Screening for Safety: Evidence-Based Tools to Prevent Suicide in Primary Care
By Kristin Dreves, MPH, CHES, Adolescent Health Project Manager, Oregon Pediatric Society
Recently, I lost someone I grew up with to suicide. As both an attempt and loss survivor, I am acutely aware of the desperation and hopelessness that leaves someone feeling like there’s no other way out and also the heartbreak and destruction that suicide leaves in its wake. Suicide death leaves no opportunities to say goodbye, no second chances to turn things around.
As one of the lucky ones, I know the power of second chances. When given the gift of time and professional help, I can attest that there is hope, there is light at the end of the tunnel, and there is a chance to thrive.
Over two million young people attempt suicide each year, with 90% of attempts among youth unknown to parents.[i] With suicide the 2nd leading cause of death for young people,[ii] youth suicide prevention is top priority.
At the Oregon Pediatric Society (Oregon Chapter of the American Academy of Pediatrics), we are devoted to doing our part to prevent suicide and promote positive mental health outcomes for youth. Along with Trauma Informed Oregon, OPS has been very active supporting Oregon’s Youth Suicide Intervention and Prevention Plan.
To this aim, OPS provides adolescent mental health training for primary care teams. OPS Screening Tools and Referral Training (START) around ACEs/Trauma Informed Care, Substance Abuse, Depression, and Suicide Prevention are collectively designed to promote screening, assessment, and management of pediatric mental health issues by providers practicing trauma informed care.
We focus on primary care because:
- 35% of pediatric patients are seeing their primary care provider as their primary mental health care provider[iii]
- 23% of young people were seen by their primary care provider within one month prior to completing suicide and 62% were seen within the past year[iv]
- In contrast, only 15% of young people were seen by a mental health provider within one month of suicide, 24% within the previous year, and 38% within their lifetime
In Fall 2017, OPS convened a panel of statewide experts to represent various perspectives and practices to inform best practice training for healthcare providers around youth suicide risk assessment, lethal means counseling, and safety planning.
One of the discoveries from this panel included screening and assessment tools specifically designed for pediatric primary care providers. The brief 4-item, evidence-based asQ (Ask Suicide Questions) Screening Tool (below), was designed by the National Institute of Mental Health (NIMH) as an effective and reliable suicide risk screening tool for pediatric patients ages 10-24.[v]
If a positive screen occurs on the asQ Suicide Risk Screening Tool, a provider can follow-up with the asQ Brief Suicide Safety Assessment (BSSA), which is designed to take around 10-15 minutes to complete, depending on the situation. The BSSA includes methodology and scripts around talking to patients, talking to parents, lethal means restriction, safety planning, and determining next steps. The BSSA may be completed by a physician, physician’s assistant, nurse practitioner, or mental health practitioner.
The following outcomes are determined based on screening and assessment results:
- Immediate referral to Emergency Department
- Safety planning with urgent referral to mental health provider within 72 hours
- Safety planning with non-urgent referral to mental health provider
- No further intervention needed at this time
The asQ Toolkit available from the NIMH includes the asQ Information Sheet, asQ Screening Tool (in multiple languages), Brief Suicide Safety Assessment Guide, Nursing Script, Parent/Guardian Flier, Patient Resource List, and Educational Videos.
OPS START training also includes additional content around lethal means restriction, safety planning, office implementation, case scenarios, and community resources. Trainings are team-led by a Pediatrician and Child Psychologist.
If you are a primary care provider and would like OPS to provide training for your clinic or School-Based Health Center, please contact us at firstname.lastname@example.org.
You don’t need to be a physician to make a difference. Suicide prevention necessitates cross-sector collaboration. We are all in this together. Whether you’re a health care provider, a politician, or a community member, you can do your part to offer support, policies, and resources that help keep people safe. Don’t give up on us.
 Zalsman G. Genetics of Suicidal Behavior in Children and Adolescents. In: Dwivedi Y, editor. The Neurobiological Basis of Suicide. Boca Raton (FL): CRC Press/Taylor & Francis; 2012. Chapter 14.
 Oregon Health Authority Youth Suicide Annual Report 2014-2015. Retrieved from http://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/SAFELIVING/SUICIDEPREVENTION/Documents/youth-suicide-annual-report.pdf
 Elizabeth L, Anderson ML, Chen JM, Jeanne VC. Outpatient Visits and Medication Prescribing for US Children with Mental Health Conditions. Pediatrics. 2015; 135(5):1178-1187. doi: 10.1542/peds.2015-0807. Retrieved from https://www.nimh.nih.gov/health/publications/nimh-answers-questions-about-suicide/index.shtml
 Luoma JB, Martin CE, Pearson JL. Contact With Mental Health and Primary Care Providers Before Suicide: A Review of the Evidence. The American journal of psychiatry. 2002;159(6):909-916. doi:10.1176/appi.ajp.159.6.909.
 National Institute of Mental Health, asQ Information Sheet. Retrieved from https://www.nimh.nih.gov/labs-at-nimh/asq-toolkit-materials/asq-tool/information-sheet_155866.pdf
OPS member Dr. Carl Eriksson, MD, MPH, FAAP, works in Critical Care Medicine at OHSU and shared best practices on Antiviral Treatment of Patients with Influenza. Dr. Eriksson also serves on the AAP Disaster Preparedness Advisory Council.
Parental Adverse Childhood Experiences and Offspring Development at 2 Years of Age
OPS member R.J. Gillespie, MD, MHPE, has been doing innovative work around prenatal Adverse Childhood Experiences (ACEs) and pediatric outcomes for years. His contributions are highlighted in the recently published Pediatrics article "Parental Adverse Childhood Experiences and Offspring Development at 2 Years of Age."