“It’s not just that we’re more aware of adolescent suicide,” said Michael Scharf, MD, chief of child and adolescent psychiatry at the University of Rochester Medical Center and a REACH faculty member. “The rate really is going up. Teen suicide is still rare, but it’s increasing.”
Primary care providers (PCPs) can help teens at risk of suicide, first of all, by being willing to talk about it. “Some people think that asking about suicidal ideation makes the kid more likely to act,” said Dr. Scharf. “But evidence shows that asking either has no impact or has a relieving effect; it frees the patient to talk about the issue.”
“You need to think ahead of time of what to ask and how, so you feel comfortable,” said Dr. Scharf. “You need a go-to way to assess risk and how likely the kid is to follow through.” (See Resources below.) The assessment results can range from “nothing to do here” to “send this kid to the emergency department.”
“The tricky part,” Dr. Scharf said, “is what to do in between.”
Some providers use safety contracts, in which they secure a patient’s promise to contact a trusted adult before attempting suicide. Unfortunately, said Dr. Scharf, experience and data show that these contracts are not effective.
Instead, Dr. Scharf works with patients to devise a safety plan outlining concrete steps they can take when they feel unsafe. He asks patients what they have done in the past to feel better and sets up a sequence of steps: first try this, then that.
Developing a safety plan not only gives the patient coping skills to try when distressed, but also enables the clinician to assess whether the patient is capable of participating in helping himself. “The safety plan has to be realistic. If the kid says he’d call the President [before taking steps to end his life], that’s a kid who isn’t engaged in keeping himself safe.”
Dr. Scharf shared stories of two patients with suicidal ideation to illustrate when safety plans can be effective. The first patient described the roots of her depression in the breakup of a relationship, plus multiple past losses and trauma. “But when we talked through what she was thinking, she talked about wanting to be dead in order to be out of the distress she was in. She didn’t have a [suicide] plan.” Dr. Scharf helped this girl set up a safety plan revolving around her mom, deep breathing, and a craft the girl enjoyed. This patient then could go home, with a plan for mental health follow-up.
The second patient also recounted recent losses. But conversation revealed that “her level of hopelessness made her unable to meaningfully engage in safety planning.” This patient had to go to the emergency room immediately and was then hospitalized.
Setting up a safety plan, with its inherent risk assessment, may be more than you can do in an office visit, Dr. Scharf noted. He recommends arming yourself in advance with a list of resources.
First, find out if your state or region offers a child psychiatry access program for PCPs. (See Resources.) Whether or not you have access to such a program, you should also know about local resources, including any suicide hotlines, mobile crisis services, and other supports.
If you think the patient may be at risk — whether or not you are sure — consultation or referral is vital. If the patient refuses help, involving police or EMS may save a life.
Beyond the clinical setting, Dr. Scharf encourages providers to get involved with local suicide prevention efforts. “It might seem trite,” he said, to participate in a walkathon or speak to a peer-to-peer support group, but “these efforts make people more willing to talk about mental health and to seek help when needed. They are a key part of building community capacity to deal with teen suicide.” Your involvement can extend your impact well beyond your patient base.
Dr. Scharf recommended several resources PCPs can use to assess suicide risk and prevent attempts.
The ASQ (Ask Suicide-Screening Questions) from the National Institute of Mental Health is short, validated in many settings, and accompanied by a set of online tools. Other tools are available in The REACH Institute’s GLAD-PC Toolkit.
Consult the National Network of Child Psychiatry Access Programs to see if a program exists in your state.
If no local hotline is available, refer patients and caregivers to the American Foundation for Suicide Prevention national hotline at 800.273.TALK or have them text TALK to 741741.
Sources of Strength works with high schools to identify peer leaders who can teach others to access help when in need.
Many prevention organizations are local, often started by community members in response to a tragedy. Ask law enforcement officers, teachers, and faith leaders what’s available in your community.
“The opportunity to learn information to help me manage psychiatric conditions in my patients in this time where demand clearly outweighs supply of services, is going to be excellent for me as a PCP in my community.”