electronic health record (Table 2): the clinician acknowledging the positive screen, the use of additional risk stratification screening, the use of a standardized follow-up measure, each patient’s current level of psychiatric treatment (whether they were already receiving mental health services and/or prescribed medication), the presence and types of referrals/interventions (referral to mental health services, referral to the emergency department, safety plan, new or changed medication prescription, plan to follow-up with pediatrician, talking to parents), and reasons a pediatrician did not recommend a given intervention if no intervention was given.

Table 2.

Variables Extracted From the Medical Record.

Item	Description	Response type
Any documentation	Pediatrician mentioned the patient’s endorsement of SITB in the progress note or elsewhere in the chart	Yes/No
Further risk assessment	Evidence that the pediatrician did any further risk assessment or interview about SITB or SI	Yes/No
Standardized instrument	Pediatrician used a standardized instrument, such as the ASQ or C-SSRS for further risk assessment	Yes/No
Already in mental health services	Chart contains evidence that the patient was already in mental health services before the WCV	Yes/No
Already prescribed medication	Chart contains evidence that the patient was already prescribed a psychiatric medication prior to the WCV	Yes/No
Interventions
Safety plan	Discussed a safety plan (e.g., contact ED, call family member/friend, call suicide helpline, coping skills)	Yes/No
Follow-up with pediatrician	Scheduled follow-up with pediatrician to revisit SITB or SI	Yes/No
New mental health referral	Recommended or placed a new referral to mental/behavioral health services	Yes/No
New or changed medication	Prescribed new medication for mental health or altered regimen of existing medication	Yes/No
Referral to ED	Referred patient to Acute Psychiatry Services (APS) same day as visit	Yes/No
Other	Any other intervention	Free response
Reason for not doing more	If no intervention was given, pediatrician explained a reason for not doing more	Free response

Abbreviations: APS, acute psychiatry services; ASQ, Ask Suicide-Screening Questions; C-SSRS, Columbia-Suicide Severity Rating Scale; ED, emergency department; SITB, self-injurious thoughts and behaviors; SI, suicidal ideation; WCV, well-child visit.

Ethical Considerations

The Mass General Brigham Institutional Review Board approved this study (protocol #2022P001646). Informed consent was not deemed necessary as it was a retrospective case series based on standard clinical care.

Analysis

Descriptive statistics were computed for the prevalence of past 2-week SITB, past-month SI, and lifetime suicide attempts in the full sample of patients screened with the PHQ-9M between January and June 2022. The analytic subsample included all adolescent patients who screened positive for the past 2-week SITB and/or past-month SI during this timeframe. In the analytic subsample, we assessed the prevalence and variety of same-day follow-up assessments, referrals, and interventions based on data collected from patient charts. Among patients who had at least 2 health supervision visits with evidence of a PHQ-9M between January 2022 and June 2023, paired t-tests and McNemar’s/Wilcoxon tests were used to analyze changes in scores and item-level risk on the PHQ-9M between the 2 visits.

Results

Sample

The study included 1686 adolescents aged 13.0 to 17.9 years old (M = 15.08, SD = 1.21) who were screened with the PHQ-9M at a well-child visit from January through June 2022 at 1 of 7 primary care sites in an academically affiliated health care network in the greater Boston area. The overall sample was 50.06% (n = 844) female, with most patients reporting English as their preferred language (62.57%, n = 1055) and Medicaid as their insurance (61.15%, n = 1031) (Table 3). Almost half reported Hispanic ethnicity (47.57%, n = 802) and “other” race (43.48%, n = 733). There was substantial overlap between these categories: 75.94% of individuals reporting Hispanic ethnicity reported “other” race. The analytic subsample consisted of 102 adolescents (M age = 15.16, SD age = 1.08) who endorsed SITB and/or SI on the PHQ-9M. Compared to other patients, patients in the analytic subsample were more likely to be female (60.78% vs 49.24%, χ² = 5.11, P < .05) and Medicaid-insured (75.49% vs 60.23%, χ² = 9.76, P < .01). However, they had similar distributions of preferred language (P = .78), ethnicity (P = .57), and race (P = .66) (Table 1).

Table 3.

Demographic Characteristics of Full Sample and Analytic Subsample.

	All WCVs (N = 1686) (%)	Nonanalytic subsample (n = 1584) (%)	Analytic subsample (n = 102) (%)	χ² (P value)
Sex				5.11 (P < .05)
Female	842 (50.06)	780 (49.24)	62 (60.78)
Male	844 (49.94)	804 (50.76)	40 (39.22)
Ethnicity				1.12 (P = .57)
Hispanic	802 (47.57)	749 (47.29)	53 (51.96)
Non-Hispanic	771 (45.73)	727 (45.90)	44 (43.14)
Unknown	113 (6.70)	108 (6.82)	5 (4.90)
Race^a				3.27 (P = .66)
Asian	94 (5.58)	90 (5.68)	4 (3.92)
Black	170 (10.08)	160 (10.10)	10 (9.80)
White	559 (33.16)	530 (33.46)	29 (28.43)
Other	733 (43.48)	682 (43.06)	51 (50.00)
Two or more	60 (3.56)	55 (3.47)	5 (4.90)
Unknown/declined	70 (4.15)	67 (4.23)	3 (2.94)
Language				0.50 (P = .78)
English	1,055 (62.57)	994 (62.75)	62 (60.78)
Non-English	629 (37.31)	588 (37.12)	40 (39.22)
Unknown/declined	2 (0.12)	2 (0.13)	0 (0.00)
Insurance				9.76 (P < .01)
Public (Medicaid)	1,031 (61.15)	954 (60.23)	77 (75.49)
Private	641 (38.02)	616 (38.89)	25 (24.51)
Unknown	14 (0.83)	14 (0.88)	0 (0.00)

Categories with <3 respondents were merged into “Other” to protect confidentiality.

Prevalence of Suicide Risk

In the full sample of patients who completed a PHQ-9M between January and June 2022 (N = 1686), 5.04% (n = 85) endorsed past 2-week SITB at least “several days.” 2.49% of patients (n = 42) endorsed past-month SI. In total, 104 patients (6.21%) endorsed past 2-week SITB and/or past-month SI. The final analytic subsample consisted of 102 patients whose progress notes were available and complete (2 progress notes were empty and did not have any available text to code). In addition, 4.09% of patients (n = 69) reported a lifetime suicide attempt, including 44 patients who did not endorse past 2-week SITB or past-month SI. Within the analytic subsample of patients who endorsed past 2-week SITB or past-month SI (n = 102), 24.51% (n = 25) reported a lifetime suicide attempt.

Interrater Reliability of Chart Abstraction

To establish interrater reliability, a random subset of 20 charts was reviewed by 2 coders. The pooled kappa was 0.73, indicating substantial agreement.²² Coding discrepancies were resolved through discussion among all 3 coders.

Follow-Up Questions/Discussion

Of the 102 charts in the analytic subsample, 79 (77.45%) mentioned SITB/SI in the progress note or elsewhere in the chart (e.g., diagnoses; Figure 1). In addition, 76 (74.51%) progress notes contained evidence that the pediatrician did any further risk assessment or interview about SITB/SI (Figure 1). Only one of these follow-up assessments used a standardized measure (the Columbia Suicide Severity Rating Scale); in the rest of the cases, pediatricians asked their own follow-up questions.

Current Level of Care

Of the 102 patients in the analytic subsample, there was evidence that at least 40 (39.22%) were already receiving mental health services and 18 (17.65%) were prescribed medications. In total, 43 patients (42.16%) were already receiving mental health services and/or medication. Of the 23 patients whose progress notes did not mention SI or SITB, 8 (34.78%) were already receiving mental health services and/or prescribed psychiatric medications (Figure 1).

Same-Day Interventions/Referrals

The 6 coded interventions were: referral to mental health services, referral to the emergency department, safety plan, new or changed medication prescription, plan to follow-up with pediatrician, and talking to parents (Table 2). Overall, 68 (66.67%) patients in the analytic subsample received a same-day intervention or referral for SITB/SI or a directly related mental health condition. Of the 79 progress notes that mentioned SI, 63 (79.75%) included 1 of the 6 coded interventions (Figure 1). Of the 23 progress notes that did not mention SI or SITB, 5 (21.74%) nonetheless included at least 1 of the 6 coded interventions (Figure 1).

At baseline, the average PHQ-9M score of patients who received at least one intervention (M = 13.79, SD = 0.70) was significantly higher than those of patients who did not receive at least one intervention (M = 9.59, SD = 0.70). The prevalence of interventions increased as patients’ PHQ-9M risk levels increased, from no risk (36.36%) to mild (52.38%) to moderate (66.67%) to moderate-severe (83.33%) to severe risk on the PHQ-9M (84.62%), χ² = 11.36, P < .05. The prevalence of interventions did not differ significantly between patients with a past suicide attempt (64.00%) and those without a past suicide attempt (67.53%), χ² = 0.11, P = .75. However, patients with a past suicide attempt were more likely to already be receiving mental health services and/or medication than those without a past suicide attempt (56.00% vs 33.77%), χ² = 3.91, P < .05.

Number and Types of Interventions

Interventions were frequently used in combination with each other. Among patients with at least 1 of the 6 follow-up actions, the average number of actions per patient was 2.12. The most commonly documented action was a mental health referral (n = 40), followed by talking to parents (n = 35), follow-up with primary care provider (n = 30), a safety plan (n = 26), new or changed medication (n = 9), and referral to emergency services (n = 4). During chart abstraction, coders also made note of “other” recommendations or interventions given in response to SITB or depression that fell outside of the 6 coded interventions. The following “other” recommendations were noted in at least 2 charts: sleep hygiene advice or aids, nutrition advice, encouraging regular exercise, and providing information about mindfulness websites and apps.

Patients With no Same-Day Interventions/Referrals

Of the 34 patients with no same-day intervention or referral, 24 (70.59%) of their progress notes included at least one discernable reason for not having follow-up (Figure 1). Patients whose progress notes did not mention SITB or SI were still considered as having a reason for not doing more if, for example, the patient denied symptoms of depression or the patient was already receiving mental health services. Overall, the most common reasons for not doing more were: the patient was already receiving services or on a waitlist for services (n = 13), the patient denied SITB, SI, or depression when verbally asked (n = 9), the patient or family declined a referral or intervention (n = 5), and the patient misunderstood the questions or reported an error such as hitting the wrong button (n = 4; Figure 1). Of the 34 patients with no same-day intervention or referral, 10 (29.41%) were missing a reason for not doing more (Figure 1).

Change in Risk at Follow-Up

Of the 102 patients in the analytic subsample, 42 had a follow-up PHQ-9M screen at an encounter approximately 1-year later (January-June 2023). Of the 42 participants with 2 complete screens, 27 (64.29%) received any of the 6 coded same-day interventions at Time 1. Similar to the full sample, the most commonly documented action among those with 2 complete screens was a mental health referral (n = 16), followed by talking to parents (n = 13), follow-up with primary care provider (n = 10), a safety plan (n = 9), new or changed medication (n = 3), and referral to emergency services (n = 1). Among these patients, the mean overall PHQ-9M score decreased substantially and significantly from Time 1 (M = 12.33, SD = 0.96) to Time 2 (M = 8.29, SD = 1.03), crossing the PHQ-9M’s threshold from “moderate” (≥10) to “mild” (≥5) depression risk, t(41) = 3.53, P < .01. A Wilcoxon signed-rank test showed that frequency of thoughts of self-harm, as measured by question 9 on the PHQ-9M, declined significantly, from a median score of 1 (“several days”) at Time 1 to a median score of 0 (“not at all”) at Time 2, z = 4.36, P < .001. As shown in Table 4, of 19 patients who endorsed past-month SI at Time 1, only 2 (10.53%) remained at risk at Time 2. Of 23 patients who did not endorse past-month SI at Time 1, 3 (13.04%) went on to endorse past-month SI at Time 2. In addition, the overall proportion of patients endorsing past-month SI fell significantly from Time 1 to Time 2, McNemar’s χ² = 9.80, P < .01 (Table 4).

Table 4.

Patients Endorsing Past-Month SI at Time 1 Versus Time 2.

		Time 2
		No past-month SI (%)	Past-month SI (%)	Total (%)
Time 1	No past-month SI	20 (86.96)	3 (13.04)	23 (100)
Time 1	Past-month SI	17 (89.47)	2 (10.53)	19 (100)
	Total	37 (88.10)	5 (11.90)	42 (100)

Abbreviations: SI, suicidal ideation.

Discussion

The findings from this retrospective chart review reflect the complexity of evaluating the outcomes of suicide risk screening conducted in the context of depression screening. In this study, the general prevalence of SITB, SI, and suicide attempts in an adolescent primary care sample was consistent with similar studies and with national trends.^7-13 Overall, the compliance of providers with administering follow-up questions (74.5%) and implementing same-day actions (66.67%) was high. In addition, when individual cases with no intervention were examined more closely, we found that many progress notes documented a thorough assessment and a potentially “valid” reason for why more was not always done. For example, some patients were already in services, misunderstood the question due to language barriers, or refused further follow-up.

Another common finding was for patients to endorse SITB or SI on their screening questionnaire and later deny it during verbal follow-up questioning. This presents a conundrum for pediatricians as it can limit a thorough safety evaluation. While the clinical context is difficult to discern from a chart review, maintaining a nonjudgmental and empathetic stance is essential. Reinforcing confidentiality policies and the role of their pediatrician in the process can help address unspoken concerns. Often, patients, especially children and adolescents, are fearful about the implications of positive screening. Realistically exploring the various levels of additional support, from an urgent care referral to an inpatient hospitalization, may help reduce anxiety. Discussing the discrepancy and collaborating with caretakers when necessary can also help provide additional information for further risk stratification.

A handful of cases involved mental health referrals without documentation of concerns related to the screening. There are a variety of reasons for this to occur. For example, erroneous documentation, lack of a clear indication, and concerns for patients’ confidentiality are possible reasons for these apparent omissions. However, care should be taken to weigh the risks, benefits, and practicality of referring. The mental health system is almost universally strained, with local waitlists for the patients in this study exceeding half a year to become connected to services. These concerns speak to another qualitative strength of this study’s results: providers, in general, appropriately triaged levels of risk with the intensity of care. Our implementation of the Epic medical record system actively pushes a pop-up alert to the provider when there is a positive SITB or SI response. Anecdotally, providers reported that this system helped to ensure that a positive screen is not missed and that the results could be acted upon in a timely manner, which likely supported the providers’ ability to triage appropriately. Although patients with more severe risk were more likely to have a same-day action documented in their charts, providers did not follow an algorithmic determination of treatment decisions (for example, mild risk = continue to monitor, moderate risk = referral to psychiatry, severe risk = refer to the emergency department). The lack of standardized referral and intervention pathways in this study allowed for flexibility in clinical decision-making. Given the complexities of severe mental health concerns, many providers were able to tailor their treatment plans for each situation and combine different approaches. For example, providers could prescribe medication and create a safety plan that included contingencies to present to the emergency department while starting the referral process to psychiatry.

The needs of individual adolescents with SITB or SI may change over time, as shown by the small sample of patients who were re-screened approximately 1 year after their initial visit. Most patients who endorsed past-month SI on the index screen no longer endorsed these thoughts a year later, though a handful of patients remained at risk or were newly at risk in the second year. On average, these patients experienced a decline in depression scores and in the frequency of SITB. Prior research has similarly documented 1-year declines in depressive symptoms and suicidality among adolescents who endorsed SI at baseline screening.²³ This suggests that adolescent SITB and depressive symptoms are dynamic, although causal factors are difficult to determine. Routine screening for suicide risk in primary care and detailed documentation of follow-up assessment, interventions, and reasons for not intervening can be useful for monitoring patients’ evolving needs over time. Actions such as safety planning and providing educational resources for patients and parents can aid in the management of suicide risk, even if the risk is not determined to be acute at the time of the visit.

This study has several limitations, including the relatively small sample size, which limits the generalizability of the results and precludes tests of differences across subgroups. In addition, the reliance on manual chart reviews introduces potential uncertainty in the data. While the presence or absence of recommended interventions was noted, the study lacks information about additional interventions that may have been provided but not recorded in the charts. There was limited information about whether patients were already receiving services, as patients may have been receiving care outside of the health system under study. This study was also unable to determine whether patients who were referred for interventions went on to receive those services. In addition, the USPSTF notes that there is limited evidence demonstrating whether engagement in treatment following a positive suicide risk screen is associated with improved mental health outcomes.⁵ It is important for additional research to elucidate this gap between referral and intervention and the efficacy of those interventions to better understand the true outcomes of suicide risk screening in primary care.

Evaluating the outcomes of suicide risk screening in adolescent primary care is a multifaceted endeavor, in part due to the complexity of adolescent suicide risk itself. In the absence of a standardized protocol for clinicians to follow in assessing and managing suicide risk, the clinicians in this study used highly varied interventions, which were individualized to patients’ specific needs and their desires for additional support. In an era of increasing standardization and automation in health care decision-making, this study highlights the importance of ensuring that after standardized screening occurs, follow-up should involve a clinical assessment and individualized treatment planning.¹⁶ Our study can inform the development of guidelines based on stepped care and collaborative care models. Stepped care models involve providing different levels of intervention depending on the severity of a patient’s needs. This approach requires routine monitoring of a patient’s symptoms over time so that the level of care can be adjusted based on changes in the risk level.²⁴ Guidelines can also incorporate principles of shared decision-making by involving adolescents and their families in collaborative discussions about the screening results and intervention options, which can improve alignment between interventions and a family’s personal and/or cultural values, preferences, and needs.²⁵

Although primary care providers have previously reported barriers and inadequate training to manage suicide risk,^6,14-17 this study shows that most were able to provide a same-day intervention or referral, and that interventions were more intensive based on the level of severity. This study thus provides evidence that primary care providers are an important component in addressing adolescent mental health needs. Training programs and professional societies should invest in better preparing primary care pediatricians to assess and address suicide risk. Beyond training, primary care pediatricians must be equipped with system-level support. Universal screening implementation should be weighed with the availability of an adequate referral network that reflects the dynamic and varied needs of patients and their families. Health systems should be prepared for increased identification of at-risk adolescents and to mobilize mental health resources to respond to this need. Health systems should consider how collaborative care strategies, including interdisciplinary teams, integrated behavioral health, and care coordination, can support primary care pediatricians in addressing suicide risk in their adolescent patients.

Author Contributions

WB, KLL, TSB, MJ, and JMM: conceptualized and designed the study. AAB, KSB, and MF: helped design the study. WB, KLL, and TSB: analyzed and interpreted the data. WB and TSB: took the lead in writing the manuscript. All authors critically revised the manuscript and gave final approval.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this work was underwritten by the Fuss Family Fund.

Ethical Approval

The Mass General Brigham Institutional Review Board approved the current study (protocol #2022P001646).

ORCID iD

Talia S. Benheim

References

Centers for Disease Control and Prevention. Youth risk behavior survey. 2021. Accessed January 2, 2024. http://www.cdc.gov/YRBSS.

Stene-Larsen

Reneflot

Contact with primary and mental health care prior to suicide: a systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019;47(1):9-17. doi:10.1177/1403494817746274.

Ahmedani

Simon

Stewart

, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29(6):870-877. doi:10.1007/s11606-014-2767-3.

American Academy of P. Screening for suicide risk in clinical practice. Accessed July 1, 2023. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/strategies-for-clinical-settings-for-youth-suicide-prevention/screening-for-suicide-risk-in-clinical-practice/.

Mangione

Barry

Nicholson

, et al. Screening for depression and suicide risk in children and adolescents: US preventive services task force recommendation statement. JAMA. 2022;328(15):1534-1542. doi:10.1001/jama.2022.16946.

Green

Gottschlich

Burr

WH.

A national survey of pediatricians’ experiences and practices with suicide prevention. Acad Pediatr. 2023;23(7):1403-1410. doi:10.1016/j.acap.2023.01.010.

Aguinaldo

Sullivant

Lanzillo

, et al. Validation of the ask suicide-screening questions (ASQ) with youth in outpatient specialty and primary care clinics. Gen Hosp Psychiatry. 2021;68:52-58. doi:10.1016/j.genhosppsych.2020.11.006.

Davis

Jones

, et al. Adolescent depression screening in primary care: who is screened and who is at risk? J Affect Disord. 2022;299:318-325. doi:10.1016/j.jad.2021.12.022.

Davis

Rio

Farley

Bush

Beidas

Young

JF.

Identifying adolescent suicide risk via depression screening in pediatric primary care: an electronic health record review. Psychiatr Serv. 2021;72(2):163-168. doi:10.1176/appi.ps.202000207l.

10.

Etter

McCord

Ouyang

, et al. Suicide screening in primary care: use of an electronic screener to assess suicidality and improve provider follow-up for adolescents. J Adolesc Health. 2018;62(2):191-197. doi:10.1016/j.jadohealth.2017.08.026.

11.

Gardner

Klima

Chisolm

, et al. Screening, triage, and referral of patients who report suicidal thought during a primary care visit. Pediatrics. 2010;125(5):945-952. doi:10.1542/peds.2009-1964.

12.

Holcomb

Dutta

Bergmann

, et al. Suicidal ideation in adolescents: understanding results from screening with the PHQ-9M and the PSC-17P. J Dev Behav Pediatr. 2022;43(6):346-352. doi:10.1097/DBP.0000000000001063.

13.

Jenkins

Singer

Conner

Calhoun

Diamond

Risk for suicidal ideation and attempt among a primary care sample of adolescents engaging in nonsuicidal self-injury. Suicide Life Threat Behav. 2014;44(6):616-628. doi:10.1111/sltb.12094.

14.

Bellairs-Walsh

Byrne

Bendall

, et al. Working with young people at risk of suicidal behaviour and self-harm: a qualitative study of Australian general practitioners’ perspectives. Int J Environ Res Public Health. 2021;18(24):12926. doi:10.3390/ijerph182412926.

15.

Diamond

O’Malley

Wintersteen

, et al. Attitudes, practices, and barriers to adolescent suicide and mental health screening: a survey of Pennsylvania Primary Care providers. J Prim Care Community Health. 2012;3(1):29-35. doi:10.1177/2150131911417878.

16.

Radovic

Anderson

Hamm

, et al. Perceived facilitators of and barriers to implementation of a decision support tool for adolescent depression and suicidality screening: focus group and interview study. JMIR Ment Health. 2021;8(9):e26035. doi:10.2196/26035.

17.

Leahy

Schaffalitzky

Saunders

, et al. Role of the general practitioner in providing early intervention for youth mental health: a mixed methods investigation. Early Interv Psychiatry. 2018;12(2):202-216. doi:10.1111/eip.12303.

18.

Aalsma

Keys

Ferrin

, et al. Adolescent suicide assessment and management in primary care. BMC Pediatr. 2022;22(1):389. doi:10.1186/s12887-022-03454-4.

19.

Chisolm

Klima

Gardner

Kelleher

KJ.

Adolescent behavioral risk screening and use of health services. Adm Policy Ment Health. 2009;36(6):374-380. doi:10.1007/s10488-009-0245-8.

20.

Johnson

Harris

Spitzer

Williams

JB.

The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health. 2002;30(3):196-204. doi:10.1016/s1054-139x(01)00333-0.

21.

Guidelines for Adolescent Depression in Primary Care. PHQ-9: modified for teens. 2010. https://www.aacap.org/App_Themes/AACAP/docs/member_resources/toolbox_for_clinical_practice_and_outcomes/symptoms/GLAD-PC_PHQ-9.pdf.

22.

De Vries

Elliott

Kanouse

Teleki

SS.

Using pooled kappa to summarize interrater agreement across many items. Field Methods. 2008;20(3):211-225. doi:10.1177/1525822X08317166.

23.

Kaess

Schnyder

Michel

, et al. Twelve-month service use, suicidality and mental health problems of European adolescents after a school-based screening for current suicidality. Eur Child Adolesc Psychiatry. 2022;31(2):229-238. doi:10.1007/s00787-020-01681-7.

24.

Berger

Fernando

Churchill

, et al. Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults. Early Interv Psychiatry. 2022;16(4):327-341. doi:10.1111/eip.13180.

25.

Fitzpatrick

Holcomb

Weisz

Langer

DA.

Shared decision-making as a tool for navigating multi-stakeholder discrepancies in youth psychotherapy. J Clin Child Adolesc Psychol. 2023;52(1):95-107. doi:10.1080/15374416.2022.2127105.