While suicide is the second leading cause of death among youth aged 10-24 years, only about 1 in 3 pediatricians use standardized tools to assess suicide risk, according to a recent study published in Pediatrics.

Despite a 2022 recommendation from the American Academy of Pediatrics (AAP) for universal suicide screening in youth over age 12, a new national survey revealed an implementation gap. This disconnect — driven by a lack of awareness and a critical shortage of mental health resources — highlights missed opportunities to identify at-risk youth, nearly 90% of whom visit a healthcare provider in the year before a suicide attempt.

The question is, “How do we get more pediatricians to screen? And how can we disseminate guidelines more effectively across outpatient primary care and pediatric subspecialties?” said Alexandra Huttle, MD, MSc, assistant professor of clinical pediatrics at Weill Cornell Medicine in New York City and lead author of the study. “That only about one third of pediatricians are reporting standardized screening for suicide risk is surprising.”

Huttle noted several barriers to screening, including lack of time, support, and resources, and a national shortage of mental health clinicians for referrals.

In the same year the AAP issued its initial recommendation, the US Preventive Services Task Force said there was insufficient evidence to support suicide risk screening in children and adolescents. However, in 2023, the AAP released a clinical report that reaffirmed the importance of screening adolescents.

Who Is Screening?

The study analyzed data from a national survey of pediatricians enrolled in the American Board of Pediatrics Maintenance of Certification program. Survey respondents reported using suicide-specific screening tools, including the Ask Suicide-Screening Questions or the Columbia-Suicide Severity Rating Scale. But others used the Patient Health Questionnaire for Adolescents (PHQ-A) and the PHQ-9, which screen for depression and include a question about suicidality.

Among 5003 respondents, 36.7% reported conducting standardized suicide risk screening for their patients. Emergency medicine physicians were significantly more likely to report screening than general pediatricians (adjusted odds ratio, 2.83; 95% CI, 2.13-3.77).

Huttle said this may reflect adherence to the Joint Commission National Patient Safety Goal, which dictates that hospitals, where many emergency physicians work, are required to screen patients with mental health concerns for suicide risk using a validated screening tool starting at the age of 12.

Roughly one third of respondents were not knowledgeable about the AAP recommendation to screen for suicide. Pediatric subspecialities showed significant variation in screening. Those working in cardiology, critical care, gastroenterology, and infectious diseases were significantly less likely to report screening using standardized tools than general pediatricians.

Of the pediatricians who used a standardized screener, 28.8% reported using suicide-specific screening tools only, 26.4% used the PHQ-A, 16.6% used the PHQ-9 only, 11.7% used the PHQ-9 in combination with a suicide-specific tool, and the remainder were unsure or used other tools.

Many practices that conduct depression screening think doing so checks the box for suicide risk screening, said Maria Rahmandar, MD, medical director of the Substance Use and Prevention Program at Lurie Children’s Hospital of Chicago and associate professor at the Northwestern University Feinberg School of Medicine in Chicago, who helped author the 2023 AAP report.

But screening for depression may not be sufficient for identifying suicide risk. One study found that depression screening alone using the PHQ-A failed to detect nearly one third of youth at risk for suicide.

Research suggests potential missed opportunities for pediatricians to identify risk, intervene early, and prevent suicide. One case-control study found that among youth aged 10-24 years who died by suicide between 2000 and 2015, 42% had a healthcare visit in the month before death, and 88% had a visit in the previous year.

Megan Heere, MD, professor of clinical pediatrics at the Lewis Katz School of Medicine at Temple University in Philadelphia, said she and her colleagues routinely screen children for depression and suicide beginning at age 12. They use the PHQ-9, and if the suicidality question is positive, utilize the Ask Suicide-Screening Questions form.

“We are identifying kids that haven’t told anybody, and for some reason, today is the day they thought they could tell us” about their suicidal feelings, she said.

Rahmandar said she has seen the benefits of universal screening at her clinic. In one case, a patient came in for period concerns but divulged that she was having serious thoughts of wanting to die and had come up with a plan.

“We were able to get them into help, and they spent some time in the inpatient psychology unit and then were ultimately connected to care to help them feel better,” Rahmandar said.

One of the most powerful benefits of suicide screening is the chance to develop a safety plan, Rahmandar said.

“If you can intervene during the time where those thoughts get strong, there’s a good chance you’re going to save their life.”

Huttle’s study was supported by the American Board of Pediatrics Foundation. Rahmandar and Heere reported having no financial conflicts of interest.

Brenda Sandburg is a freelance journalist for Medscape Medical News. She has written about the biopharmaceutical industry and legal issues for the Pink Sheet and American Lawyer Media.