Upstream Prevention Strategies to Prevent Suicidal Ideation-Related ED Visits

In 2020, 23% of all youth deaths aged 5 to 19 in the United States were by suicide, a preventable cause of death.¹  Youth emergency department (ED) visits for suicidal ideation (SI) represent a critical benchmark for youth mental health. In this issue of Pediatrics, Brewer et al present new findings on increasing trends in SI-related ED visits for youth in Illinois, 2016 to 2021.²  The design allowed for pinpointing changes over time, including the first 14 months of the COVID-19 pandemic. Visit rates were divided into 22-month periods. Rates during fall months were analyzed to control for temporal variations before and during the pandemic. The sharpest increase was seen in fall 2019, before the start of the pandemic, followed by an even larger spike during fall 2020. Was it the pandemic that exacerbated the increase or is this a growing trend? These rising rates underscore the worsening mental health crisis for youth, as noted by the 2022 Surgeon General report and several youth mental health organizations.^3,4 

Brewer et al examined over 80 000 ED visits coded for SI, of which 24.6% resulted in hospitalization. Youth aged 14 to 17 years had the highest increase in SI-related ED visits of any age group. Notably, 5- to 13-year-old youths had SI-related ED visit rates comparable to 18- to 19-year-old youths, who typically have higher rates. Overall, increases were higher for females. Over one-half of youth with SI-related visits were uninsured or on Medicaid and had significantly lower likelihood of hospitalization than privately-insured youth, suggesting that insurance status influences mental health care of patients at risk for suicide. The largest difference in hospitalization was for youth with a primary diagnosis of SI who were 84% less likely to be hospitalized than those presenting with serious mental illness, depression, anxiety, or substance use.

What are public health prevention measures that can make a difference in lowering ED visits for SI in youth? An influx of acute mental-health–related visits can impose burdens on patients and their families and disrupt efficient ED flow. If one-quarter of patients who visit the ED for mental health reasons are being hospitalized, interventions are needed that focus on safe transitions from inpatient hospitalization back to the community, to prevent return visits to the ED.⁵  Furthermore, ED interventions like safety planning,⁶  lethal means counseling,⁷  and family-centered interventions^8,9  might even reduce the likelihood of hospitalization. Research is needed to better understand the underlying reasons for higher hospitalizations rates on weekends. Previous studies have suggested lack of coverage and lower quality of care for higher acuity patients with weekend ED visits.^10,11 

SI-related ED visits can also be prevented through early detection and intervention in other clinical and community settings. For example, pediatricians are uniquely positioned to identify youth with SI, through universal suicide risk screening, which has been successfully implemented in pediatric primary care settings using suicide risk clinical pathways.^12–16  In February of 2022, Bright Futures announced recommendations that pediatricians screen all patients aged 12 years and above for suicide risk, in addition to screening for depression. The American Academy of Pediatrics and the American Foundation for Suicide Prevention launched the Blueprint for Youth Suicide Prevention,¹⁷  which is a roadmap for pediatric health care providers to embed suicide prevention in their practices. This online resource can guide pediatricians on best clinical practices including screening, assessment, and brief interventions. Other important examples can be seen in suicide prevention programs where youth at risk can be detected. Programs such as Youth Aware of Mental Health¹⁸  and Signs of Suicide¹⁹  have evidence-based programs that are effective in reducing SI and attempts.

Brewer et al should be commended for highlighting the growing trend in ED SI-related visits for youth. Their findings mirror increasing trends in children’s mental health ED visits nationally,²⁰  which has been exacerbated since the onset of coronavirus disease 2019.^4,21  In 1999, the Surgeon General Dr David Satcher first declared suicide a national public health problem. Since then, over 47 000 5 to 19 year olds have died by suicide. National organizations have set a goal of reducing the suicide rate by 20% by 2025.²²  However, achieving rapid reductions in the youth suicide rate will require broad implementation of the most promising preventative strategies delivered in real-world clinical and community settings in which at-risk youth are served.²³  These strategies must prioritize underserved or understudied youth at highest risk (eg, minoritized youth, LGBTQ+ youth; those in the child welfare system or the juvenile justice system, and those living in rural areas).

Universal suicide risk screening in pediatric primary care^12,15  and school-based suicide prevention programs^18,19  can identify youth at risk often before it becomes an emergency. For patients who do visit the ED, giving them tools like safety planning⁶  and family-based interventions^8,9  may help reduce suicide risk, return visits and allow for safe discharge to home. The Brewer et al data must continue to be a call to action; through upstream interventions,²⁴  health care systems and schools can be leveraged to reduce youth suicide.

ED

emergency department

SI

suicidal ideation