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Assessment, Referral, and Treatment of Suicidal Adolescents

February 4, 2013 Comments off

Assessment, Referral, and Treatment of Suicidal Adolescents

Source: Pediatric Annals

Suicide is the third leading cause of death among adolescents.1 Most youth who complete a suicide never came into contact with a mental health professional prior to their death by suicide. Pediatricians are ideally suited to screen high-risk adolescents for suicide because of their position as first-line providers that are most likely to encounter a previously undiagnosed case.2

However, studies suggest that screening of distressed adolescents is underutilized in the primary care setting. By one account, only 23% of providers routinely screened for suicide risk factors.3 Barriers to screening include a shortage of time and discomfort about adequately assessing suicide risk. A lack of mental health resources, including adequate numbers of child and adolescent psychiatrists across the nation, have led to the development of collaborative models of care to assist primary care providers in treating psychiatric disorders. Initial studies on these models indicate they lead to more frequent screening for mental health disorders.4

Education of medical professionals has had promising results in reducing suicide rates.5 An understanding of risk factors, protective factors, interviewing, and safety planning for a suicidal adolescent is essential for preparing general pediatric practitioners to address this important public health issue.

In 2009, there were 4,371 completed suicides in the United States in the age group 15 to 24 years, making it the third leading cause of death in this population.1 As many as 62% of patients younger than the age of 35 years who died by suicide had been in contact with a primary care provider in the year before their death; 23% of them were seen by a primary care provider in the month before their death.2 It is estimated that there are between 100 and 200 attempts for each completed suicide.6

The annual physical exam is an ideal forum in which to assess high-risk youth for suicide, but most patients report they are not being screened for emotional issues.7 Discomfort around assessing suicidal risk may have worsened after the Food and Drug Administration (FDA) issued a black box warning on antidepressant use in children and adolescents in 2004, stating, “the increased risk of suicidal thoughts and behavior (‘suicidality’) in children and adolescents being treated with antidepressant medications.”8 This advisory did not recommend against using selective serotonin reuptake inhibitors (SSRIs) in adolescents, but it did recommend close follow-up after initiating an SSRI. Following this warning, the treatment of depression in adolescents with SSRIs decreased by 16% in the following 2 years. Population-based studies have demonstrated a concurrent increase of completed suicides by 18.2% following a steady decline from the mid-1990s to 2004.9

The US Preventive Services Task Force (USPSTF) states that there is insufficient evidence to recommend routine suicide screening in primary care. However, the task force suggests that pediatricians “perform routine depression screenings for adolescents aged 12 to 18 years when appropriate services are in place to ensure accurate diagnosis, treatment and follow-up care.”10 The American Academy of Child and Adolescent Psychiatry (AACAP) and the American Academy of Pediatrics (AAP) Task Force on Mental Health jointly published an article, recommending that primary care providers (PCPs) complete routine behavioral screening for adolescents, as long as appropriate mental health follow-up services were available.11

Implementing these suggestions will require further education for pediatricians on recognizing warning signs for suicide and identifying, evaluating, and treating emotional disorders.

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