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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 4
| Issue : 2 | Page : 164-173 |
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Systematic Youth Suicide Screening in a General Hospital Setting: Process and Initial Results
Andres Julio Pumariega1, Udema Millsaps2, Gerald Richardson3
1 Division of Child and Adolescent Psychiatry, University of Florida College of Medicine, Gainesville, Florida, USA
2 Department of Psychiatry, Tower Health Reading Hospital, Reading, Pennsylvania, USA
3 Department of Psychiatry, University of Florida College of Medicine, Gainesville, Florida, USA
| Date of Submission | 27-Jun-2022 |
| Date of Decision | 29-Jun-2022 |
| Date of Acceptance | 30-Jun-2022 |
| Date of Web Publication | 22-Aug-2022 |
Correspondence Address:
Andres Julio Pumariega
Division of Child and Adolescent Psychiatry UF Health Springhill 2, 8491 N.W. 39th Avenue, Gainesville32606, FL
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_15_22
Objectives: Adolescent suicide rates have been rising since 1999, and efforts to identify youth at risk with systematic approaches are important in secondary prevention. The Columbia Suicide Severity Rating Scale (C-SSRS) screener is a tool that has demonstrated predictive validity in identifying youth at risk of attempting suicide. Health care settings are key venues where at-risk youth can be identified effectively. Methods: A tertiary hospital in the Northeast U.S. developed a suicide risk protocol, consisting of systematic screening of patients for suicidal ideation/behavior with a screening version of the C-SSRS and a response algorithm based on risk levels derived from the screen. A total of 840 nurses were trained on the C-SSRS Screener, with a response protocol addressing environmental safety and psychiatric consultation. Results: This report focuses on the screening results for adolescents (ages 12–17) within this cohort, occurring over a 11-year period. Posttraining inter-rater reliability on the C-SSRS Screener definitions of ideation and behavior were high and independent of level of education or mental health experience. Of 6126 patients screened in this age group, 9.6% were in the highest risk category, as compared to 0.93% of adults during a 12-month period. Middle adolescents, females, African American and Latino patients, patients with psychiatric diagnoses, and patients with some medical diagnoses were at significant risk. Conclusions: These findings suggest that a systematic screening and clinical response protocol using the C-SSRS screener can potentially enhance the ability to identify suicide risk in the adolescent population in medical surgical hospitals and can focus services on patients with the most need.
Keywords: Adolescents, screening, suicide
How to cite this article:
Pumariega AJ, Millsaps U, Richardson G. Systematic Youth Suicide Screening in a General Hospital Setting: Process and Initial Results. World Soc Psychiatry 2022;4:164-73 |
| Introduction | |  |
Suicide is the fourth leading cause of death among 15–29-year-olds globally.[1] Among youth ages 10–24 in the United States, 6807 suicides occurred in 2018, being the second leading cause of death after unintentional injuries.(36,658) Suicide accounted for approximately 33.9% of injury-related deaths among this age group. During 2009–2018, suicide rates among youths aged 14–18 years increased from 6.0 to 9.7/100,000 population. During 2018, per data from a nationally representative sample of EDs, approx. 95,000 youths aged 14–18 years visited EDs for self-harm injuries.[2] Conventionally, 3 of 4 teen suicide attempters are female and 4 of 5 suicide completers are male, but male-to-female ratios are trending to equalization recently. Suicide among African American male youth and Latina youth significantly increased from 1980 to present,[3] and Lesbian, Gay, Bisexual, and Transgendered (LBTQ) youth seriously considered suicide or attempted at 2–3 times the rate of cisgendered straight youth with 45% seriously considering attempting suicide in the past year.[4] More teens die from suicide than from AIDS, cancer, heart disease, birth defects, stroke, and multiple other illnesses combined.[1] Youth suicidality has been increasing at an even higher rate during the COVID pandemic, with some healthcare institutions reporting increases of over 50% in suicide-related emergency department visits.[5],[6]
Conventionally, youth suicide prevention efforts have been focused in school settings, and many systematic screening programs have been associated with such prevention programs.[7],[8],[9] However, suicide screening in schools has been more challenging in recent years due to the burdens of obtaining parental consent, and pressures from more conservative parents and governments that are hesitant about public health approaches to youth mental health. There has been more emphasis on suicide screening in medical settings such as emergency departments, where higher risk youth present for treatment,[10],[11] with youth finding such screening not only acceptable but also to be expected.[11] Some attention has also been focused on primary care suicide screening for youth,[12] especially given that many patients are seen in primary settings shortly before dying from suicide, including as many as 90% of adolescents.[13]
There are certainly pros and cons to the systematic screening of youth for suicidality. There are many challenges associated with such efforts, including the workforce and logistical burdens of screening on the setting (hospitals, medical offices, schools, etc.), especially the burdens of response and finding mental health resources to address the needs of youth at imminent risk. There are problems in maintaining fidelity to the administration of screening tools and in providing training to staff in these settings. Screening tools also have a significant respondent burden as well as varying levels of sensitivity, specificity, and predictive validity, so there is always risk of over-or under-identifying (with good screeners typically sacrificing sensitivity for specificity to minimize false negatives and under-identification). There are also operative myths about screening for high-risk behavioral scenarios such as suicidality, such as that identification increases liability or that bringing up suicidality to a vulnerable youth actually increases risk (all findings suggest the opposite). On the other hand, we have the obvious benefits from systematic screening, such as the use of consistent definitions and terminology to identify youth at risk, the prevention of high morbidity and mortality outcomes, and the focus of services for those at highest risk.
As suicide in general and youth suicide in particular has been recognized as a major public health problem, the implementation of systematic suicide screening has been recommended in major policy documents around mental health and suicide prevention. The World Health Organization (WHO), in its Mental Health Action Plan[14] recommends that nations develop and implement comprehensive national strategies for the prevention of suicide (including screening), with special attention to groups identified as at increased risk of suicide, including lesbian, gay, bisexual, and transgender persons, youth and other vulnerable groups of all ages based on local context. In the US, the National Suicide Prevention Strategy[15] recommended efforts to educate public on suicide prevention, making hotline and crisis service resources available, and promoting screening, identification, and referral/treatment. Furthermore in the U.S., The Joint Commission, the major accrediting body for healthcare organizations, include suicide prevention in its National Patient Safety Goals (NPSG January 15, 2001),[16],[17],[18] which calls for healthcare organizations to find out which patients are most likely to try to commit suicide, promotion of suicide screening in health care, and at minimum screening in high risk groups, with a goal to screen in all medical populations.
Suicide screening and triage response program at a North-east U.S. Hospital
In response to the TJC National Patient Safety Goal on Suicide Risk,[16],[17],[18] the Department of Nursing at a Northeastern U.S. Hospital (NEUSH) began a process of identifying an optimal screening tool to be used hospital-wide, and an interdisciplinary team identified the Columbia Suicide Severity Rating Scale (C-SSRS) as an evidence-based best practice that should be implemented in the institution.
The original C-SSRS was developed in conjunction with the U.S. Food and Drug Administration study of the risk for suicidality in youth prescribed antidepressants. Posner et al., the lead investigator in this effort, determined that a prospective measure for suicide risk would be far more valid (for epidemiological purposes) and efficacious (in assisting in suicide prevention). Posner et al.[19] developed the C-SSRS, a measure that rated severity of ideation, presence and severity of suicidal behavior, and intensity of suicidal ideation. Posner et al.[20] demonstrated that C-SSRS lifetime ideation at baseline, at the highest levels (4 or 5, plan or intent) demonstrated prospective (predictive) correlation with suicide attempts in adolescent suicide attempters for the following year. They found that patients with baseline prior ideation of 4 or 5 or prior suicidal behavior are 4–5 × more likely to report suicidal behavior at follow-up than patients with negative baseline report, and patients with both are 8 more likely to report suicidal behavior.
In consultation with Dr. Kelly Posner and her team at Columbia University, a briefer 6 item C-SSRS Screener was developed with a lower time burden than the full C-SSRS [2–3 min; [Figure 1]]. A significant infrastructure was developed to implement the suicide screening process at NEUSH, including updated policies and procedures, for maintenance of patient safety, a clinical response protocol for patients screening positive at different levels of risk, an electronic version of the C-SSRS Screener inserted in the electronic nursing record for administration by the primary nurse (embedded in the initial nursing assessment for all admissions), and a systematic education process for all nurses and consultation psychiatrists (C-SSRS Screener, full C-SSRS and the clinical protocol). The clinical response protocol was consistent with the predictive findings regarding ideation severity of 4 and 5 and suicidal behavior predicting short-term risk of suicidal behavior.
Triage responses with corresponding action steps were developed for the five levels of risk and presence of suicidal behaviors.(1) No action taken– Individuals who report no recent (past week, 1 week–1 year) or lifetime (over a year ago) suicidal behavior and no suicidal ideation (Risk Level 0).(2) Mental Health Self-Referral-Individuals at risk Levels 1 or 2 (positive for items 1 and/or 2, and/or having any lifetime suicidal behavior over 1 year prior) were recommended to self-refer to a mental health professional, with recommendation entered in their discharge planning instructions and into a progress note notifying their attending physician and provided a list of mental health resources and a crisis hotline number.(3) Care Team Consult-Individuals with an ideation consistent with item 3, and/or positive for any recent (between a week and a year ago only) suicidal behavior on item 6 received consultation from a psychiatric nurse, who reviewed the patient's history and observed behavior, briefly interviewed the patient, re-rated the C-SSRS Screener, and triaged the response either up to a psychiatric consultation (4) or down to an outpatient self-referral.(2) (Risk Level 3).(4) Psychiatric Consultation-Individuals with an ideation severity positive for questions 4 and/or 5, and/or who had any recent suicidal behavior (within the past week) on item 6 were automatically recommended for a psychiatric consult. The attending physician was notified both on a progress note and by a page from nurses. (Risk Level 4/5). If a psychiatric consult is ordered or a psychiatric nursing Care Team consult is pursued, the consultant probes into lifetime suicidal ideation and other indicators of suicidal risk using the full C-SSRS to decide patient disposition.
Patients rated at Risk Levels 3 through 5 were placed on an environmental safety precaution protocol. This protocol included patient placement in a private room with a discrete identifier for suicide risk monitoring for anyone entering the room, receiving a “safe” dietary tray (either plastic utensils or finger foods), and a patient safety monitor assigned to sit within arm's length of the patient at all times. The room was safety-proofed by removing all potentially hazardous objects, including unnecessary furniture, tubing, cords, bags, and any liquids potentially harmful if ingested. The electronic health record automatically scored the C-SSRS Screener and followed the algorithm outlined in [Figure 1] to generate an appropriate recommendation.
The C-SSRS Screener could be deferred until the patient is medically stable and cognitively able to answer questions. Conditions necessitating deferral included confusion/delirium, sedation/confusion from medication overdose or anesthesia/recovery, and temporary communication barriers, but if a patient demonstrated irreversible conditions (IQ <50, permanent communication barriers from neurological or cognitive impairment), the screening is waived.
Evaluation aims
The goal of this study of the program was to determine the feasibility of the C-SSRS Screener and response protocol in a hospital setting. The primary aims were as follows:
- To evaluate the inter-rater agreement on the C-SSRS Screener in a large heterogeneous sample of trained nurse raters
- To determine the feasibility of systematic suicide screening for adolescents in a general hospital
- To determine the demographic and clinical (psychiatric and medical) characteristics of the adolescent patient population as they relate to high risk for suicidality (as characteristic of a typical medical-surgical hospital).
| Methods | | |
Participants
Raters
A total of 837 nurses and student nurses (93% female) were educated on the C-SSRS Screener. The education level ranged from a high school diploma to a doctorate. Staff members' years of nursing experience ranged from <1 to 43 years, with a mean of 11 and a median of 6 years. One hundred twenty-eight had some mental health specialty training, while 161 had previously received training to evaluate suicidal risk. Additional participants in C-SSRS Screener training included all consultation psychiatrists and psychiatric nursing Care Team consultants.
Patients
A total of 6126 patients ages 12–17 years of age or older admitted at NEUSH between October 2010 and June 2020 were screened.
Missing data from this analysis
The C-SSRS screening version was administered from July 1, 2012, to January 31, 2013, but the resulting level data was lost because it was not imported from the old electronic health system to the new electronic health system (from Clin Doc©, to Epic©) or downloaded prior to the new EMR starting on February 2, 2013.
Measures
Suicidal ideation and behavior
The C-SSRS Screener included the Suicide Ideation subscale from the original C-SSRS and one composite Suicide Behavior item [previous description and [Figure 2]. The C-SSRS Screener was administered at admission or deferred until the patient was able to respond.
Primary diagnoses
The ICD-10 primary diagnoses for each youth, whether psychiatric or medical, was categorized under broad categories, with some combination of related organ systems. These included the following: Medical Diagnoses-Gastrointestinal and abdomen, neurological, cardio-respiratory, ENT/ophthalmological/dental, orthopedic/musculoskeletal/rheumatological, infections/autoimmune/allergy, women's health (ob/gyn and breast), head injury, poisoning, endocrine/metabolic, laceration/trauma, and dermatological/soft tissue/nail.
Psychiatric Diagnoses-mood disorders, suicide attempt/ideation/self-harm, anxiety and related disorders, disruptive and related disorders, psychosis and related disorders, substance abuse, and other psychiatric disorders.
Data management and analysis
Data was downloaded on a monthly basis from the NEUSH electronic health record system and used to evaluate:
- Demographic characteristics (age, gender, race/ethnicity) across the patients assigned to the 5 risk levels of the C-SSRS Screener, using Chi-square analyses
- Presence of various psychiatric (7) and medical (12) diagnostic categories across the patients assigned to the 5 risk levels of the C-SSRS Screener, using Chi-square analyses
- Relative significance of the above independent variables using logistic regression analysis.
In addition to the above analyses, intra-class correlations[21] were used to test posttraining inter-rater reliability of suicidal behavior and ideation definitions on the C-SSRS using the brief clinical case vignettes used in training. Chi-square analysis was also performed to test correlations between the response accuracy to each of the 14 hypothetical training case vignettes and years of experience and education level of trainees.
Human subjects review
The evaluation of this clinical protocol was approved by the Institutional Review Board of this NEUSH, which granted a waiver of written informed consent as well as a waiver of authorization under the Health Information Portability and Accountability Act. All data collected from medical records were de-identified and aggregated to prevent the identification of any individual patients.
| Results | | |
Pumariega et al.[22] previously reported the results of inter-rater agreement analyses of all nurses trained at NEUSH using 14 hypothetical brief case vignettes where multiple choice questions were used as posttest on raters' training on the C-SSRS. A total of 840 nurses were trained on the administration and rating of the brief C-SSRS and the overall suicide response protocol. There were no significant differences in inter-rater agreement/reliability based on gender, level of education, years of experience, prior mental health training, and prior suicide assessment training [Table 1]. They also reported on the results of screening on 26,747 patients 18 years of age or over (13,548 females and 13,199 males) screened from July 1, 2010, to June 30, 2011. They found significant correlations to the C-SSRS screener ratings by gender (female; Chi-square = 36.857, P < 0.000), race/ethnicity (minority, Chi-square = 107.611, P < 0.001) and Latino status (Chi-square = 33.818, P < 0.000). They found a total of 89 patients rated at Level 3 and 161 at Levels 4 or 5 using the C-SSRS screener: Rating only 0.93% (250/26747) of admissions as needing any type of consult. There was a high correlation of C-SSRS screener to the full C-SSRS scores when both were performed.
By comparison, the number of youth screened was smaller due to there being a relatively small number of pediatric beds at NEUSH. However, youth screened were found to be at a significantly higher risk for suicidality over adults hospitalized in the same institution, with an overall percent of 9.6% rating at Risk Level 4/5 (vs. adults-Chi-square = 36.489, P < 0.0000). Risk level increased from ages 12–16, with a small decrease at age 17 [Table 2]. Adolescent females (12.6% at Risk Level 4/5) had significantly higher risk levels than males [5.8% at Risk Level 4/5; [Table 3]]. There was a significant difference among the different race/ethnicity categories, with Blacks/African Americans and White/Caucasians having a higher percent Level 4/5 than Others (which were largely Latino/Hispanic but were not accurately categorized by the electronic health record system) [Table 4]. | Table 4: Adolescent Admissions: C-SSRS Score Distribution by Race/Ethnicity
Click here to view |
The correlations to psychiatric diagnoses to suicide risk level rated by the C-SSRS screener were also significant. The highest category was Suicide Attempt/Ideation/Self Harm, consistent with both the results on the screener as well as the many admissions for suicide attempts to medical-surgical beds. However, all other psychiatric diagnostic categories had a significant higher percent of Level 4/5 than the baseline for the overall population [Table 5]. The correlations to medical diagnoses were also significant, but all lower percentages of Level 4/5 high risk than the baseline except for Poisoning and Lacerations and Trauma (as might be expected given suicide attempts). However, patients with Gastrointestinal, Neurological, and Dermatological/Soft Tissue diagnoses had significant percentages for Level 4/5 high risk when compared to adult admissions [[Table 6] and Pumariega et al.[22]]. | Table 5: Adolescent Admissions: Psychiatric Diagnostic Category vs CSSRS Score Distribution
Click here to view |
We examined the trend of suicide risk ratings year over year during the period covered by our data (2010–2020). The percentages of Level 4/5 risk were relatively lower in the years 2010 through 2012, with a significant increase in 2013 that continued through 2019, with a dip during the first 6 months of 2020. This pattern is consistent with the rise in youth suicidality seen during the latter 2010s, with the decrease in the first 6 months of 2020 coinciding with the first 6 months of the COVID pandemic lockdowns. The data did not capture the period of time when major increases in youth suicidality were reported as the pandemic progressed [Table 7].[5],[6] | Table 7: Columbia Suicide Severity Rating Scale screening results by calendar year (percent level 4/5 highlighted)
Click here to view |
[Table 8] presents a logistic regression analysis that was performed examining the relative risk presented by the different independent variables (age, gender, race/ethnicity, psychiatric diagnosis vs. medical diagnosis). All independent variables were statistically significant, slightly less for race/ethnicity. The model predicted 15.6% of the variance (Nagelkerke R2).
| Discussion | | |
The results of this study support the premise that youth suicide screening in hospital settings is feasible and high yield. It is both important for prevention and for diagnostic validation, as in the case of youth who present to hospitals or emergency rooms under suspicious medical circumstances, or in determining the severity of identified psychiatric disorders. It also places psychiatric needs on par with medical needs, while it triages resources where needed most. Suicide screening with a tool that differentiates severity of risk helps to focus psychiatric consultation/assessment in the hospital setting on those most at risk for future attempts, while youth at moderate risk are referred to outpatient resources with some degree of confidence. Pumariega et al.[22] also reported on data that demonstrated suicide risk screening led to the reduction of patient safety monitor (1:1) utilization, focusing this limited resource on those at highest risk for suicide attempts. Suicide risk screening also involves minimal resource investment, to operationalize with fidelity and consistency, particularly with the use of electronic clinical records that support administration, scoring, and algorithmic response along with staff training. In fact, suicide screening augments the effectiveness of limited mental health resource by recruiting general medical professionals in this important endeavor.
Our results also support the significance of suicide risk for certain populations, such as younger teens, young women, minority populations, youth with psychiatric disorders, and youth with certain medical conditions. The identification of these populations adds further external/concurrent validity to screening results. It also provides valuable data for services planning for busy medical centers where increasing number of youth are taken at times of crisis.
There are limitations inherent in youth suicide screening as well as in this study itself. Screening results are largely dependent on patient self-report and transparency, though some studies support this is expected in most youth.[11],[12] There are also some small number of youth who refuse or are unable to participate due to their medical condition as pointed out in the data tables. There is also some risk of inconsistent administration of the screening instrument by primary nurses, though the investment in training staff was geared to maximize fidelity and to help nurses feel comfortable and confident in asking questions about this sensitive topic.
| Conclusions: Future of Youth Suicide Screening | | |
Suicide screening with youth is certainly an important tool to address the current epidemic of youth suicidality. The last report of the U. S. Preventive Services Task Force in 2013[23] indicated the evidence at that time to be insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in a primary care setting. However, there has been much work on youth suicide screening since that time in medical settings, including psychiatric, emergency departments, hospital, and primary care settings that may alter this conclusion. The C-SSRS screener is in broad use nationally and internationally in both adult and adolescent populations.[24] The National Network of Depression Centers in the U.S. has embarked on an initiative advocating for systematic suicide screening in ambulatory psychiatric settings, combining the C-SSRS screener with other mental health screening tools, especially for new visits to alert for high-risk patients. This can usher in an additional use for such screening, focused on population management and using screening and electronic health records to focus resources on the most high-risk youth even within mental health settings. The Columbia Lighthouse Project is even advocating for a more grass roots use for the C-SSRS, by youth who are concerned about peers, now including a Community Card version of the screener that can guide youth to rate their friends.
As pointed out by WHO,[1] suicide screening is an important part of prevention, but efforts to implement systematic screening are embryonic in most nations. However, the Columbia Lighthouse Project, which develops and promotes the C-SSRS screener, has taken the initiative to translate the instrument to many languages. So far they have established linguistic translations and validations with content and criterion validity in 82 languages for use with children and youth,[24] with at least two international studies[25],[26] so far evaluating translations clinically (in Spanish and Turkish). Much more cross-national work om clinical implementation of suicide screening is needed. However, a challenge inherent in this work is to adapt the instrument for differences in affective temperaments, especially the frequency of their presentation in dominant form, which have been shown to have cultural and geographical characteristics and relationship to patterns of prevalence of affective illness.[27] This calls for cross-cultural research that takes such differences in affective temperaments into account when evaluating suicide risk.[28]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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