Suicide-risk screening may identify cases that typically fall through the cracks during depression screening, new research suggests.
The study, published in Pediatrics, found that the Ask Suicide-Screening Questions (ASQ) identified 2.2% of additional cases compared with those screened for any type of depression or other mental illnesses, and 8.3% of additional cases compared with those who screened positive for major depressive disorder.
About 3.2% of U.S. children between the ages of 3 and 17 have been diagnosed with depression, according to the Centers for Disease Control and Prevention. The American Academy of Pediatrics and the U.S. Preventive Services Task Force recommends that all teens be routinely screened for depression. However, there’s no specific recommendation that adolescents should also be screened for suicide in addition to depression screening.
The study highlights the high baseline rates of depression and suicide risk and the need for pediatric practices to plan for them and develop strategies about how they’re going to provide follow-up care, including treatment for suicidal teens.
“We began this project because we were concerned that we might be missing teens with increased risk of suicide by screening only for depression,” study author Alex Kemper, MD, said in an interview. “Our goal with this project was really to compare standard depression screening tools that we’ve used for a long time with a suicide-specific instrument just to see if we would identify additional cases with a suicide-risk instrument.”
Dr. Kemper and colleagues collected data from 803 mostly Medicaid-enrolled adolescents across 12 primary care practices. The subjects were between the ages of 12 and 20 years, with no recent history of depression or self-harm, who were screened with the Patient Health Questionnaire–9 Modified for Adolescents (PHQ-9A) and ASQ. For the study, two PHQ-9A screening strategies were evaluated: screening for any type of depression or other mental illness (positive on any item) or screening for major depressive disorder.
In addition, the researchers found that 56.4% of patients had a positive PHQ-9A screen for any type of depression and 24.7% had a positive PHQ-9A screen for major depressive disorder. Meanwhile, 21.1% of the population received a positive screen result. Of those who responded on the PHQ-9A that they did not have suicidal thoughts in the past month, 13.2% had a positive ASQ result.
Dr. Kemper, division chief of primary care pediatrics at Nationwide Children’s Hospital and professor of pediatrics at the Ohio State University, both in Columbus, said the suicide-risk screening questions were more direct and clear than were the two suicide questions included in the PHQ-9A screening.
For example, the PHQ-9A includes the following suicide-risk 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?” The teen can respond with “not at all,” “several days,” “more than half the days” or “nearly every day.”
Meanwhile, the ASQ questionnaire focuses on a more narrow time period and includes questions such as “In the past few weeks, have you wished you were dead?” and “Have you ever tried to kill yourself?” Teens respond by answering “yes” or “no.”
“So I think the difference is by asking questions that are really direct and very clear about suicide risk, you end up identifying more cases than this kind of general question about thoughts of killing yourself,” Dr. Kemper explained. “It makes sense when you think about where adolescents are in terms of their development, that the more specific you [are], the more likely you are to find what you’re looking for.”
Kelly Curran, MD, who was not involved in the study, said that because some of the ASQ questions “overlap” with the suicide-risk questions on the PHQ-9A, she didn’t expect the ASQ to identify more positive cases.
However, Dr. Curran said it is possible for suicidal teens to fall through the cracks during a depression screening because some of them may not self-identify as depressed.
“I don’t think we often think about the importance of linguistics or how something is asked,” said Dr. Curran, associate professor in the department of pediatrics at the University of Oklahoma, Oklahoma City.
“So asking [teens] these kind of direct questions about suicide may pick up on these cases of people who don’t necessarily have the insight into their sadness or their general kind of thought process.”
Dr. Kemper said he hopes the study would encourage pediatricians to adopt depression screening if they’re not already doing it and to think about whether they should implement suicide-risk screening in their practice. The study also highlights the importance of following up after a positive screening.
“There are a lot of teens who have depression or increased suicide risk that you wouldn’t identify if you didn’t screen, and a key aspect of any kind of screening is that you need to be prepared to provide follow-up care after a positive screening,” he explained.
Study limitations include the fact that the subjects were recruited from a single health care system that serves mostly urban and low-income communities, and that the study was not designed to determine test accuracy.
Dr. Kemper and Dr. Curran indicated that they have no financial disclosures.