Identifying and addressing suicide risk in patients, especially children and adolescents, is of utmost importance in the medical field.
In a recent talk for CHOC’s Grand Rounds, Dr. Micaela Thordarson, pediatric psychologist, discussed how physicians should play a crucial role in suicide prevention by conducting accurate screenings and implementing appropriate intervention strategies.
In this article, Dr. Thordarson aims to provide physicians and medical staff with essential information and guidelines for effectively assessing suicide risk and engaging in meaningful conversations with their patients.
Youth suicide prevalence and necessary response
Suicide is a widespread issue, particularly among youth. Data shows that a significant number of high school students have seriously considered suicide or attempted it, says Dr. Thordarson.
The Centers for Disease Control and Prevention (CDC) conducts surveys on risky behaviors, including suicidal thoughts and behaviors. In the 2021 data, it was found that 22% of California high school students had seriously considered suicide in the past 12 months.
This means that, on average, over five students in a typical high school classroom have seriously considered suicide. Additionally, 10% of students attempted suicide, meaning over two students in a classroom may have attempted suicide within the past year.
About 3% of students reported attempting suicide to the extent that it required medical intervention to save their lives.
Talking about suicide with patients
Which such a high prevalence of suicidal thoughts and behaviors, talking about suicide and understanding suicide risk is essential for physicians who work with youth and families. While it may be a challenging and emotional topic, it is crucial to have practical knowledge and strategies to effectively intervene and support individuals at risk.
Dr. Thordarson offered the follow steps for physicians when pinpointing and addressing suicide risk in their practices:
First, physicians need to prioritize their own well-being before addressing suicide risk, she says. Regulating emotions and approaching the topic calmly is crucial to ensure clear thinking and effective communication. Taking care of oneself allows physicians to provide the best support for their patients.
Talk about suicide in an appropriate manner
When discussing suicide, it is important to use appropriate language. Instead of saying “committed suicide,” use phrases like “died by suicide.” Avoid using terms that downplay the seriousness of suicidal behaviors, such as “suicidal gesture.” Emphasize that any behavior related to suicide requires attention and support.
When assessing suicide risk, it is crucial to approach the conversation directly and with empathy. Avoid using euphemisms and ask straightforward questions about suicidal thoughts or intentions.
Research has shown that discussing suicide does not increase the likelihood of self-harm but, in fact, encourages help-seeking behavior. By showing openness and understanding, physicians create a safe space for patients to discuss their feelings without judgment.
Understand active vs. passive suicidal ideation and intent
Suicidal ideation refers to thoughts, plans, and means associated with suicide. Active suicidal ideation involves explicit statements or thoughts about wanting to kill oneself. Passive ideation is more indirect and includes statements like wishing to not be alive or wanting to go to sleep and never wake up. Active ideation generally poses a higher risk.
Suicidal intent plays a significant role in assessing suicide risk. While some individuals may think about suicide frequently, their intent may be low. Conversely, others who think about suicide less often but express strong intent require immediate attention.
Use the Joiner’s Model of Suicide
Suicide risk is influenced by three main factors: hopelessness, perceived burdensomeness and lacking social belongingness. Hopelessness, in particular, is a common driving factor for suicidal behaviors, says Dr. Thordarson. It is important to consider these factors when assessing risk, even if individuals deny suicidal thoughts explicitly.
Recognize additional suicide risk factors
Several other factors contribute to suicide risk, including the absence of joy, rigid thinking or perfectionism, chronic pain or medical conditions, limited supervision, limited verbal expression, family conflict, recent major changes, social isolation and being a member of genderqueer or sexual minority communities. Recognizing these risk factors helps in identifying individuals at higher risk.
Acknowledge the importance of prior self-harm behaviors and family history
Individuals with a history of self-harm behaviors or suicidal attempts are at an increased risk for future suicidal behaviors. Similarly, a family history of suicide indicates both genetic and environmental influences on suicide risk. Physicians should pay close attention to these factors when evaluating risk, says Dr. Thordarson.
Suicide risk screening and intervention techniques for physicians
With the tools to screen for suicide risk and intervene when necessary, physicians can make a tangible difference in saving lives and promoting the overall well-being of their patients, says Dr. Thordarson. Physicians should consider the following when addressing suicide with their pediatric patients:
Utilize validated screening tools
Incorporating validated suicide screening tools, such as the Ask Suicide-Screening Questions (ASQ) from the National Institute of Mental Health (NIMH), can significantly improve the accuracy of risk assessments.
The ASQ is a brief set of questions that can be easily administered to patients during their visit, says Dr. Thordarson. By using a standardized tool, physicians can identify patients who require further assessment and intervention promptly.
Use active listening and provide emotional support
Once a patient screens positive for suicide risk, active listening becomes a vital component of the physician’s role. By being present, non-judgmental and empathetic, physicians can help patients feel understood and less isolated.
Avoid asking “why” questions that might lead to justification but instead acknowledge the pain and loneliness they might be experiencing. This approach builds trust and demonstrates that patients are not alone in their struggles.
Create a safety plan
Collaborating with patients to create a safety plan is an effective way to empower them and provide tools for managing crises, says Dr. Thordarson.
A safety plan involves identifying warning signs, triggers and coping skills that patients can utilize when they feel overwhelmed. Encourage patients to develop a list of supportive individuals, hotline numbers and distracting activities.
Caregivers should be taught how to make their child’s environment safer by removing access to firearms, knives, other sharps, prescription and over-the-counter medications. Increasing supervision is vital so that youth who are having suicidal thoughts have more support and less opportunities to impulsively act in lethal ways.
Additionally, consider recommending the use of mobile apps like the Virtual Hope Box, which offers various coping strategies and resources.
Avoid common stigmatic pitfalls when discussing suicide
Physicians should be mindful of common mistakes when discussing suicide risk. Avoid dismissing a patient’s pain based on their age or circumstances, as even children and adolescents can experience significant distress.
Refrain from labeling suicidal thoughts as selfish, as patients might believe they are relieving others of burdens. Remember that suicidal behaviors can be contagious among youth, so caution should be exercised when discussing suicide within peer groups.
Overcome challenges in accessing services
Getting individuals connected to outpatient mental health services can be challenging, especially for those with commercial insurance, says Dr. Thordarson. Insurance panels may include outdated or unsuitable providers, making it difficult for families to find appropriate care.
Persistence is key when navigating this process and advocating for appointment searches and case managers can improve the chances of finding available providers within a reasonable timeframe.
Addressing suicide risk in patients requires physicians to be well-informed, empathetic and skilled in communication. By prioritizing suicide prevention and incorporating these strategies, physicians can play a significant role in saving lives and promoting mental health in their patients.
For more about CHOC’s pediatric mental health services