The startling increase in the number of adolescents thinking about and attempting suicide is a wake-up call for pediatric healthcare providers to take action and help these children at risk.
Michael S Jellinek, MD
Gregory Plemmons, MD
Resource tools for screening emotional and mental health
Hospital admissions for suicide attempts and suicide ideation in adolescents are on the rise. Recently published data show that the numbers of hospital encounters and admissions for suicide attempts and suicide ideation in young persons more than doubled during the period 2008 to 2015.1
Coming on the heels of recommendations recently issued by the American Academy of Pediatrics (AAP) for depression screening and treatment options for primary care providers (PCPs),2,3 the data bolsters the need for pediatricians and PCPs to recognize and screen for mental health issues in their patients to help stem and, hopefully, reverse this trend toward suicide.
“Depression and suicide are pediatric issues,” says Michael S. Jellinek, MD, professor emeritus of Psychiatry and of Pediatrics, Harvard Medical School, Boston, Massachusetts. “The prevalence is so high and the consequences so great, this is part of pediatrics and there will never be enough mental health professionals to transfer these needs to them.”
Jellinek, who did not participate in the study but provided comment on it, is unequivocal in what he sees as the role of pediatricians in addressing suicide and other mental health issues in their patients. “Screening, recognition, and initial management are pediatric responsibilities,” he emphasizes.
Suicide attempts and ideation
Suicide is the third-leading cause of death among US adolescents, and suicide ideation and attempts are strong indicators of children at risk of dying by their own hand.
Despite this, sufficient mental health providers needed to identify and help these children remain limited and many of these children end up in emergency departments (EDs) and acute care hospitals for crisis care for suicide ideation or attempts.
Given that, one way of identifying changes over time in the burden of suicide ideation and attempts is to look at data from EDs and inpatient units at children’s hospitals in the United States.
That is what Plemmons and colleagues did in this study. Using clinical and billing data from 49 US children’s hospitals contained in the Pediatric Health Information System Database, the investigators examined changes in the burden of suicide ideation and attempts between 2008 and 2015.1 They also looked at the demographic and clinical characteristics of these children.
Table 1 lists the key findings of the study.
Of the total number of children who presented to hospitals with suicide ideation or attempts, the study found that more than half were hospitalized. In addition, although there was a rise in both suicide ideation and attempts in all age groups and both sexes, adolescents aged between 15 and 17 years and those aged 12 to 14 years had the greatest increase. Rates were particularly high in adolescent girls.
When looking at when these events tended to incur, the study found a strong seasonal variation with peak occurrence in the fall and spring and the lowest occurrence in the summer.
This last finding came as a surprise to the study authors. According to the lead author of the study, Gregory Plemmons, MD, associate professor of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, this suggests that school may play an important role. “This is generally opposite from the findings seen in adults,” he says, “for which summer appears to be the highest time for suicide ideation and attempts.”
In the study, the investigators cite current attention given to how schools and social media influence adolescent behavior and the possible role of social contagion. However, they underscore that the relationship between school and suicide ideation is an area that needs further study.
Clarion call to pediatricians
Improving detection of depression and other issues that may make young persons more susceptible to thinking about and attempting suicide is highlighted by the data from the study.
For pediatricians, this means getting more involved in screening for and managing mental health issues in their patients. “Pediatricians have a unique opportunity to screen for depression and suicide, and to talk to children and their families about the importance of mental as well as physical health,” says Plemmons.
Jellinek underscores this by listing a number of things that pediatricians can be doing in the clinic to improve detection of children at risk for depression and suicide (Table 2).
Although emphasizing all these as important steps to identifying adolescents at risk of suicide, Jellinek says that increasing the use of screening instruments (PHQ-9 or Pediatric Symptom Checklist) is the most relevant. For more information on where to find downloadable forms, see “Resource tools for screening emotional and mental health,” page XX..
“These are embedded in electronic medical records and increasingly used as a quality requirement in response to the unrecognized and unmet mental health needs of adolescents in pediatric primary care,” Jellinek says.
Plemmons also emphasizes the need for pediatricians to advocate for mental health support in local communities. “It’s crucial to remove the stigma surrounding seeking mental health care and promote wellness,” he says.
Plemmons urges pediatricians to be aware of the increasing influence of many factors, such as social media and cyberbullying, that may be contributing to the rise in suicide ideation and attempts.
All this is not easy, emphasizes Jellinek. “Dealing with adolescent depression and suicide is difficult work,” he says. “Pediatricians will benefit from training and the collaboration of a trusted mental health professional.”
“These patients cause much worry and I would recommend never worrying alone,” Jellinek advises.
The increase in the number of adolescents thinking about and attempting suicide is a wake-up call for pediatricians and other healthcare providers to take more action, both in the clinic and community, to identify and help children at risk. Pediatricians can implement some steps in the clinical visit to screen for children and adolescents at risk of depression, stress, and other factors that may make them susceptible to suicide. Working with a trusted mental health professional is encouraged to help both the child as well as the pediatrician.
1. Plemmons G, Hall M, Doupnik S, et al. Hospitalization for suicide ideation or attempt: 2008-2015. Pediatrics. 2018;141(6):e20172426.
2. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D; GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081.
3. Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein REK; GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics. 2018;141(3):e20174082.