TOPIC 42: Suicide Risk – Understand Screening, Evaluation, and Management of Suicide Risk
OFFICIAL ABP TOPIC:
Understand screening, evaluation, and management of suicide risk
BACKGROUND
Suicide is the second leading cause of death for 10- to 24-year-olds. Rates of suicidal ideation (SI) and attempts have risen in recent years, particularly among female adolescents, LGBTQ+ youth, and racial minority groups. Pediatricians play a critical role in screening for SI and intervening to mitigate suicide risk.
SUICIDE RISK FACTORS AND PROTECTIVE FACTORS
|
Category |
Risk Factors |
Protective Factors |
|
Individual |
Depression, anxiety, bipolar disorder, substance use, nonsuicidal self-injury, prior attempts, neurodevelopmental disorders |
Self-esteem, effective coping skills, cultural/religious beliefs discouraging suicide |
|
Relationship |
Adverse childhood experiences (e.g., abuse, neglect), family history of suicide, bullying/cyberbullying |
Supportive relationships with family and peers |
|
Community/Societal |
Suicide clusters, structural racism, acculturation stress, rural settings |
Community, family, and cultural connectedness |
|
Lifestyle Factors |
Poor sleep, sedentary behavior, excessive screen time |
Adequate sleep, physical activity, improved diet |
SUICIDE RISK SCREENING AND EVALUATION
The AAP recommends screening all youth aged 12+ annually for suicide risk. Adolescents should also be screened in higher-risk situations (e.g., mental health concerns, ED visits).
VALIDATED SCREENING TOOLS
|
Tool |
Purpose |
Strengths |
Limitations |
|
Ask Suicide Screening Questions (ASQ) |
Screens for SI in pediatric settings |
Brief, validated in ED/primary care |
May miss long-term SI; limited to recent weeks |
|
PHQ-9 |
Screens for depression, incl. suicide |
Widely used for depression |
Not validated for suicide risk alone |
If a screen is positive, conduct a brief suicide safety assessment either through open-ended conversation or tools such as the Columbia Suicide Severity Rating Scale (C-SSRS) or the ASQ Brief Suicide Safety Assessment. The assessment should address:
- Frequency and severity of suicidal ideation.
- Presence of a plan or access to lethal means.
- Protective factors and support systems.
Most youth with SI, plans, or suicide attempts also have preexisting mental health disorders, most commonly depression. A thorough history should include assessment for the following:
|
CONDITION |
DISTINGUISHING FEATURES |
KEY TESTS/EVALUATIONS |
|
Major Depression |
Depressed mood, lack of energy, feelings of worthlessness |
PHQ-9 or clinical interview |
|
Generalized Anxiety Disorder |
Excessive worry, restlessness, difficulty concentrating, sleep disturbance |
Anxiety screening tools, thorough history |
|
Substance Use Disorder |
Recent substance use, impaired judgment |
Substance use history, toxicology screens |
Nonsuicidal self-injury is a risk factor for suicidal behavior, but it should be distinguished from suicidal ideation or plans for suicide.
MANAGEMENT OF SUICIDE RISK
Immediate Safety
Evaluate for suicidal thoughts, abuse/neglect, and risky behaviors through a suicide safety assessment.
- Anyone at imminent risk of suicide (current suicidal intent or plan or positive answer to ASQ question #5: “Are you having thoughts of killing yourself now?”) requires an immediate safety/mental health evaluation and possible hospitalization.
- For patients at moderate risk of suicide, the pediatrician should provide an urgent mental health referral, safety planning, and close follow-up.
Safety Planning
Create a personalized plan with coping strategies, emergency contacts, and methods to limit access to lethal means (e.g., firearms or other weapons, medications, illicit substances). Encourage healthy lifestyle choices, including regular physical activity, balanced diets, and maintaining sleep hygiene, as part of routine preventive counseling.
Psychotherapy
Cognitive behavioral therapy and dialectical behavioral therapy have both been shown to be effective in suicide prevention. Address any mental health disorders such as depression and anxiety with psychotherapy and medications if indicated.
Family Engagement
Involve families in safety planning and provide psychoeducation. Family-based approaches like attachment-based family therapy can strengthen relationships and reduce suicide risk. School-based programs like Sources of Strength and Signs of Suicide have been shown to significantly reduce suicide attempts and improve protective factors. Encourage families to explore such programs where available.