Teen Suicide: Risk Factors, Screening and Prevention (S1:E24)

It's important information for our primary care providers. I think that's one of the fun parts about allergy. The biggest challenge is making sure you have the correct diagnosis. What is the best outcome or place to send this child? This is Charting Pediatrics from Children's Hospital Colorado, where we examine the latest treatments for the most common complaints in pediatric medicine. And now your host, Dr. Dan Nicholas, pediatrician at Children's Colorado.

Welcome to Charting Pediatrics. I am Dr. Dan Nicholas. Every week on the show, we invite our pediatric colleagues to join us as we examine the latest treatments for the most current topics in pediatric medicine. Before we jump into today's episode, I want to... say thank you all for listening. In just four short months, we have reached nearly 10,000 downloads. On behalf of our Charting Pediatrics host team, thank you for sharing the show with your friends and colleagues.

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Today we have a special episode about suicide and are fortunate to be joined by Dr. Jenna Glover of the Children's Hospital Colorado Pediatric Mental Health Institute. Dr. Glover is Director of clinical psychology training at Children's Hospital Colorado and an assistant professor of child psychiatry at the University of Colorado School of Medicine. Jenna, welcome. Thanks for having me today.

Jenna, usually we ask people a little bit about their background. Can you tell us a little bit about your training and what brought you to Colorado? Yeah, so I've been a clinical psychologist for about a decade now, and my primary area that I work with is eating disorders, LGBT youth, and children and adolescents with mood and depressive disorders. And so I...

Decided to come to Colorado because there was an opening to be a training director, and I have a love of teaching and supervising students, and so that's what brought me here. Excellent. I also love teaching our trainees. Today, obviously, we're talking about a very serious issue.

It's been requested by a number of our podcast listeners who are seeing an increasing number of patients in their practice who are at risk for suicide. As we cover a very real and serious topic facing our patients, can you set the stage for our or some of the statistical trends as it relates to teen suicide? Yeah, so teen suicide has been steadily increasing over about the last decade. It is the second leading cause of death in children 10 to 24 years of age.

One of the things that I think is really troubling for me is that there's about 3,400 suicide attempts a day by high school students. And so what that means is about one in every 15 high school students will have a suicide attempt in any given year. Positive part of that is we know that about four out of every five teenagers who try to complete suicide have warning signs.

And I think what's especially interesting for our listeners today is that 83% of all suicides that were completed in the last year saw their PCP that year. And so typically they see them in the month the suicide occurs. And so there's a real opportunity for our primary care providers to be screening and making sure that they're getting the support they need to these kids. Can you expand a little bit on what would...

possible warning signs be? So there are a variety of different warning signs in terms of biological factors, just kind of genetics, what is the family history, and if there's a history of psychiatric disorders, that increases the risk.

And the presence of psychiatric disorders is one of the biggest warning signs. So we know that about 90% of completed suicides, that person had a mental health disorder, and about 80% of those were not treated. So that's a really important one to screen for. In terms of... psychological factors, poor frustration tolerance, impulsivity, problems with body image.

low self-esteem and one of the largest hallmark warning signs is a sense of hopelessness and so that definitely is a red flag that should come up we also know that Previous attempts is one of the biggest red flags, and that's the best predictor of future attempts, is if there's previous, as well as self-interest behaviors. There's also important environmental factors to think about, so how isolated is the teenager.

A loss of any kind, so a relationship, divorce of parents, or death in the family also increases risk. One of the other things that's important to think about is exposure to suicide. So there is a... contagion problem that happens when a suicide occurs and especially in our local community we've had a great deal of suicides happen during the last year that have received a lot of attention in the media.

The other thing that's important to think about and ask parents about is access to weapons. And so if there are firearms in the home, that definitely increases the risk. And that's something that often people don't think to ask about, but that's a really important risk factor to screen for.

And then one of the other things that sometimes gets overlooked is asking kids about their social media habits. And so the more social media sites that they have accounts on, that actually increases their risk of depression. So two or three more, the risk goes up.

And cyberbullying is a really big predictor. So kids who are cyberbullied are five times more likely to attempt suicide than their peers who are not. The other thing that we often don't think about asking about is if they are the perpetrator of cyberbullying.

are actually also at an increased risk of completing suicide. So I think it's important to think about those online habits as well. That's great. And those are a lot of things for us to consider. You had mentioned in the introduction that you were interested in LGBT. Can you just briefly touch on that if it's a risk factor for suicide? It's definitely a risk factor for suicide, and that's a really important thing to be thinking about and screening for.

We know that kids who are in the LGBT community face a lot more stigma and because of that extra stress that usually is. Being activated on a daily basis, they're going to be at that increased risk. It's also really important to screen for if there's any gender dysphoria that's potentially happening and being aware and having that on your radar because those kids are much more likely. They're about 50% more likely.

to try to complete suicide. Okay, wow. What about, you had talked a little bit about screening and the importance of screening, given these risk factors. Can you tell us a little bit about most of our listeners are primary care physicians out there? Can you talk a little bit about the best way for us to screen for suicide in our patient population? Yeah.

A really, really helpful resource that I would direct listeners to is the Suicide Prevention Resource Center. That's sprc.org. And if you go into their webpage, they have a tab for effective prevention. And in there, they have several resources. and a toolkit for primary care providers for how to screen for suicide and a variety of different tools to implement suicide assessment screenings within their office.

I think a really really helpful way to screen for suicide is to start implementing the PHQ-9. That's just a quick and easy way to screen for those different things. Also having the Columbia Suicide Severity Rating Scale is a great tool to have in terms of helping you walk through and determine what level of risk a patient is at. So those just really quick instruments will help you screen as well as determine level of risk. And they're easy to give and pretty self-explanatory. And how are those?

available online? Are they free to download? They are free. Yep. They're free to download. And like I said, that Suicide Prevention Resource Center has a variety of those tools online for primary care physicians to download for their use. And at what age would you start? I know, you know, the PHQ-9 obviously has certain age requirements, but what age do you start thinking about screening for suicide particularly?

So, I mean, suicide can happen in children as young as five years of age. I really think it's important once children are nine years and older that you should definitely be screening. If there are other risk factors, though, if you've got a really impulsive, dysregulated kid, it's not.

uncommon for children when they're very upset to make statements like I want to kill myself and that freaks parents out and so it's important to have education to tell parents that that's not something that's uncommon in terms of how children are trying to express themselves when they're very upset, but at the same time, we need to take those things seriously. And so I think with those really dysregulated, impulsive kids, that even at a younger age, those questions should be asked.

How do you typically talk to the patients and the families about suicide risk, both proactively and reactively? Yeah, so I think it's really important to be direct about this. And you want to basically educate parents and patients and destigmatize some of the things that happen around suicide. So that this is something that does commonly happen and educating them on the risk factors, like things like loss. cyberbullying, difficulty at school.

several of the things that I talked about before. So when those risk factors are in place, making sure that questions are directly asked. I think it's important. A lot of parents think that if you talk about suicide, that's going to increase kids thinking about it, or maybe their risk of actually

trying suicide, that's absolutely false. So it's important to send the message that talking about these things directly actually lowers the risk. I think it's also important for providers to let parents know that when suicide is coming up in the community. Those should be conversations that are had with their kids directly.

What are your thoughts about this? Have you heard about this? Have you ever had those thoughts? Also, suicide comes up in popular media. 13 Reasons Why was a really big thing this last year. They're going to have a second season. And so I think proactively saying, do you know what this show is?

heard about it have you had those thoughts and so those are really important conversations not just assume that oh this isn't a problem because I haven't seen it but parents really should be talking to their kids about it And I think giving them that information that this will actually help reduce the risk is helpful to parents to hear. Yeah, I can tell you, I think that one of the biggest learning points for me in my own training was that.

There's this feeling that talking about suicide is suggestive and will lead to increases. And so what you just covered is really helpful, I think, for all of our listeners to talk about with their families. What 13 Reasons Why is it's a Netflix show where, no secret here, the child or adolescent commits suicide at the end of the show. And it was a really popular show, Adolescents. So anyway.

One of the scariest things as a primary care provider, and especially for our providers who are out in the community, out in rural areas, is once we have identified someone who may be at risk, you know, has either ideation or a plan or something like that is what do we do? Yes. Can you talk a bit about that? Definitely. The important thing is to determine what is the level of risk. And so a low risk.

Patient would be somebody who's having thoughts of suicide, but no intent or plan and no past suicide attempts. When low risk is there, I think it's important to encourage family to connect with a mental health provider and schedule a fall.

follow-up within the next month to make sure that that's actually happened and the symptoms haven't increased from there. I think talking to parents and letting them know this is a normal symptom of depression and that gives us information about where this kid is at. But we also need to take it seriously and we need to be looking for these risk factors. In terms of like moderate risk, that would be somebody who has a plan and they have been having these thoughts, but they don't have intent.

and they don't have a significant history. When there is a plan in place that does increase the risk, and so really you want to work on trying to connect them to seeing a mental health professional in the next week, and then you want to do some safety planning with them. Sometimes people think that in the past, like suicide contracts and having a kid sign something saying basically I won't kill myself.

there's no empirical evidence that those are helpful. And in fact, they actually might be hurtful. And so instead, we really encourage providers to engage in safety planning with the kids. So a basic safety plan would be identifying what are kind of the triggers that would increase the risk and the warning signs. What are the coping strategies that this... could use, who are the social contacts that they could reach out to, who are the family resources that they could reach out to.

And essentially, what are the numbers that they could call and what do the family need to do if the risk increases? And so I think with an appointment with a mental health professional sometimes in the next week and a good safety plan in place.

can feel okay letting them leave the office. It's really important to document all of those things and the level of risk with that. And then finally, for people who are high risk, so these are patients who have a plan, they have intent, they have past attempts. or that they are highly agitated or impulsive. Also, their level of substance use is really important too.

to look at, so if they're frequently abusing substances. So all those things would be high-risk kids. At that point, they really should be evaluated at an emergency department, and they should be constantly monitored until they're able to be transferred.

That's very helpful. And I think especially in the moderate category, those are some very practical tips. I think that... people can use in their office. You had mentioned as one of those things is to see a mental health professional, which is not always possible depending on where you practice. So in a case where a primary care physician is seeing someone and screens appropriately, but is surprised by a positive screen.

and they don't have access to mental health resources, taking those few initial steps are very important. What would you recommend for follow-up, or how would you take it from there if they can't get into mental health? Yeah, so I think if they can't get into mental health services, there needs to be an agreement in terms of monitoring with parents.

child basically isn't alone and the safety plan is in place. And then I would recommend that the child, depending on when they're seen in that week, is seen within the next five days to see if anything has changed. I think one of the ways to judge this too is what are anticipated stressors that are going to be coming up in a week. And so if you know that a kid has a huge test or that they're having relationship problems.

You probably want to see that kid again the same week to make sure that nothing has changed. If there are less stressors and there's a good safety plan in place, you can probably wait another week to see them. But probably within a span of seven days, you would want to be touching base with them again. Okay.

That's very helpful. I used to practice actually in Massachusetts. I remember they had, it was like a phone call line that providers, if they couldn't get appointments, at least could get advice over the phone. Are there other resources like that, either locally or nationally, that our listeners might... want to know about? Yeah, definitely. So there is the, within Colorado, there's the Colorado Crisis Service line that they can call. So the number is 1-844-493-TALK.

And one of the nice things about the Colorado Crisis Service is that they also have a text line, and a lot of adolescents would prefer having the text line instead. And so they just need to text the word TALK to 38255. So that's a really, I think, great resource. Also within Colorado, there's the Second Wind Fund, and that is a resource that helps basically connect families to mental health services and ensuring that they're going to get appointments immediately for children who are...

experiencing suicidal ideation. So I think that's a really, really important one. And nationally, there is the National Suicide Prevention Lifeline number. And so this is throughout the nation. Anybody can call. So the number is 1-800- 8273-TALK, which is 8255. They also offer a live online chat, and so I think it's really important that patients leave, and that's the best standard of care, that they have those numbers in place, and that's part of their safety plan.

Mentalhealth.gov also is a great resource because it has a variety of different search engines and connects to different organizations throughout the United States. And so that's a great place to also look for what services might be available. Excellent. Thank you so much. That's very helpful. Do you ever run across families where there's sort of a disconnect between child and parent in terms of the child being at risk, but the parent sort of being in denial? And how would you approach that?

Yes, that I think happens frequently, that parents will either minimize that it's not that concerning or that... There's just nothing going on. And so I think it's really important to have honest conversations that outline these are all of the risk factors and duty and safety is the most important. One of the things that's hard for parents to understand is that suicide risk is not a fixed point. It is a fluctuating experience. And so there's going to be times where kids will be fine for...

a long period of time, and then they can very quickly become acutely suicidal. And because of the way the teenage brain is engineered, they're not going to think of long-term consequences, and they're going to be quite impulsive. And so I think it's really important for parents to understand that even though it seems like everything is okay, very quickly this can escalate. And so we need to have a plan in place and you need to be monitoring these things because this can happen.

quickly. And so, and seeing how parents feel about that, what's their concern, why they don't think that this is maybe a serious concern. And I think providers sharing really directly, this is something that needs to be taken seriously. So Dr. Glover, I realized that you're a...

psychologists and don't regularly prescribe medication, but we will have patients who are on medications for a lot of the comorbidities, maybe mood disorders and that type of thing. I was just wondering if there were any sort of tips that you wanted to. share with our audience in terms of how to deal with medications safely.

Yes. So I think that's very important, especially when you have a teen who is at moderate to high risk that medications are secured in the house. So not just the medications that teens are taking, but all medications. So I think it's important for providers to instruct families to buy medication lock boxes so you can buy these at any pharmacy, at Walmart, at Target.

and really instructing the importance of those medications being monitored. And when there is acute risk, parents really should be responsible for distributing the medication, making sure that it's being taken consistently and that they know where all the medication in the house is. Excellent.

Just in closing, are there any resources here at Children's Hospital Colorado that our primary care providers may utilize? Yeah. So I would encourage them to utilize one call, which is our provider to provider consult line. And the number is 720-777.

And this will give them the opportunity to quickly consult with somebody on my team and they'll be able to give them great information and help talk through some of these issues, especially when there is kind of questions about risk and not sure what to do. Excellent. Thanks so much, Jenna.

That was a very serious topic, obviously, and I think we've covered some really important aspects in how to care for these patients who are at risk. In closing, what we usually like to ask our providers is, what is your favorite part? your daily medical practice.

I think my favorite part is just the fun, ridiculous stories that my patients come in and tell me that are off the wall and things that I think are important, are not important to them and learning what is important to them. And I think that's probably the joyful part of my day. Kids are great. Thanks so much for coming, Jenna. Thanks for having me.

If you have more questions on this topic or a suggestion for a future podcast topic, write to chartingpediatrics at childrenscolorado.org. If you like this podcast, please rate us and share with others who might be interested. This is a production of Children's Hospital Colorado.