FAQ: Youth Suicide Prevention in Primary Care

Yes. Zero Suicide has created a document to assist: Suicide Care Pathway Coding for Primary and Behavioral Health Care.

We recommend screening patients for suicide risk at every visit due to the fluid nature of youth suicidality and impulsivity. We understand this is a high benchmark. We work with clinics to meet them where they are with the eventual goal of screening at all visits or as many visits as possible.

We recommend using a suicide-specific screening instead of taking a stepped approach to screening with an initial depression screening. Suicidal thoughts and behaviors often occur outside of depressive symptoms/disorders.

We encourage suicide-specific screening tools as suicidal thoughts and behaviors can occur outside of depressive symptoms/disorders. Review this comparison of common screening tools.

PCMH encourages clinics to adopt validated suicide-specific screening tools. Thus, we universally recommend use of the asQ to screen for suicide. The PHQ-A contains non-validated suicide screening questions. However, we understand that quality improvement projects start in different places for different clinics. If your clinic would like to initially implement the Youth Suicide Prevention Care Pathway with a non-validated suicide screening tool with the potential to later move to a validated tool, we can support your implementation plan.

• Suicide screenings are standardized protocols used to identify individuals who may be at risk for suicide. Suicide screening tools are typically brief and narrow questionnaires used for early identification of individuals potentially at risk for suicide. Suicide screenings are not definitive in diagnostic nor definitive indications of a condition and disorder. 
• Suicide assessments are longer and more comprehensive questionnaires focused on an individual’s functioning across multiple domains intended to increase a providers understanding of an individuals risk factors, protective factors, and warning signs. Suicide assessments are conducted to confirm suicide risk, estimate the immediate danger to the patient, and determine a course of treatment.

The benefits of screening at every visit outweigh the risk of screening fatigue. We have seen that youth patients generally accept being asked about suicide by their providers. You can show youth patients and their families your commitment to their overall health and decrease screening resistance by saying statements like “Your mental health care is just as important to me as your physical health and, because of this, [our clinic/I] have decided to ask you questions about this routinely.”

No, this is a pervasive myth that exists in our culture. In fact, screening for suicide reduces stigma and allows individuals to access help, rethink their options, and share their stories with others.

Generally this is not a problem we encounter. However, if your clinic is concerned about this, we recommend making suicide screening a clinic policy and providing parents with a letter to let them know about the change in your office. We provide sample language for these types of letters in our training materials.

To increase a youth’s willingness to openly and accurately answer questions on suicide screens, we recommend clinics allow space for youth to speak privately and directly to their providers, without guardians present. Also, providers who ask screening questions confidently, directly, and without judgement are viewed positively by youth, which increases their willingness to answer questions accurately. 

It depends. We recommend clinics begin universal screening at 10 years old.*  However, we know that youth at younger ages are attempting and dying by suicide. For youth 8 and up who present with a chief psychiatric complaint, we recommend targeted screening. If suicidal ideation is suspected for youth under the age of 8, providers should immediately conduct a thorough suicide assessment. 

*The asQ is validated for youth 10 years old and up.

It takes about 20 seconds to administer the asQ. In our experience, more than 90% of patients will screen negative on the asQ and this will be the only time commitment to the pathway for those visits. For more information on the asQ screening and their toolkit please visit the NIMH website.

The asQ screener is available in over 13 languages. For more information on the asQ screening and their toolkit please visit the NIMH website.

We recommend providers verbally ask the screener questions to the youth directly, confidently, and nonjudgmentally. However, we understand screening practices vary from clinic to clinic. Some practices have incorporated the asQ screener as a part of confidential iPad screening while the youth are waiting to be seen. Other clinics screen using a paper form youth can fill out without parent input. If your clinic screens patients prior to their clinic visit, we recommend creating a process to review their responses as they come in, in case of positive screening. For more information on the asQ screening and their toolkit please visit the NIMH website.

Anywhere from 5-35 minutes, depending on the patient’s screening result and assessed risk level. In our experience, around two-thirds of patients screening positive on the asQ will fall into the low risk category. The time it takes providers to conduct the suicide assessment for these patients typically ranges from 5-15 minutes, depending on provider skill and familiarity with the patient and assessment tool. Similarly, around one-third of patients screening positive on the asQ will fall into the intermediate or imminent risk categories. These patients will require further management which can take up to another 15-20 minutes to complete.

Suicide prevention is everyone’s business. We encourage providers, nursing staff, EHR specialists, billing and coding specialists, and any other clinic champions interested in suicide prevention to participate! Staff members are frequently in positions to observe changes in behavior or hear patients express suicidal ideation.

Lethal means safety refers to reducing a suicidal individual’s access to highly lethal means, like securing medications and weapons around the home, until the suicide crisis is resolved. Because many suicide attempts occur with little planning during a short-term crisis, keeping highly lethal means away from a person experiencing a suicidal crisis is imperative to saving their lives. While we do discuss lethal means safety as a component of the care pathway training, we also recommend every provider take the online course Counseling on Access to Lethal Means (CALM), available for free on the SPRC or Zero Suicide websites, to deepen their learning. 

There are two one-hour trainings on the Youth Suicide Prevention Care Pathway. Additionally, to receive MOC Part IV, PI-CME or PI-MOC you will be required to participate in at least two consultation/implementation meetings, along with monthly data reporting for at least six months.

Absolutely. The implementation support PCMH provides meets clinics where they are in their journey to increase suicide screening rates. The training components of the project are standard, but the workflow development and implementation plan can look different at every clinic. Please reach out to info@pcmh.org to discuss clinic-specific implementation considerations.

During the pre-training consultation, we will discuss who at the clinic will be directly involved in carrying out the components of the Youth Suicide Prevention Care Pathway. These individuals will need to take the two training sessions.

Yes, behavioral health providers can be integrated into the care pathway for patients who present with risk for suicide.

Yes! PCMH is excited to bring this work to school-based health centers.

Yes! Qualifying pediatricians may earn Quality Improvement 4 Maintenance of Certification (MOC part IV) through the American Board of Pediatrics. Qualifying Family Medicine providers, NPs, and PAs can earn PI-CMEs through the American Academy of Family Practice or PI-MOC through the American Board of Family Medicine.