The Blueprint: Strategizing and Partnering to End Youth Suicide

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Q&A

The American Academy of Pediatrics and American Foundation for Suicide Prevention (AFSP), together with experts from the National Institute of Mental Health, created an educational resource to support pediatric health clinicians and other health professionals in identifying strategies and key partnerships to support youth at risk for suicide: the Blueprint for Youth Suicide Prevention.¹ To tell us more about this resource, Psychiatric Times™ sat down with Christine Yu Moutier, MD, the Chief Medical Officer for the AFSP.

Psychiatric Times™ (PT): The Blueprint for Youth Suicide Prevention is the first major interdisciplinary effort to infuse suicide risk reducing strategies into pediatric care and youth community settings. How do you want this to help child and adolescent psychiatrists and mental health professionals? How can child & adolescent psychiatrists support this initiative?

Christine Yu Moutier, MD: The Blueprint provides steps for primary care pediatric health providers—ideally working alongside child and adolescent psychiatrists and other mental health professionals—to engage in suicide preventive actions in the health care settings where children and teens receive routine health care. Pediatricians are very trusted resources for families and medical settings are well-positioned to identify changes in mental health and screen for common conditions such as depression, anxiety, substance use problems, and eating disorders. All of these current efforts can be extended to specifically screen for suicide risk and provide education, support, and resources to patients and families.

Suicide is the second leading cause of death in youth and young adults, aged 10 to 24 years and many young people that die by suicide visit a health care provider in the months or weeks prior to the death—38% of adolescents had contact with a health care system within the 4 weeks before their death² and 34% of people 15 years of age and older had contact with a health care provider in the week before their death.³

That is why health care systems are a critical setting to identify youth at-risk for suicide and coordinate suicide prevention strategies that can have a dramatic impact on saving lives. The Blueprint for Youth Suicide Prevention can help psychiatrists and other mental health professionals address youth suicide prevention via care delivery, identify and remove common barriers for patients who need care and support, as well as implement strategies for integrating suicide prevention within the larger health care system.

Health system leadership and staff can protect youth mental health by considering the following clinical suicide prevention approaches:

-Risk identification, screening, and assessment;

-Indicated interventions, including safety planning and lethal means counseling for youth with suicidal ideation or behavior;

-Treatment such as the use of medications, more health care visits, or referral to evidence-based suicide risk reducing treatment; and

-Recovery including support systems that help individuals maintain progress, encourage posttraumatic growth, and find meaning and purpose.

PT: We know that minority youth are at an increased risk for suicide. In the Blueprint, a key takeaway is that health equity is critical to suicide prevention. Can you tell us more about that? Furthermore, what is the difference between equity and equality?

Moutier: In recent years, we have learned so much about the ways structural racism and health inequities have been long affecting the mental health and suicide risk of minoritized communities. For example, research shows experience(s) with discrimination impacts youths’ risk for suicidal thoughts and access to developmentally and culturally responsive mental health services is limited in many communities, clinics, and schools.⁴ Yet there is little research that explores suicidal thoughts, behaviors, and risk factors among LGBTQ2S+, American Indian, Alaska Native, Black, and Latinx communities nor the impact racism, historical or intergenerational trauma has on suicidal ideation.

Clinical suicide prevention efforts are needed to provide comprehensive, effective, and culturally appropriate care to youth populations, including: Black youth, American Indian and Alaskan Native, Latino youth, Asian American youth, LGTBQ2S+ youth, youth in rural and medically underserved communities, youth involved in the child welfare system or who have experienced family disruption, youth involved in the juvenile justice system, and youth with special care needs such as developmental disabilities.^5-14

Health equality assumes everyone can attain or reach their full potential if given the same resources when it comes to their health. However, we know that people are not at the same starting line and need different supports to reach their optimal health at a personal, community, and system level. That is why it is even more crucial we strive to achieve health equity. This involves reducing long-standing socioeconomic, cultural, and other barriers for medically underserved communities to receive the comprehensive, effective, and culturally appropriate care and treatment they need.

PT: Right now, there is a lot of legislation targeting the LGBTQ+ community (the “Don’t Say Gay” bill in Florida, and the anti-transgender directive in Texas). Do you think legislation like this will have an impact on rates of LGBTQ+ suicide? Are the upward trends of suicide in youth similar for LGBTQ+ youth as they are for cis youth?

Moutier: At the American Foundation for Suicide Prevention (AFSP), we are concerned. For many years, AFSP has funded research related to LGBTQ2S+ experiences and their potential impact on both suicide risk and protection. We also have taken strong positions in the policy arena when research supports a connection to suicide risk, such as our work across many states to ensure that conversion therapy is not accessible to minors. AFSP stands with the consensus of every major health organization and supports bans on practicing conversion therapy on minors.

Suicide most often occurs when stressors and health issues converge to create an experience of hopelessness and despair. For LGBTQ2S+ youth in particular, stigma, prejudice, and discrimination can increase the likelihood of stress, depression, traumatic experiences, violence, and serious mental health concerns. Conditions like depression, anxiety, and substance problems, especially when unaddressed or when people lack access to quality mental health care, pose a greater risk for suicide.

During the pandemic, we have seen more pro-mental health and suicide prevention legislation pass at federal and state levels, thanks to the 40,000 volunteer field advocates with AFSP and our colleague organizations like NAMI, MHA, Jed Foundation, and Trevor Project all raising our voices together. This reflects investments in research demonstrating effective strategies, combined with the voices of people with lived experience and suicide loss, clinicians and people from all walks of life joining in the incredible mental health and suicide prevention movement. However, it is our individual and collective responsibility to continue supporting the mental health and wellbeing as well as prevent suicide amongst LGBTQ2S+ youth, especially in light of legislation like Don’t Say Gay that restrict discussion of sexual orientation and gender identity in public schools and are harmful to LGBTQ2S+ youth mental health.

PT: The Blueprint stresses the importance of a collaborative care, multi-layered model. Will you talk a little more on why it is imperative that psychiatrists, primary care physicians, teachers, parents/guardians, and all clinicians caring for the child need to work together to prevent suicide?

Moutier: Suicide risk involves a complex set of factors at the individual, community, and societal levels. Child and adolescent psychiatrists as well as other mental health professionals understand the unique ways in which mental health impacts various stages of development in youth. This expertise can be extended beyond the clinic through a team-based, collaborative, and integrated care model by engaging schools and local communities in youth suicide prevention initiatives.

Youth face barriers in their school and local community due to a variety of social factors, community resources, as well as systemic racism and discrimination. They also face barriers when it comes to mental health support. That is why it is crucial for schools and community partners to work together to understand the resources and care systems available in their local community so pediatric health clinicians can best support mental health amongst youth based on where they live, learn, work, and play.

PT: In screening young patients for suicide, risk may be difficult to properly gauge with a parent/guardian in the room, as the patient may be less open in their responses. If the parent/guardian refuses to leave the room, what would you recommend to the screening psychiatrist?

Moutier: There are strategies clinicians are well versed in, in order to have private 1:1 conversations with children and teen patients. This issue is very relevant to sensitive conversations about suicidal thoughts and feelings surrounding this level of distress. The need for a nuanced approach to these sensitive conversations is addressed in the Youth Suicide Prevention Blueprint as seen in the section on Confidentiality and Parental Engagement.

PT: How is screening for suicide via telehealth different than in person including how it should be done as well as the efficacy of the screening?

Moutier: Many communities lack sufficient access to mental and behavioral health support. When traditional in-person mental health care appointments are unavailable, clinicians can help individuals and families consider alternative options like telehealth. Telehealth is an effective, convenient alternative to in-person screening, as it is mobile-friendly and uses multiple languages, interpreters, and assistive technologies to facilitate visits. It also has similar reliability and accuracy to in-person screening.

The patient, their family, and provider should determine together if telehealth is the appropriate modality for screening, if in-person is preferred, or if a hybrid approach will meet the child’s mental health care needs based on the nature or complexity of the child’s mental health condition, comfort level with telehealth, and ease of access.

For those who may not have access to telehealth capabilities, other resources such as a school psychologist, social worker, and/or other community-based resources are available. That is another reason why teachers, parents/guardians, and clinicians working together is imperative to preventing youth suicide.

Speaking of telehealth resources, all pediatricians should be aware of a wonderful resource available in many states, thanks to the incredible dedication of Pediatric Mental Health Care Access (PMHCA) Programs, sometimes referred to as Child Psychiatry Access Programs (CPAPs). These are programs that provide timely training and support to pediatric primary care clinicians (PCCs) and other clinicians related to detection, assessment, treatment, and referral of behavioral health conditions within their practice. This support is provided as part of a peer-to-peer, telehealth-based consultation model—PCCs can connect with off-site child/adolescent behavioral health professionals by phone, video call or email/web-based consultation. You can find more information on increasing access to behavioral health care via telehealth here.

PT: We have all heard the myth that bringing up topics like suicide will “put the idea in their heads.” Can you talk about why that is untrue? Do myths like this encourage stigma?

Moutier: People may think if “I ask if someone if they are suicidal, I will put the thought in their head” or “I’m going to increase risk,” because they have heard of the concept of suicide contagion, which stems from unsafe messaging that sensationalizes suicide and details suicide methods through media, social media, or other key moments of messaging. However, asking how an individual is feeling and if they are having thoughts of suicide in an open, caring manner has clearly not been shown to increase risk, and actually is thought to open up potentially game-changing dialog that may be the first step in getting professional treatment. When you ask someone about suicidal thoughts directly, it provides them with the opportunity to share what may have been not disclosed. And often times, suicidal thoughts being held in secret and never having the opportunity for processing, support or treatment, is thought to lead to worse outcomes including suicide risk.

In the past, before a body of scientific research led to an understanding of what drives suicide risk, many myths prevailed. This led to stigma and erroneous views of suicidal behavior resulting in harshly punitive ideas and judgment of people who experience suicidal thoughts, attempt suicide, or ultimately lose their lives to suicide. Now that a multidisciplinary group of scientific fields are shedding light on the actual drivers of suicide risk, cultural views are changing and bringing an understanding that while complex, suicide is a health issue.

PT: This Blueprint was developed at the Virtual Summit on Youth Suicide Prevention. Is there anything you’d like to highlight from the Summit?

Moutier: The Youth Suicide Prevention Summit was an incredible convening of over 100 experts including pediatricians, suicide experts, youth organization and school leaders, people with lived experience, and researchers over 3 days! It was moving in the level of engagement and dedication shown across every sector of society from health to education to juvenile justice. We also held 2 subsequent convenings—1 focused on the role of government agencies some of whom had never seen themselves as having a role in suicide prevention, and 1 focused on equity and minoritized youth, both of which had extremely high levels of engagement and sense of urgency. We are so grateful to ALL who gave of their time and expertise in developing the Blueprint, and those who will engage in the implementation of these potentially life saving actions.

PT: Thank you!

To see more of Dr Moutier’s thoughts on suicide, see Breaking the Trend: New CDC Data on Suicide.

Dr Moutier is chief medical officer of the American Foundation for Suicide Prevention, New York, NY.

Reference

1. Suicide: Blueprint for Youth Suicide Prevention. American Academy of Pediatrics, American Foundation for Suicide Prevention, National Institute of Mental Health. 2022. Accessed March 9, 2022. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/

2. Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29(6):870-877.

3. Laanani M, Imbaud C, Tuppin P, et al. Contacts with health services during the year prior to suicide death and prevalent conditions a nationwide study. J Affect Disord. 2020;274:174-182.

4. Madubata I, Spivery LA, Alvarez GM, et al. Forms of racial/ethnic discrimination and suicidal ideation: a prospective examination of African-American and Latinx youth. J Clin Child Adolesc Psychol. 2022;51(1):23-31.

5. The Congressional Black Caucus. Ring the alarm: the crisis of Black youth suicide in America. Emergency TaskForce on Black Youth Suicide and Mental Health. Accessed March 15, 2022. https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf

6. American Indian and Alaska Native populations. Suicide Prevention Resource Center. Accessed March 15, 2022. https://sprc.org/scope/racial-ethnic-disparities/american-indian-alaska-native-populations

7. Vargas SM, Calderon V, Beam CR, et al. Worse for girls?: gender differences in discrimination as a predictor of suicidality among Latinx youth. J Adolesc. 2021;88:162-171.

8. Wyatt LC, Ung T, Park R, et al. Risk factors of suicide and depression among Asian American, Native Hawaiian, and Pacific Islander youth: a systematic literature review. J Health Care Poor Underserved. 2015;26(2 Suppl):191-237.

9. Estimate of how often LGBTQ youth attempt suicide in the U.S. The Trevor Project. March 11, 2021. Accessed March 15, 2022. https://www.thetrevorproject.org/research-briefs/estimate-of-how-often-lgbtq-youth-attempt-suicide-in-the-u-s/

10. Fontanella CA, Hiance-Steelesmith DL, Phillips GS, et al. Widening rural-urban disparities in youth suicides, United States, 1996-2010. JAMA Pediatr. 2015;169(5):466-473.

11. Ivey-Stephenson AZ, Crosby AE, Jack SPD, et al. Suicide trends among and within urbanization levels by sex, race/ethnicity, age group, and mechanism of death — United States, 2001–2015. MMWR Surveill Summ. 2017;66(18):1-16.

12. Katz LY, Au W, Singal D, et al. Suicide and suicide attempts in children and adolescents in the child welfare system. CMAJ. 2011;183(17):1977-1981.

13. Abram KM, Choe JY, Washburn JJ, et al. Suicidal thoughts and behaviors among detained youth. Juvenile Justice Bulletin. July 2014. Accessed March 15, 2022. https://ojjdp.ojp.gov/sites/g/files/xyckuh176/files/pubs/243891.pdf

14. Rybczynski S, Ryan TC, Wilcox HC, et al. Suicide risk screening in pediatric outpatient neurodevelopmental disabilities clinics. J Dev Behav Pediatr. 2021 Oct 15. Online ahead of print.