Even before the COVID-19 pandemic, youth suicides were, sadly, on the rise. Among youth in the United States, more than 25% who die do so from suicide.1
During the pandemic, in May 2020, hospital emergency department (ED) visits for suspected suicide attempts began to increase among adolescents aged 12 to 17 years, especially in adolescent girls.2 From February 21 to March 20, 2021, suspected suicide-attempt ED visits were 50.6% higher among girls aged 12 to 17 years than during the same period in 2019. Among boys in the same age range, suspected suicide-attempt ED visits increased 3.7%.2
In 2021 the American Academy of Pediatrics (AAP) and the American Foundation for Suicide Prevention (AFSP), in collaboration with experts from the National Institute of Mental Health (NIMH), created a “Blueprint for Youth Suicide Prevention.” This blueprint is designed to support pediatric health clinicians in advancing equitable youth suicide prevention strategies in all settings in which youth live, learn, work, and spend time.1
We spoke with Christine Yu Moutier, MD, Chief Medical Officer for the American Foundation for Suicide Prevention (AFSP), about the blueprint and how clinicians can utilize this document.
Above image: Christine Yu Moutier MD Credit: AFSP.org
This blueprint for youth in suicide prevention has been created by different entities. Why is it significant that these organizations combined forces?
Dr Moutier: This is the first national blueprint for youth suicide prevention, particularly one that is primary care facing. It was the first time that such an innovative, interdisciplinary collaboration focused on youth suicide prevention has been possible, so it was important that the 2 leading national organizations in our respective areas, the American Foundation for Suicide Prevention (AFSP) and the American Academy of Pediatrics (AAP), came together. I think there are several layers to the significance. It signals a new day in terms of primary care, particularly pediatrics, and prioritizes mental health and suicide prevention in such a clear way with the guidance in the blueprint. And in a way, also owning the critical role that they can serve.
Even though pediatricians or other health care individuals may not be trained as mental health professionals, they are well-poised to address suicide risk: they are trusted resources for children and parents, they often know their patients over many years, and are accustomed to checking on milestones of healthy development. And while many families might struggle to find a mental health professional trained in child/adolescent psychiatry or psychology, most children have a pediatrician and may feel comfortable opening up to them about depression, anxiety, sleep problems, substance use, or suicidal thoughts.
I think that this is a really big step in the right direction. And it’s a step squarely into the space of what the role for primary care can be in serving a frontline role in screening for and addressing mental health. It’s also true that we didn’t always have evidence-informed actions to take in the primary care setting that showed reductions in suicidal behavior. However, new developments in the field in recent years are providing solid steps such as validated screening and risk assessment instruments, safety planning, lethal means counseling, family education, communication, referral, and follow up.
US Surgeon General Vivek Murthy, MD put out an Advisory on the Youth Mental Crisis last year. How is the blueprint different?
Dr Moutier: This blueprint distinguishes itself by having granular guidance and resources that are linked out in a clinical section of guidance and then 2 other sections that are less clinically focused: a community engagement part, and a policy initiative.
The process of developing the blueprint was also very unique. We included 90 key partner organizations across many sectors; individuals with lived experience including young adults who had been suicidal, as well as parents who lost children to suicide. We also had a focus on the 3 areas of clinical, community, and policy level suicide prevention with a continuous lens toward equity and lived experience. Five days of summit meetings and a thorough review process with all of the partners’ feedback incorporated led to the production of the blueprint. The process was extremely collaborative, led by a team from AAP, AFSP and experts from NIMH.
I would say what has come the closest to this type of resource is SAMSA [Substance Abuse and Mental Health Services Administration] of the US Department of Health and Human Services and their Suicide Prevention Resource Center, which has various documents and tool kits related to youth suicide prevention.
But again, no document has ever been created by and directed towards primary care. This blueprint really tries to show how primary care and behavioral health experts can work together, as well as ways for pediatricians to work with families, schools, sports/clubs, juvenile justice, faith organizations, and child welfare systems in forming cross-sectoral partnerships to advance suicide prevention.
Taking a public health approach, we know that community-based education and programs have a key role to play in primary and secondary prevention, and having a strong and prepared clinical workforce that’s trained in suicide prevention is also critically important. I want to point out that in the clinical arena of suicide prevention, the changes recommended in the blueprint must be led by health system leaders since individual clinicians can’t carry all of the responsibility for policies and work flows that make suicide prevention a priority — these must be prioritized by the health system at an organizational level.
What is significant about this blueprint for clinicians?
Dr Moutier: The newest thing is that if we even looked at let’s say, 10 years ago, certainly 15 years ago, the scientific discoveries around clinical tools both for screening that are appropriately validated for different age groups and populations, even racial ethnic groups, the validated and well-established tools weren’t there. We didn’t have solid risk assessment pathways like the ASQ [Ask Suicide-Screening Questions], which was recently validated by the NIMH multi-site research team.
And then, depending on a patient’s determination of their level of risk from that risk assessment tool, what steps can be taken that are also evidence-based? So, things like safety planning, lethal-means counseling, education, and support to the youth as well as the parents, and any other family members involved.
Then we have referrals. We’ve always had referrals to behavioral health, but now we even have specific referrals to suicide risk-reducing psychotherapies like cognitive behavioral therapy for suicide prevention (CBT-SP), dialectical behavior therapy, attachment-based family therapy, CAMS (Collaborative Assessment and Management of Suicidality) and ASSIP (Attempted Suicide Short Intervention Program). All of those steps have been developed by clinical researchers who were specifically looking at suicide risk as the primary outcome.
Fifteen years ago, suicide was always a secondary outcome of a treatment for depression, or a treatment for anxiety, or addiction, or PTSD. But it was never viewed as a clinical target on its own. That I would say is one of the most important differentiating aspects to what the science does tell us now, and what was incorporated into this youth suicide prevention blueprint: That suicide is its own clinical target. And not to say that it doesn’t relate to those mental health experiences, but it’s not enough to assume that only detecting depression and treating depression is the way to get the most impact on suicide risk reduction.
How feasible is it for clinical settings to implement suicide prevention programs and screenings?
Dr Moutier: It is feasible and there are some demonstrated health systems that have already done this. Nationwide Children’s Hospital for example, in Ohio, is one of the systems. CHOP [Children’s Hospital of Philadelphia] in Philadelphia and the Emergency Department and Connecticut Children’s Medical Center are others.
At the beginning of the COVID-19 pandemic, the AAP implemented certain key steps for all pediatric clinics to take related to COVID prevention and care. Utilizing their Project Echo system, AAP has been able to help pediatricians and clinical systems implement new practices on over 100 clinical topics, several of which are mental health related. The mental health ECHOs are so popular that there are waiting lists, so we know that pediatricians want this training and we hope they will engage in the same way with the implementation of suicide preventive practices.
So, when you put new clinical steps even for complex health issues into that framework which has a clear and established pathway for implementing and training, and also for the health system to form new workflows and pathways in order to implement new topics for clinical care, these steps that are in the blueprint for suicide prevention can be made doable and feasible.
In fact, along those lines, we are about to embark on an implementation scaling project with the AAP. It was always the intent with this blueprint project to not stop at merely producing a resource. We’ll find ways to bring it to life and put it into action through implementation. We’re very excited about that implementation project, which is going to lean on AAP’s Project ECHO, which is a collaborative learning process.
The blueprint mentions telehealth. What are your thoughts when it comes to telehealth and mental health?
Dr Moutier: We think telehealth can be a major help in certain ways, and in fact, the Action Alliance and the National Action Alliance for Suicide Prevention put out a guidance document about telehealth and suicide prevention. It’s not specific to youth, but the principles still apply.
Basically, it says that even though you’re not in person with the patient, we as clinicians should not shy away from screening and caring for people at risk for suicide. Because so much of the clinical care steps that relate to suicide prevention are about the communication between the clinician and the patient, and the clinician and the family members.
One of the key steps in suicide preventive practice is to have some ongoing follow-up communication with the patient. In fact, studies of “Caring Contacts” for suicide risk reduction are almost all entirely not done in person. They’re accomplished through postcards, emails, text messages, and phone calls, far more than in-person visits.
To sum up the “Caring Contacts” literature, about 13 out of 15 of these studies showed that when people are at risk for suicide — let’s say, they recently attempted suicide, and now they’re coming out of the hospital, or the emergency department — if they receive a series of these messages over the course of 12 to 18 months — anywhere from 6 to 15 messages in these studies — compared with the treatment as usual group that doesn’t get the communications, there is between a 40% and 70% reduction in the likelihood of a subsequent suicide attempt.
It’s hard to fathom that just this simple method of reaching out with a caring message can actually reduce risk. So, telehealth services show a lot of promise. Also, of course it helps for finding a child psychiatrist or other mental health professional if there is a dearth in the local area.
For pediatricians, there is a system called the National Network of Child Psychiatry Access Programs (NNCPAP) that’s set up state-by-state — although not all states have this — with a panel of child and adolescent psychiatrists who stand ready to be contacted by pediatricians for consultation. That’s sort of a telehealth mechanism for receiving expert consultation or guidance for pediatricians.
Christine Yu Moutier, MD, Chief Medical Officer, AFSP
SAMHSA (US Substance Abuse and Mental Health Services Administration)
Dialectical Behavior Therapy (Approach to Treating Individuals at High Risk for Suicide)
ASSIP (Attempted Suicide Short Intervention Program)
1. Suicide: Blueprint for Youth Suicide Prevention. American Academy of Pediatrics. Accessed April 2, 2022. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/
2. Emergency Department Visits for Suspected Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic — United States, January 2019–May 2021. CDC. Published online June 18, 2021. Accessed April 25, 2022. https://www.cdc.gov/mmwr/volumes/70/wr/mm7024e1.htm?s_cid=mm7024e1_whttps://www.cdc.gov/mmwr/volumes/70/wr/mm7024e1.htm?s_cid=mm7024e1_w