Teens who have frequent suicidal thoughts are at risk for a variety of psychological and social problems, according to a new study by researchers at Massachusetts General Hospital (MGH). These findings, reported in the Journal of Developmental and Behavioral Pediatrics, can help pediatric primary care physicians identify and care for youths at risk for depression, anxiety, attention disorders and other conditions that respond well to treatment.
Suicide is the second leading cause of death among people aged 10 to 24 in the United States, a grim reality that creates a challenge for primary care physicians, notes MGH psychiatrist Michael Jellinek, MD, who provided clinical leadership for the study.
Pediatricians are in a very difficult position. Many primary care pediatricians believe that they're supposed to prevent suicide. But research shows that there are no really accurate ways to predict suicide for an individual patient."
Michael Jellinek, MD, MGH psychiatrist
What's more, while every suicide is a tragedy and the rate has climbed among young people in recent years, says Jellinek, it is a rare occurrence in most pediatricians' patient populations: About one in 10,000 adolescents commits suicide.
Screening tools are available that can be used to measure an adolescent's emotional state, including whether they have had thoughts of dying by suicide (known as suicidal ideation). "Of course, we must urgently help teenagers at the highest risk of suicide," says Jellinek. "But we really have to address the whole group of teens who may need help, rather than trying to focus all of our resources on predicting which adolescent is at imminent suicide risk."
Several decades ago, Jellinek and longstanding collaborator Michael Murphy, Ed.D., of MGH's Division of Child Psychiatry, developed a screening questionnaire called the Pediatric Symptom Checklist (PSC), which has since become widely used. The PSC, which is completed by parents, asks how often a child engages in a number of behaviors, such as "fights with other children," "is distracted easily," and "feels sad, unhappy." Applying this instrument, Jellinek and Murphy set out to develop an approach to screening that would help pediatricians better understand and respond to adolescents with suicidal ideation. Their team included lead author Juliana Holcomb, who was a clinical research coordinator in the Division of Child Psychiatry at MGH at the time of the study.
The group worked with a national database that included medical records for 5,411 adolescents aged 11 to 17 who had completed a brief, standardized questionnaire that's widely used to screen for depression in youths, known as the Patient Health Questionnaire (PHQ-9), which they filled out prior to routine physical exams. The form asks how often during the past two weeks the teen had experienced a number of symptoms, including: "Thoughts that you would be better off dead, or of hurting yourself in some way." Possible responses are "not at all," "several days," "more than half the days," and "nearly every day."
In what may be the first study of its kind, the researchers used these two, large sets of questionnaire data and came to several conclusions about teens who contemplate suicide. First, they found that about five percent of the adolescents in the study had experienced suicidal ideation during at least several days in the two weeks prior to completing the question, explains Holcomb. Not surprisingly, symptoms of depression are often closely linked with suicidal thoughts, she points out. "But we saw that adolescents who reported suicidal ideation were not just experiencing depression. They have many other emotional difficulties," she says.
For example, data from these questionnaires showed that teens who had frequent thoughts of suicide also experienced psychosocial problems such as internalizing (being withdrawn, depressed and/or anxious), externalizing (disruptive behavior, aggression), and attention difficulties. The more often a teen reported thinking about suicide, the study found, the more likely they were to have additional psychosocial problems. Most relevant to suicide prevention, data showed that teens in this group also had more suicide attempts.
"The message is that, although we can't necessarily predict an individual's death by suicide in pediatric primary care, we can identify adolescents who are at risk and who are struggling," says Holcomb. "All of these individuals, regardless of whether they will attempt suicide, deserve the highest quality of care and relief of their psychosocial distress," which could mean recommending lifestyle changes, guidance for the family, medication, or referral to a mental health clinician.
Jellinek believes that suicidal ideation should be thought of as an indicator for psychological and social problems in much the same way blood tests are used to identify adolescents at risk for diabetes, anemia and other conditions. "The approximately five percent of teenagers identified by the PSC and PHQ-9 should be treated almost like they have a chronic disease," says Jellinek. "It's a group that needs care management and ongoing attention, which pediatricians already do routinely with other chronic conditions."
Jellinek is also a professor of Psychiatry and of Pediatrics at Harvard Medical School. Holcomb is now a graduate student in the Department of Psychology at Suffolk University in Boston.
This work was supported by the Fuss Family Fund and a grant from the National Institute of Mental Health.
Holcomb, J.M., et al. (2022) Suicidal Ideation in Adolescents. Understanding Results from Screening with the PHQ-9M and the PSC-17P. Journal of Developmental & Behavioral Pediatrics. doi.org/10.1097/DBP.0000000000001063.