Suicide is the second leading cause of death for patients aged 10-24yo in the US. Suicide risk can be mitigated by appropriate screening, bolstering of protective factors, indicated treatment, community resources, and referrals to mental health providers.
In 2021, the AAP developed a Blueprint for Youth Suicide Prevention that serves as a clinical resource to support adolescent patients who may be at risk for suicide, recommending a 3-tiered approach:
- Brief screen with a validated measure
- Brief suicide safety assessment for anyone who screens positive to the above measure
- Disposition determined by the brief suicide safety assessment.
Validated Screening Measures:
Preferred screening measures in youth include the Ask Suicide-Screening Questions (ASQ) and the Suicide Behavior Questionnaire-Revised (SBQ-R). The PHQ-9, although validated for depression screening, is controversial in its utility for assessing suicide risk because of its reliance on a single, broad question that incorporates non-suicidal self-injury: “In the last two weeks, have you had thoughts that you would be better off dead, or of hurting yourself in some way?” The expanded PHQ-9 Modified for Adolescents (aka PHQ-A) has two more targeted questions: “Has there been a time in the past month when you have had serious thoughts about ending your life?” and “Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?” Neither of these two questions are assigned a numerical value, so we have to actively look at these answers on the PHQ-A. In spite of these two additional questions, the PHQ-A has been shown to miss a third of youth who screen positive for suicide risk.
Brief Suicide Safety Assessment (BSSA):
The BSSA is a brief conversation with the patient that assists in further triage by evaluating their personal risk of suicide as well as protective factors (e.g., frequency of suicidal thoughts, plans, psychiatric symptoms, suicide attempt history, reasons to live, social support, etc.) Recommended tools for the BSSA include the Columbia Suicide Severity Rating Scale (C-SSRS), Ask Suicide-Screening Questions Brief Suicide Safety Assessment (ASQ BSSA), and the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T). Safety assessments are generally designed to be performed one-on-one between the clinician and the patient prior to incorporating the caregiver into the conversation.
- Note: If the patient is found to be at imminent risk for suicide on screening, they do not need a BSSA because we already know they need an emergent mental health and safety evaluation. The BSSA is a way to triage patients screening positive (but not imminent) to determine next steps.
Disposition based on BSSA:
When patients are found to be at risk for suicide, they need compassionate care that prioritizes safety. We should praise patients for talking about thoughts they usually keep to themselves. We should listen openly and patiently, without judgement. No one can be “convinced” out of suicidal thoughts. Attending to the patient in a caring and compassionate way may help them feel less alone with their thoughts and struggles, for which trauma-informed care principles are essential.
For patients at non-imminent risk of suicide, safety planning is a brief intervention that can reduce suicide risk. Building a safety plan with a patient can help establish support and incorporate caregivers while introducing additional resources such as the 988 Lifeline and Crisis Text Line.