The United States Preventive Services Task Force (USPSTF) has found evidence to support screening for anxiety in youth aged 8 to 18 and for depression in adolescents aged 12 to 18 but viewed the extant data as inadequate to definitively evaluate the benefits and risks of screening for suicidal risk in youth.1 We agree with the USPSTF recommendations regarding anxiety and depression but believe a stronger case can be made for universal screening for suicidal risk in adolescents in clinical settings. The authors of these reports are to be commended for their painstaking work in synthesizing and translating a tremendous amount of information into concrete recommendations. Herein, we will discuss our rationale for disagreeing with the USPSTF’s conclusion that there are insufficient data either for or against screening for suicidal risk in adolescents.
In contrast to the USPSTF’s stance on screening for suicidal risk in adolescents, the American Academy of Pediatrics and the AFSP, in collaboration with the National Institute of Mental Health, recently published the Blueprint for Youth Suicide Prevention, which outlines strategies to assist pediatric health clinicians in the identification and care for suicidal youth.2 A key recommendation of the Blueprint calls for universal screening for suicide risk in youth ages 12 years and older in clinical settings, including primary care. The Blueprint’s recommendations, based on the extant scientific literature, are aimed to address the public health emergency of rising adolescent suicide and suicide attempt rates, which have increased particularly sharply in Black youth.3 To delay action until the studies suggested by the USPSTF can be conducted will defer addressing the second-leading cause of death in this age group by another decade. Part of the reason for a divergence of opinion between the USPSTF and that articulated in this Blueprint is attributable to the USPSTF’s systematic review methodology, which led to the exclusion of key studies that support the accuracy of instruments designed to screen adolescents for suicidal risk. Although the USPSTF concludes that there are no validated measures of suicidal risk in adolescents and that both the potential harm and benefit from screening adolescents for suicidal risk are unknown, we cite evidence to the contrary.
1. There Are Validated Measures of Suicidal Risk
Both the Ask Suicide-Screening Questions and the CASSY have been shown to accurately predict subsequent suicidal behavior and return to emergency departments for suicide-related presentations in adolescents;4,5 time to administer these measures is brief: roughly 20 seconds on average for the Ask Suicide-Screening Questions6 and 80 seconds for the CASSY.5 The USPSTF’s inclusion criteria for studies of screening instruments required “the screener to be compared with an assessment of increased suicide risk on the basis of an interview by a qualified professional.” This requirement is inconsistent with the scientific literature, which has consistently revealed that expert clinician predictions of suicidal behavior are not much more accurate than chance.7 The use of this criterion resulted in the exclusion of studies of the above-noted screening tools that included >20 000 youth participants8 and used more stringent standards for assessing validity, namely, accuracy in predicting returns to the emergency department (ED) for suicide-related reasons as verified by medical record review or future suicide attempts as assessed by follow-up clinical interviews.5
2. There Are No Iatrogenic Effects Due to Screening for Suicidal Risk
The USPSTF stated that the risks of screening for suicide risk in youth are unknown. However, a meta-analysis across 13 studies, including 4 studies involving a total of 2915 adolescents documented that inquiry about suicidal risk does not increase participants’ risk for suicidal behavior or psychological distress.9
3. Screening for Depression Can Also Identify Youth at Risk for Suicide
The USPSTF supports screening adolescents for depression with instruments like the Patient Health Questionnaire adapted for adolescents, which includes 1 item (Item 9) about the recent frequency of thoughts of death or self-harm. Therefore, if clinicians implement USPSTF recommendations for screening for depression, they are already implicitly recommending screening for suicidal risk, because those with more frequent thoughts of death or self-harm as reported in Item 9 are at higher risk for suicidal behavior.10 However, more than one-third of those who attempt suicide within a month of Patient Health Questionnaire screening deny thoughts of death or self-harm.10 Screening tools specifically validated for suicide risk screening can identify at-risk youth more accurately than depression screening alone.11
4. Universal Screening of Youth for Suicidal Risk Can Be Beneficial
First, screening for suicidal risk in clinical settings, such as primary care and EDs, can identify patients at high suicidal risk who would otherwise be missed because they do not present with behavioral health concerns.4,8,11 Second, although the USPSTF is concerned about the “burden of false positives,” most adolescents who screen positive for suicidal ideation or behavior have at least 1 lifetime mental health disorder and would, therefore, benefit from a mental health referral.12 Third, there is evidence from studies of suicidal adult ED attendees that screening plus linkage to mental health care can protect against subsequent suicidal behavior compared with usual care.13
Other Types of Research That May Be Informative
In the era of learning health care systems, it should be possible to ascertain the benefits and risks of the implementation of suicide-risk screening by monitoring the impact of screening on an ongoing basis. Methods complementary to self-report screening, such as machine learning algorithms derived from electronic health records have been shown to improve the prediction of future suicide attempts above and beyond self-report alone.7,8 Developing and testing such alternatives may be particularly critical in identifying those individuals who screen negative for suicidal risk, but then go on to make a suicide attempt or die by suicide. Because suicidal ideation may be a less-frequent precursor of suicide attempts in Black youth than among white youth, complementary assessment approaches to self-report may be particularly salient for reversing the disturbing secular trends in suicidal behavior among Black youth.3 Although less well-studied, data obtained from mobile sensing and social media hold promise for the identification of real-time temporal inflections of suicidal risk that may aid in preventing adolescent suicidal behavior, which is often impulsive.
Conclusions and Recommendations
In summary, it is our studied opinion that (1) screening for suicidal risk can identify youth who might otherwise be missed, (2) those who screen positive for suicidal risk will benefit from mental health evaluation and referral, (3) risks associated with screening are minimal, and (4) there are promising interventions to prevent the occurrence of suicidal behavior postscreening. We agree with the USPSTF’s recommendation for further research to assess the benefits and risks of screening for suicidal risk, which we believe should be augmented by research about the potential utility of alternative means of risk stratification to complement self-report. Finally, screening youth for suicidal risk will be most impactful if paired with a brief intervention that develops a safety plan, links the suicidal patient to the appropriate mental health services, and is implemented in all clinical settings. The USPSTF’s recommendations for screening for anxiety and depression have the potential to improve the quality of life of American youth who are now experiencing an unprecedented surge in mental health needs. Adding a brief universal screen for suicidal risk to these 2 important recommendations can help clinicians and health systems address the national imperative of reducing the morbidity and mortality of adolescent suicidal behavior with the tools we have now.
Drs Bridge and Brent drafted the initial manuscript and critically reviewed and revised the manuscript; Dr Birmaher critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: This article was supported by a grant from National Institutes of Mental Health (NIMH), “The Center for Accelerating Suicide Prevention in Real-world Settings (ASPIRES)” (P50MH127476, Dr Bridge) and NIMH grant, “The Center for Enhancing Triage and Utilization for Depression and Emergent Suicidality (ETUDES) in Pediatric Primary Care” (P50MH115838; Dr Brent). The funders had no role in the writing or review of the manuscript.
CONFLICT OF INTEREST DISCLOSURES: Dr Bridge receives research grant funding from the National Institute of Mental Health (NIMH), the Centers for Disease Control and Prevention (CDC), and the Patient-Centered Outcomes Research Institute (PCORI); he is a member of the Scientific Advisory Board of Clarigent Health and a scientific board member of the American Foundation for Suicide Prevention (AFSP). Dr Birmaher receives research support from NIMH and royalties for book chapters. Dr Brent receives research support from NIMH, AFSP, the Once Upon a Time Foundation, and The Beckwith Institute, receives royalties from Guilford Press, from the electronic self-rated version of the C-SSRS from eRT, Inc, and from performing duties as an UptoDate Psychiatry Section Editor, receives consulting fees from Healthwise, receives Honoraria from the Klingenstein Third Generation Foundation for scientific board membership and grant reviews, and is a scientific board member for AFSP. Intellectual Property, currently with no financial interest: funding from NIMH supported the development of intellectual property for BRITE, the As Safe As Possible intervention, the Computerized Adaptive Screen for Suicidal Youth (CASSY) measure, a suicide risk machine learning algorithm, and the Screening Wizard screening tool.
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