Understanding Limitations of Suicide Risk Identification Practices in Healthcare

Suicide is currently the second leading cause of death among youth and young adults ages 10-24. Despite decades of research, suicide attempt rates continue to rise across the U.S., particularly among young people, underscoring the urgency for increased prevention. People who die by suicide often see a healthcare provider prior to their death, most in the prior year, and about half within a month prior to their death, including young people. Identifying patients with elevated suicide risk in healthcare settings via screening has become increasingly common and is aligned with recommendations for suicide risk screening put forth by the American Academy of Pediatrics, the American Foundation for Suicide Prevention, and the American Academy of Child and Adolescent Psychiatry. Moreover, screening followed by risk assessment and safety planning has recently demonstrated effectiveness for preventing suicide attempts in population-based studies among patients receiving mental health specialty and primary care.

Suicide risk screening is a key function of high-quality suicide care defined by the Zero Suicide framework. However, recent research found that in a sample of adolescents (ages 13-17) who had attempted or died by suicide, about a third had not reported suicide risk on the in 30-90 days prior to their death. Our team’s prior qualitative research with adult suicide attempt survivors indicated that some patients at risk for suicide may not report their suicide risk on a healthcare screener for a multitude of reasons, such as fears of stigma and coercive care, not having suicidal thoughts at the time of the screening, and not wanting to burden their providers. Adults have also described how self-reporting suicidal thoughts involves weighing the desire for help against fears of stigma, vulnerability and loss of autonomy. A recent study among youth receiving therapy, underscored concerns about confidentiality as the most common reason for non-disclosure. Additionally, our team’s recent quality improvement research indicates teens may experience a broad range of emotions (e.g. self-conscious, happy, stressed, overwhelmed) when asked about suicidal thoughts.

Understanding how to improve existing suicide risk identification practices is critical for improving engagement of adolescents and their caregivers in supportive healthcare that can effectively prevent adolescent suicide attempts and death. Therefore, the objective of this proposal is to use qualitative methods to improve our understanding of limitations of suicide risk screening among children and teens via phenomenological and child-centered anthropological approaches.

Specific Aim: To conduct qualitative analysis of semi-structured interviews (target N=100) with dyads (N=50) of parent/guardians and their children and teens (aged 10-17) who made a suicide attempt after a healthcare encounter during which they reported having no suicidal thoughts on a standard suicide risk screening tool.

The project team will leverage a partnership between multi-disciplinary teams at Kaiser Permanente Washington and Johns Hopkins, learning health systems that serve socio-demographically diverse populations of children and teens across service settings. This research will inform national recommendations for improving suicide risk screening among children and teens.