On the AAP's latest clinical report on teen suicide
I want to commend the new Clinical Report, “Suicide and Suicide Attempts in Adolescents,” issued by the American Academy of Pediatrics (AAP) Committee on Adolescence. The lead author, Benjamin Shain, MD, and the Committee wrote a clear, concise, well-referenced report that is highly relevant to the practicing primary care pediatrician.
Let me note a few comments in the report that highlight why this is such a difficult, dangerous, and frustrating topic.
The rate of suicide in 15- to 19-year-olds is increasing, and the estimated 1748 deaths by suicide in 2013 is likely an underestimate.
The 2013 Youth Risk Behavior Survey of students in grades 9 through 12 in the United States indicated that during the 12 months before the survey, “39.1% of girls and 20.8% of boys felt sad or hopeless every day for at least 2 weeks in a row . . . .”
“. . . [R]isk factors are common, whereas suicide is infrequent . . . . Of importance, the lack of most risk factors does not make the adolescent safe from suicide.”
“Care in interviewing needs to be taken, because abrupt, intrusive questions could result in a reduction of rapport and a lower likelihood of the adolescent sharing mental health concerns.”
These 4 points indicate that suicide and attempted suicide are quite a substantial concern during the high school years, and that feeling hopeless and having a number of risk factors noted in the report is common. Further, these risk factors do not have a linear relationship to suicidal behavior, but instead risk factors have a complex interplay in the context of the teenager’s personality, family relationships, and family history. Screening is not especially helpful because rates for suicidal ideation and depression are high and may overstate clinical depression and suicide risk to a level that may not be clinically useful.
The report suggests that once a good rapport is established and the pediatrician is alone with the teenaged patient, he or she should ask, “Have you ever thought about killing yourself or wished you were dead?” and then “Have you ever done anything on purpose to hurt or kill yourself?” First, it is often not that easy to build a rapport especially because most teenagers may only be seen once or twice a year in practice. Second, these are hard questions to ask. These need to be asked in a nonjudgmental, somewhat relaxed tone in the midst of a busy practice setting. They need to be asked in a manner that welcomes the answer, and pediatricians must feel comfortable with the skills necessary to continue the interview and to decide whether and how urgent a mental health referral is needed. This is hard, skillful work. Some teenagers will not share their feelings and some pediatricians will be ill prepared for such a major emotional burden. Pragmatically, places to which to refer these patients may be distant or have long waiting lists. This is such a hard area that many pediatricians might not want to think about it and may stick to the “pediatric” aspects of the annual visit, as though the morbidity and mortality of suicide are not “pediatric.”
As much as we might not wish to deal with these issues, they are an increasing part of pediatrics. We need to work at every level—residency and CME education—to ensure the adequacy of referral sources, the recognition of the emotional burden on the physician of comprehensive pediatric practice, and the provision of fair reimbursement for the time and value of this work. We need to acknowledge to each other that psychosocial issues such as suicide, substance use, abuse, neglect, and domestic violence, among others, all are part of good care, all are hard work, and all require professional skills.