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Article |

Adolescent Patients—Healthy or Hurting?  Missed Opportunities to Screen for Suicide Risk in the Primary Care Setting FREE

Diane L. Frankenfield, DRPH; Penelope M. Keyl, PhD; Andrea Gielen, SCDx; Lawrence S. Wissow, MD; Lisa Werthamer, MSW, SCD; Susan P. Baker, MPH
[+] Author Affiliations

From the Center for Injury Research and Policy (Drs Frankenfield, Keyl, and Gielen and Ms Baker) and the Departments of Health Policy and Management (Drs Gielen and Wissow) and Mental Hygiene (Dr Werthamer), School of Public Health, and the Department of Emergency Medicine, School of Medicine (Dr Gielen), Johns Hopkins University, Baltimore, Md.


Arch Pediatr Adolesc Med. 2000;154(2):162-168. doi:10.1001/archpedi.154.2.162.
Text Size: A A A
Published online

Context  Adolescent suicide rates have increased dramatically in recent decades. Suicide is the third leading cause of mortality among persons aged 10 to 19 years. Several official guidelines recommend screening for suicidal behavior in the primary care setting.

Objectives  To determine the prevalence of adolescent suicidal behavior known to primary care providers and to determine the knowledge, attitudes, and practice of primary care physicians in Maryland regarding screening for risk factors for adolescent suicide.

Design  Cross-sectional study using mailed survey.

Setting  Maryland from May to July 1995.

Participants  All pediatrician (n = 816) and family physician (n = 592) members of the state chapter of the American Academy of Pediatrics and the American Academy of Family Physicians, respectively, who were actively providing ambulatory care.

Main Outcome Measures  Adolescent suicidal behavior known to primary care providers and predictors of routine screening for risk factors for adolescent suicide.

Results  The response rate was 66%. Three hundred twenty-eight physicians (47%) reported that 1 or more adolescent patients attempted suicide in the previous year, but only 158 (23%) either frequently or always screened adolescent patients for suicide risk factors. Significant factors correlating with routine screening for suicide risk factors included frequently or always counseling about the safer storage of firearms in the home (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.8-10.2); agreeing or strongly agreeing that they were sufficiently trained and knew how to screen for risk factors (OR, 3.2; 95% CI, 1.7-6.3); agreeing or strongly agreeing that they had enough time during the well visit to screen for mental health problems (OR, 2.9; 95% CI, 1.6-5.3); frequently or always counseling about child passenger safety (OR, 2.7; 95% CI, 1.6-4.7); spending more than 5 minutes in anticipatory guidance during the well visit (OR, 2.7; 95% CI, 1.5-4.6); practicing in an urban setting (OR, 2.3; 95% CI, 1.2-4.7); agreeing or strongly agreeing that physicians can be effective in preventing adolescent suicide and that what they do during an office visit may help prevent adolescent suicide (OR, 2.0; 95% CI, 1.2-3.4); and female sex (OR, 1.9; 95% CI, 1.1-3.2).

Conclusions  Despite the substantial proportion of primary care providers who encountered suicidal adolescent patients, most providers still do not routinely screen their patients for suicidality or associated risk factors. More training is needed and desired by the survey respondents. Patient confidentiality issues must be addressed. Development and widespread use of a short, easily administered, reliable, and valid screening tool are recommended to help busy clinicians obtain more complete information during all visits.

Figures in this Article

VIOLENT OR unnatural death is the primary cause of mortality for adolescents in the United States. Each year, more than 2000 people between the ages of 10 and 19 years complete suicide in this country.1 Nationally and in Maryland, suicide is the third leading cause of death in this age group, surpassed only by motor vehicle crashes and homicide fatalities.1 Completed suicide rates for adolescents have risen dramatically in recent decades,1,2 causing the US Department of Health and Human Services to set a national health objective for the year 2000 to reduce the suicide rate among adolescents aged 15 to 19 years by 25%.3

Completed suicide represents only the tip of this public health iceberg. The most recent Youth Risk Behavior Surveillance System survey4 found that during the 12 months prior to the survey, 20% of students in grades 9 through 12 had seriously considered attempting suicide, 16% had made a specific plan to attempt suicide, 8% had actually attempted, and 2.6% had made a suicide attempt requiring medical attention.

Almost all of the increase in the suicide rate may be attributed to the increase in deaths by firearms during the 1960s through the 1980s.5 The Centers for Disease Control and Prevention have attributed 81% of the increase in the suicide rate from 1980 to 1992 among 15- to 19-year-olds to firearm-related suicides.3 In 1992, firearm-related suicides accounted for 57% and 68% of all suicides in the 10- to 14-year-old and 15- to 19-year-old age groups, respectively.6

Primary care providers are in a unique position to help prevent suicide in adolescents. More than 70% of adolescents see a physician at least once each year, and more than 50% visited a physician for routine health care during the previous year.79

Both adolescents and parents are receptive to and desire discussion of psychosocial problems with their primary care provider,1012 yet several investigators have demonstrated that primary care providers do not routinely screen children or adolescents for psychosocial problems and that youth with emotional disorders are underidentified.1316 Barriers to screening for psychosocial problems cited by primary care providers include environmental factors such as time constraints,1720 insufficient reimbursement,17 inadequate referral services,17 lack of reminder or prompting mechanisms in the office setting,2124 and lack of clearly defined and noncontroversial guidelines.17 Physician factors include inadequate training,17,19,22,2528 reluctance to discuss sensitive issues,17 and ineffective communication skills.2932 Patient factors include reluctance to bring up the topic33 and concern about breaches of confidentiality.3439

This study was undertaken to determine the proportion of primary care providers encountering the attempted or completed suicide of an adolescent (defined for this study as 10 to 19 years old) patient, identify the prevalence of screening for suicide risk factors, and identify predictors of screening to target educational efforts. Pediatricians and family physicians composed the primary care physician group for this study, as the literature indicates most adolescents visit a practitioner in one of these specialties for their primary care.40,41

SAMPLE AND DATA COLLECTIONS

In May 1995, a questionnaire was mailed to all currently practicing pediatricians (n = 816) and family physicians (n = 592) on the mailing list of the Maryland chapters of the American Academy of Pediatrics and the American Academy of Family Physicians, respectively. The total design method of Dillman42 was used to format the instrument and develop the data-collection protocol. The questionnaire was pilot-tested in a cognitive-iterative manner.43 Confidentiality of responses for both pilot and study participants was assured. Three mailings were conducted from May through July 1995, with only the nonresponders receiving the second and/or third mailing. Analysis was restricted to primary care physicians currently providing ambulatory care.

ANALYSIS

The dependent variable (routine screening for selected risk factors for adolescent suicide) was constructed by adding the scores of the individual items that constituted this overall construct to create one overall screening score. Screening practice was defined in the questionnaire as "either through your clinical assessment, or by the use of a questionnaire completed by the patient or the parent(s), or a combination of these methods." The items contributing to this score included screening for depression, prior suicide attempt(s), alcohol use, other substance use, history of physical abuse, and history of sexual abuse. The responses to these items ranged from 1 to 5 on a 5-point Likert scale (never, 1, to always, 5). The overall screening score was then categorized into tertiles. The respondents in the highest tertile were defined as routine screeners (primarily with responses of frequently or always screens); they were compared with those responders in the lowest tertile (primarily with responses of never or infrequently screens).

The independent variables were categorized as physician characteristics, practice characteristics, risk factors for adolescent suicide, barriers to intervention, injury prevention counseling practices, and prevalence of adolescent patient suicidal behavior (Table 1).

Table Graphic Jump LocationTable 1. Independent Variables Examined*

The items that composed the physician's reported frequency of counseling about injury prevention, perception of importance of risk factors, and perception of barriers to intervention were submitted to factor analytic techniques. Any item not significantly loading onto a factor was retained as an individual item for subsequent logistic regression analysis.

The independent variables that were significantly (P<.01 because of the multiple comparisons being assessed)44 associated with screening in the bivariate analyses or that were considered conceptually important were introduced into a logistic regression model.45

The collected data were entered into a computerized data entry software package, EpiInfo, version 6.1,46 and analyzed using SPSS for Windows, version 6.1.47

RESPONDENTS

Six hundred ninety-three completed surveys were returned by 1054 eligible respondents, for a response rate of 66%, a rate comparable with or greater than that reported by others for mailed surveys to physicians.19,4851 Respondents were 63% male, with a median age of 44 years (Table 2). Practices were predominantly located in suburban settings without on-site mental health services. Physicians reported spending a median of 20 minutes per adolescent well visit, with 5 minutes devoted to anticipatory guidance.

Table Graphic Jump LocationTable 2. Characteristics of the Sample

Compared with nonrespondents, there were significantly more respondents from the Baltimore, Md, metropolitan area and fewer from Baltimore City and the Washington, DC, metropolitan area (P<.001). Respondents were similar as to sex, but were significantly younger than nonrespondents (P = .01).

PREVALENCE OF SUICIDAL BEHAVIOR ENCOUNTERED IN PRACTICES

Three hundred twenty-eight physicians (47%) reported having an adolescent patient who attempted suicide in the past year; the number of attempts during the past year ranged from 1 to 15 per practice. Seventy-four percent of physicians reported having 1 or 2 patients who attempted suicide. Thirty-five physicians (5%) in the sample reported ever having an adolescent patient complete suicide.

PREVALENCE OF SCREENING

Table 3 depicts the distribution of screening frequency for the selected risk factors for adolescent suicide. Frequently or always screening for alcohol use or abuse was reported by 75% of respondents, for other substance use by 71%, for depression by 54%, for physical abuse by 28%, for sexual abuse by 26%, and for prior suicide attempt(s) by 22%. Overall, 158 respondents (23%) either frequently or always screened adolescent patients for the selected suicide risk factors.

Table Graphic Jump LocationTable 3. Frequency Distribution of Screening Practice for Components of the Overall Screening Score*
PREVALENCE OF INJURY PREVENTION COUNSELING

Figure 1 depicts the frequency distribution of reported injury prevention counseling practices. Frequently or always counseling ranged from 67% for child passenger safety to 34% for the safer storage of firearms in the home.

Place holder to copy figure label and caption
Figure 1.

Frequency distribution of injury prevention counseling practices.

Graphic Jump Location
PHYSICIAN BELIEFS AND ATTITUDES

Histories of attempt(s) and depression were considered to be the most important risk factors for adolescent suicide (Figure 2); testing positive for the human immunodeficiency virus, having a conduct disorder, and concern about sexual orientation were considered to be the least important.

Place holder to copy figure label and caption
Figure 2.

Frequency distribution of perceived importance of risk factors for adolescent suicide. HIV indicates human immunodeficiency virus.

Graphic Jump Location

Most respondents indicated concerns about adequate reimbursement and insurance coverage for screening for mental health problems (Figure 3). Most respondents thought that they and physicians in general can be effective in preventing adolescent suicide. Most did not consider maintaining confidentiality for their adolescent patients' issues or concerns to be problematic. Approximately one third of respondents thought they had enough time during a well visit to screen for mental health problems (no significant difference for capitated vs fee-for-service practice) and considered themselves to be sufficiently trained to screen for adolescent suicide.

Place holder to copy figure label and caption
Figure 3.

Frequency distribution of perceived barriers to intervention in the office setting.

Graphic Jump Location

Most physicians (72%) reported an interest in more training on preventing adolescent suicide. There was no association between desiring more training and screening behavior. The most frequently mentioned topic of interest was screening and assessment (mentioned by 69% of physicians), followed by clinical indicators (65%), referral options (58%), legal issues (53%), and treatment (48%).

PREDICTORS OF ROUTINE SCREENING

Forty-two percent (138/328) of physicians who reported having 1 or more adolescent patients who attempted suicide in the past year routinely screened for risk factors for suicide, compared with 33% (113/346) of physicians who reported not having an adolescent patient attempt suicide in the past year (χ2 = 7.6; P = .02).

Table 4 lists the independent factors significantly correlating with routine screening for risk factors for adolescent suicide in the final logistic regression model.

Table Graphic Jump LocationTable 4. Final Model Indicating Variables Correlating With Routine Screening for Risk Factors for Adolescent Suicide*
IMPORTANT FINDINGS

Almost one half of respondents reported having encountered 1 or more adolescent patients who had attempted suicide sometime in the past year, and 5% reported that an adolescent patient had completed suicide. Despite such exposure to this health problem in their practice, routine screening ranged from approximately 22% for prior suicide attempts to 75% for alcohol use or abuse, indicating substantial room for improvement. Other investigators52,53 have found rates of screening for psychosocial risks among adolescent patients well below what is recommended by official guidelines (ie, the American Medical Association's Guidelines for Adolescent Preventive Services).54

Physician knowledge of risk factors for adolescent suicide is incomplete. Although most physicians recognized that histories of attempt(s) or depression are important risk factors for adolescent suicide, most did not recognize the importance of conduct disorder55 or concerns about sexual orientation56 as strong risk factors. This finding, coupled with our finding that physicians who agreed or strongly agreed that they were sufficiently trained and knew how to screen for suicide risk factors were more than 3 times as likely to routinely screen for these risk factors, suggests the need for more education and training in this area. Training has been recommended by several investigators to promote prevention counseling,57,58 desired and perceived as lacking by physicians themselves,59,60 and has been shown to have a beneficial effect on physician counseling skills, practice, and outcomes.48,6170

Physicians who more strongly believed that they had enough time during a well visit to screen for mental health problems were almost 3 times as likely to screen for suicide risk factors as those who did not. There is evidence in the literature that increased information exchange does not necessarily increase visit length.62,71 Managed care organizations, as well as individual practitioners, should closely examine the competing issues for the physician's time during a well visit and devise an approach to prioritizing these issues. More attention should be given to the environmental factors that could increase the amount and quality of information exchanged during the well visit without lengthening the visit. A short, acceptable, reliable, and valid screening tool for psychosocial or mental health problems in adolescent patients is needed. Completion of this form by the patient and/or family immediately prior to the encounter with the physician could provide helpful information and allow him or her to follow up with more in-depth probes in potential problem areas. Ancillary health professionals in the practice setting could be used to administer the assessment tool to maximize the amount and quality of information exchange during the office visit. Computer-aided self-administered interviews have proved useful in eliciting information about sensitive behaviors/issues7274 and are well accepted by adolescents.7580

Female physicians were almost twice as likely as male physicians to routinely screen for risk factors for suicide. This finding is not consistent with a Nebraska study that found no difference by physician age or sex in patterns of treatment or referral of adolescent suicide attempters,81 or with a national mail survey of pediatricians28 that found no difference by sex or year of graduation in the physician's perceived ability to treat adolescent psychosocial problems.

Routinely counseling about the safer storage of firearms in the home remained the most significant predictor in the final model. In addition to regarding site storage of firearms as general safety counseling, counseling about this safety topic may also be regarded in the context of suicide prevention.

LIMITATIONS

Because of the cross-sectional study design, causal relationships cannot be determined. All data were self-reported. Recall error may have been present, with respondents "telescoping" certain responses (ie, suicide attempts in the past year). Although the confidentiality of completed questionnaires was assured, some respondents may have provided socially desirable responses. The median of 20 minutes per well visit, with a median of 5 minutes devoted to anticipatory guidance, is significantly longer than reported in the literature. According to national statistics, one half of adolescent visits to primary care providers last 10 minutes or less; another 30% last 11 to 15 minutes.82,83 Other investigators have found that the average visit length for patients aged 2 weeks to 18 years was 10.3 minutes, with 7 seconds the average amount of time spent in anticipatory guidance.84

While the response rate of 66% is comparable to or greater than response rates reported for mailed surveys to physicians, a higher response rate would have been desirable. We do not have any information on the prevalence of nonrespondent physicians' encounters with adolescent patients who are suicidal. Even if none of the nonresponding physicians had encountered a suicidal patient, almost one third (31%) of all those to whom surveys were sent would have encountered adolescent patients who were suicidal.

Finally, this survey captured information solely on physicians; no information was obtained concerning adolescent patient or family issues or concerns. These are important components of physician-patient interactions; lack of this information results in a less complete understanding of the physician-patient information exchange.

Primary care providers either may be the sole source of medical care for this population or may serve a gatekeeper role in identifying and referring high-risk youths and families. They are in a key position to offer preventive counseling to their patients and families. Medical groups have long recognized the importance of providing preventive services to adolescents. In addition to Guidelines for Adolescent Prevention Services, the American Academy of Pediatrics has published recommendations for preventive pediatric health care and the American Academy of Family Physicians has published guidelines for periodic health examinations for all age groups. Both documents describe the need to address psychosocial issues in the pediatric and adolescent age groups and provide suggested areas to cover for specific age groups.

We recommend that adolescent patients be screened for psychosocial problems at all visits. This would include screening during sports physical examinations, physical examinations for camp attendance, any short-term care visit, and any visit to the emergency department. Within the context of diminishing resources and increasing expectations and demands on their time and expertise, physicians must be able to optimize their delivery of health care services. It is incumbent on those in a position to effect change that these gatekeepers in the trenches be provided with the tools they need to provide optimal health care. This would include appropriate training during all stages of education and, after formal education has been completed, provision of helpful screening tools, reminder systems, and sufficient ancillary health care professionals to maximize or extend the services provided. Public policies and organizational goals that support preventive strategies and services and remove or diminish barriers to intervention are needed. Advocacy for reimbursement of preventive services by organized groups, such as the American Medical Association, American Academy of Pediatrics, and American Academy of Family Physicians, is required. Only with concerted comprehensive efforts will the goal of optimized appropriate health care delivery to adolescents be realized.

Box Section Ref ID

Editor's Note: One of the most dramatic bits of information from this study is that about half of the physicians encountered 1 or more adolescents who attempted suicide in the past year. What's wrong with this picture?—Catherine D. DeAngelis, MD

Accepted for publication June 29, 1999.

Corresponding author: Diane L. Frankenfield, DrPH, Johns Hopkins Injury Center, Room 537, Hampton House, 624 N Broadway, Baltimore, MD 21205 (e-mail: sbaker@jhsph.edu).

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Greenfield  SKaplan  SHWare  JE  et al.  Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3448- 457
Link to Article
Lessler  JTO'Reilly  JM Mode of interview and reporting of sensitive issues: design and implementation of audio computer-assisted self-interviewing. NIDA Res Monogr. 1997;167366- 382
Locke  SEKowaloff  HBHoff  RG  et al.  Computer-based interview for screening blood donors for risk of HIV transmission. JAMA. 1992;2681301- 1305
Link to Article
Boekeloo  BOSchiavo  LRabin  DLColon  RTJordan  CSMundt  DJ Self-reports of HIV risk factors by patients at a sexually transmitted disease clinic: audio vs written questionnaires. Am J Public Health. 1994;84754- 760
Link to Article
Millstein  SGIrwin  CE  Jr Acceptability of computer-acquired sexual histories in adolescent girls. J Pediatr. 1983;103815- 819
Link to Article
Paperny  DMAono  JYLehman  RMHammar  SLRisser  J Computer-assisted detection and intervention in adolescent high-risk health behaviors. J Pediatr. 1990;116456- 462
Link to Article
Reich  WCottler  LMcCallum  KCorwin  DVanEerdewegh  M Computerized interviews as a method of assessing psychopathology in children. Compr Psychiatry. 1995;3640- 45
Link to Article
Paperny  DM Computerized health assessment and education for adolescent HIV and STD prevention in health care settings and schools. Health Educ Behav. 1997;2454- 70
Link to Article
Turner  CFKu  LRogers  SMLindberg  LDPleck  JHSorenstein  FL Adolescent sexual behavior, drug use, and violence: increased reporting with computer survey technology. Science. 1998;280867- 873
Link to Article
Paperny  DMHedberg  VA Computer-assisted health counselor visits: a low-cost model for comprehensive adolescent preventive services. Arch Pediatr Adolesc Med. 1999;15363- 67
Link to Article
McIntire  MSFine  PFain  PR Early indicators of self-destructive behaviors in children and adolescents: primary detection by the pediatrician. Sudak  HSFord  ABRushforth  NBeds.Suicide in the Young Littleton, Mass John Wright–PSG Inc1984;
Society for Adolescent Medicine, Access to health care for adolescents: a position paper of the Society for Adolescent Medicine. J Adolesc Health. 1992;13162- 170
Link to Article
Nelson  C Office Visits by Adolescents.  Hyattsville, Md National Center for Health Statistics1991;Advance Data From Vital and Health Statistics, No. 196
Reisinger  KSBires  JA Anticipatory guidance in pediatric practice. Pediatrics. 1980;66889- 892

Figures

Place holder to copy figure label and caption
Figure 1.

Frequency distribution of injury prevention counseling practices.

Graphic Jump Location
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Figure 2.

Frequency distribution of perceived importance of risk factors for adolescent suicide. HIV indicates human immunodeficiency virus.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Frequency distribution of perceived barriers to intervention in the office setting.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Independent Variables Examined*
Table Graphic Jump LocationTable 2. Characteristics of the Sample
Table Graphic Jump LocationTable 3. Frequency Distribution of Screening Practice for Components of the Overall Screening Score*
Table Graphic Jump LocationTable 4. Final Model Indicating Variables Correlating With Routine Screening for Risk Factors for Adolescent Suicide*

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Davis  DAThomson  MAOxman  ADHaynes  RB Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA. 1995;274700- 705
Link to Article
Greenfield  SKaplan  SHWare  JE  et al.  Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3448- 457
Link to Article
Lessler  JTO'Reilly  JM Mode of interview and reporting of sensitive issues: design and implementation of audio computer-assisted self-interviewing. NIDA Res Monogr. 1997;167366- 382
Locke  SEKowaloff  HBHoff  RG  et al.  Computer-based interview for screening blood donors for risk of HIV transmission. JAMA. 1992;2681301- 1305
Link to Article
Boekeloo  BOSchiavo  LRabin  DLColon  RTJordan  CSMundt  DJ Self-reports of HIV risk factors by patients at a sexually transmitted disease clinic: audio vs written questionnaires. Am J Public Health. 1994;84754- 760
Link to Article
Millstein  SGIrwin  CE  Jr Acceptability of computer-acquired sexual histories in adolescent girls. J Pediatr. 1983;103815- 819
Link to Article
Paperny  DMAono  JYLehman  RMHammar  SLRisser  J Computer-assisted detection and intervention in adolescent high-risk health behaviors. J Pediatr. 1990;116456- 462
Link to Article
Reich  WCottler  LMcCallum  KCorwin  DVanEerdewegh  M Computerized interviews as a method of assessing psychopathology in children. Compr Psychiatry. 1995;3640- 45
Link to Article
Paperny  DM Computerized health assessment and education for adolescent HIV and STD prevention in health care settings and schools. Health Educ Behav. 1997;2454- 70
Link to Article
Turner  CFKu  LRogers  SMLindberg  LDPleck  JHSorenstein  FL Adolescent sexual behavior, drug use, and violence: increased reporting with computer survey technology. Science. 1998;280867- 873
Link to Article
Paperny  DMHedberg  VA Computer-assisted health counselor visits: a low-cost model for comprehensive adolescent preventive services. Arch Pediatr Adolesc Med. 1999;15363- 67
Link to Article
McIntire  MSFine  PFain  PR Early indicators of self-destructive behaviors in children and adolescents: primary detection by the pediatrician. Sudak  HSFord  ABRushforth  NBeds.Suicide in the Young Littleton, Mass John Wright–PSG Inc1984;
Society for Adolescent Medicine, Access to health care for adolescents: a position paper of the Society for Adolescent Medicine. J Adolesc Health. 1992;13162- 170
Link to Article
Nelson  C Office Visits by Adolescents.  Hyattsville, Md National Center for Health Statistics1991;Advance Data From Vital and Health Statistics, No. 196
Reisinger  KSBires  JA Anticipatory guidance in pediatric practice. Pediatrics. 1980;66889- 892

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