Based on the data provided by the 2010 National Vital Statistics System (NVSS), suicide serves as the second leading cause of death among youth, ages 12-17, which results from the interaction of mental health disorders and other factors. Moreover, based on the 2010 National Vital Statistics System (NVSS), the overall suicide rate for youth ages 10-19 was 4.5 suicides per 100,000 suicides. Additionally, the data obtained reveals that the suicide rate is higher among boys than girls and it is higher among older children ages 15-19 than younger children ages 10-14 (Perou, R., Bitsko, R. H., Blumberg, S. J., et al., 2013). Yet, “girls have higher rates of suicidal ideation and attempted suicide” than boys (Cash, S. J., & Bridge, J. A., 2009). The 2010 National Vital Statistics System (NVSS) also reveals that the suicide rate is higher among White children than Hispanic and Black children (Perou, R., Bitsko, R. H., Blumberg, S. J., et al., 2013). Though, (Cash, S. J., & Bridge, J. A., 2009) interpose that “rates of attempted and completed suicide are highest among Native Americans”. However, data from January 2001 through December 2015 obtained from the Web-based Injury Statistics Query and Reporting System (WISQARS) of the Centers for Disease Control and Prevention reveals that “among children aged 5 to 12 years, black children had a significantly higher incidence of suicide than white children, whereas from 13 to 17 years, the suicide rate was approximately 50% lower among black youths than among white youths”. Furthermore, it was also revealed that “the suicide rate among those younger than 13 years is approximately 2 times higher for black children compared with white children, a finding observed in boys and girls” (Bridge, J. A., Horowitz, L. M., Fontanella, C. A.,et al, 2018). Some factors that could influence the increasing rates of suicide among black children could be resulting from the “disproportionate exposure to violence and traumatic stress, and aggressive school discipline. Black children are also more likely to experience an early onset of puberty, which increases the risk of suicide, most likely owing to the greater liability to depression and impulsive aggression. Black youth are also less likely to seek help for depression, suicidal ideation, and suicide attempts” (Bridge, J.A, Asti L, Horowitz LM, et al., 2015).
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Moreover, in terms of epidemiology, data obtained between 2003-2012, from the National Violent Death Reporting System (NVDRS) on all youth ages 5 to 14 who died by suicide, revealed that, children ages 5-11, “who died by suicide were more commonly male, black, died by hanging/ strangulation/suffocation, died at home, and experienced relationship problems with family members and friends”, as compared to early adolescents, ages 12-14, who died by suicide. It was also revealed that children ages 5-11, who died by suicide were “less likely to leave a suicide note, be depressed, or experience boyfriend/girlfriend problems compared with early adolescents who died by suicide”. Furthermore, the data also revealed “among decedents with a current mental health problem, a diagnosis of attention-deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) was more common in children who died by suicide compared with early adolescents who died by suicide”. Therefore, it suggests that those children ages 5-11, who were diagnosed with ADD/ADHD “may have been more vulnerable as a group to respond impulsively to interpersonal challenges”. It was also revealed “depression/dysthymia was more common among early adolescents who died by suicide compared with children who died by suicide”. Moreover, it was also revealed that, “3.9% and 7.5% of children and early adolescents, respectively, who died by suicide tested positive for opiates, rates higher than alcohol and other substances” (Sheftall, A. H., Asti, L., Horowitz, L. M., et al.,2016). Therefore, “comorbidity of psychiatric disorders, particularly of mood, disruptive, and substance abuse disorders, significantly increases the risk for youth suicide and suicidal behavior” (Cash, S. J., & Bridge, J. A., 2009).
Furthermore, some of the known barriers in access to service use are the availability of trained primary care professionals that are able to conduct screenings for depression and suicidal symptoms, since a report found that in 29% of all suicide decedents, the child and early adolescent did disclose their suicide intent to another person before their death, which allowed time for intervention. Therefore, “Pediatric primary care is an ideal venue for physicians and nurses to ask youth directly about suicidal thoughts and behaviors. More than 80% of youth visit their primary care provider at least once annually, and a similar percentage of youth who die by suicide were examined by a health care provider in the year before their death” (Sheftall, A. H., Asti, L., Horowitz, L. M., et al.,2016). However, in a survey conducted of 671 medical professionals, “Only 25.5% of respondents reported adequate training in adolescent suicide risk assessment, and 32.9% reported adequate knowledge in this area”. Yet, “Despite low rates of training and knowledge, 64.2% of PCPs reported feeling comfortable talking with adolescents about suicide, and 58.4% reported feeling comfortable deciding which circumstances require breaking an adolescent’s confidentiality”. Nonetheless, 32.8% of the respondents in that survey cited time as a barrier to suicide risk assessment. Moreover, less than half (44.5%) of the respondents “agreed that PCPs frequently use physical health billing codes to reflect behavioral health services rendered” and “more than half (54.6%) of the providers reported feeling undercompensated by insurance companies for treating behavioral health problems related to suicide”. Therefore, the limited knowledge of primary care providers about suicide risk, lack of reimbursement for screening, poor availability of behavioral health services, and the disregard of recent recommendations for increased screenings for depression and suicidal symptoms all serve as known barriers in access to service use (Diamond, G. S., O’Malley, A., Wintersteen, M. B. et al., 2012). Moreover, another known barrier in access to service use is that, “In pediatric settings, non-Hispanic black adolescents were less likely than white youth to receive care for psychiatric disorders” which poses as a significant barrier (Costello, E.J., He, J-P, Sampson, N. A., Kessler, R. C., Merikangas, K. R., 2014).
Furthermore, in regards to best practices in treatment and services, it is known that collaborative care models are effective in integrating “mental health professionals into primary care as educators, consultants, and clinicians in order to bridge the gap between specialty and primary care, improve communication and continuity of care, and determine the most appropriate level of care”. In a study among depressed older adults, collaborative care interventions within primary care were able to better recognize symptoms of depression and obtain greater access to evidence-based diagnosis and treatment, which was “proven to be successful in decreasing both depressive symptomatology and suicidal ideation”. Therefore, the findings of this study was applied to a sample of youth participants, and the results found that improving access to evidence-based cognitive-behavioral therapy (CBT) and antidepressant medication for adolescent depression in primary care significantly improved “access to mental health care, depressive symptoms, mental health–related quality of life, and satisfaction with care”. Moreover, “The rate of suicide attempts or self-harm declined by 55% in participants receiving the intervention” and as a result, “collaborative care interventions in primary care show promise in improving care for youth with depression and reducing suicidal ideation and attempts”. Furthermore, since there is not enough research conducted on best supported interventions for adolescents specifically, the most promising interventions to reduce adolescent suicide attempts, include “(1) attachment-based family therapy to target family processes associated with depression and suicide; (2) integrated CBT for suicidal, alcohol- or substance-abusing adolescents; and (3) CBT for suicide prevention, which consists of a chain analysis of the index suicide attempt, development of a safety plan, and an individualized treatment plan designed to reduce reattempt” (Bridge, J. A., Horowitz, L. M., Fontanella, C. A., et al., 2014). Likewise, a literature review demonstrates that cognitive therapy for suicide prevention (CT-SP) is very effective in reducing the likelihood of suicide re-attempt. Therefore, “recent suicide attempters who received CT-SP were 50% less likely to reattempt than participants who received enhanced usual care (EUC) with tracking and referral”. It was also demonstrated that, “CBT plus treatment as usual (TAU) also reduced self-harming behaviors relative to TAU alone”, which further supports the efficiency of cognitive-behavioral therapy, in conjunction with other treatment options for optimal results (Brown, G. K., & Jager-Hyman, S., 2014).
Moreover, a system of care approach may be useful to improve services for youth and adolescents at risk of suicide, which includes the “integration of mental health services in general medical settings, particularly in primary care”. Accordingly, “Families typically look to primary care professionals (PCPs) as trusted resources and are more likely to allow on-site, collaborating mental health professionals to earn their trust”. Therefore, “Collaborative care interventions based on the chronic care model and applied to pediatric mental disorders in primary care have been demonstrated to be feasible and effective in improving access to mental health services, treatment outcomes, and consumer satisfaction for both disruptive behavioral problems and depression” (Campo J.V., Bridge J.A., Fontanella C.A., 2015). Thus, as part of collaborative care “ED providers may serve a unique role in suicide prevention by assessing the mental health of patients after deliberate self-harm and providing potentially life-saving referrals for outpatient mental health care” (Bridge, J. A., Marcus, S. C., & Olfson, M., 2012). Accordingly, “whenever a child experiences problems, the standard approach is to refer them to counseling or outpatient psychotherapeutic services”, and as a result, Lyons suggests “outpatient clinicians should be trained and skilled in assessment techniques (e.g., using the CANS) that guide level-of-care decision making in the system”. Most importantly, “it is critical that clinicians who are working in outpatient programs receive training in evidence-based practices and that clinics develop triage decision support mechanisms to ensure that children presenting for services are optimally matched to the type of treatment or treatments that would best serve them” (Lyons, J., 2004). Furthermore, it was found that, “clinicians who reach out to patients (especially those patients not engaged in treatment) using caring letters to express concern and support may help to reduce the rate of suicide following discharge from a psychiatric hospital”. Therefore, “Outreach programs that provide comprehensive mental health treatment and emphasize follow-up and continuity of care following discharge from the hospital may also help to prevent repeat suicide attempts” (Brown, G. K., & Green, K. L.,2014).
- Bridge, J.A, Asti L, Horowitz LM, et al. (2015). Suicide Trends Among Elementary School–Aged Children in the United States From 1993 to 2012. JAMA Pediatr. 2015;169(7):673–677. doi:10.1001/jamapediatrics.2015.0465
- Bridge, J. A., Horowitz, L. M., Fontanella, C. A., Grupp-Phelan, J., & Campo, J. V. (2014). Prioritizing research to reduce youth suicide and suicidal behavior. American journal of preventive medicine, 47(3 Suppl 2), S229–S234. doi:10.1016/j.amepre.2014.06.001
- Bridge, J. A., Horowitz, L. M., Fontanella, C. A., Sheftall, A. H., Greenhouse, J., Kelleher, K. J., & Campo, J. V. (2018). Age-related racial disparity in suicide rates among US youths from 2001 through 2015. JAMA Pediatrics, 172(7).
- Bridge, J. A., Marcus, S. C., & Olfson, M. (2012). Outpatient Care of Young People After Emergency Treatment of Deliberate Self-Harm. Journal of the American Academy of Child & Adolescent Psychiatry, 51(2).
- Brown, G. K., & Green, K. L. (2014). A Review of Evidence-Based Follow-Up Care for Suicide Prevention. American Journal of Preventive Medicine. 47(3S2):S209–S215
- Brown, G. K., & Jager-Hyman, S. (2014). Evidence-Based Psychotherapies for Suicide Prevention Future Directions. American Journal of Preventive Medicine. 47(3S2):S186–S194.
- Campo J.V., Bridge J.A., Fontanella C.A. (2015). Access to Mental Health Services: Implementing an Integrated Solution. JAMA Pediatr. 2015;169(4):299–300. doi:10.1001/jamapediatrics.2014.3558
- Cash, S. J., & Bridge, J. A. (2009). Epidemiology of youth suicide and suicidal behavior. Current opinion in pediatrics, 21(5), 613–619. doi:10.1097/MOP.0b013e32833063e1
- Costello, E.J., He, J-P, Sampson, N. A., Kessler, R. C., Merikangas, K. R. (2014). Services for adolescents with psychiatric disorders: 12-month data from the national comorbidity survey-adolescent. Psychiatric Services, 65 (3): 359-366
- Diamond, G. S., O’Malley, A., Wintersteen, M. B., Peters, S., Yunghans, S., Biddle, V., … Schrand, S. (2012). Attitudes, Practices, and Barriers to Adolescent Suicide and Mental Health Screening: A Survey of Pennsylvania Primary Care Providers. Journal of Primary Care & Community Health, 29–35. https://doi.org/10.1177/2150131911417878
- Lyons, J. (2004). The role of existing programs and services in an evolving system. Redressing the Emperor: Improving Our Children’s Public Mental Health System. NY: Praeger, 179-197 (Chapter 6).
- Perou, R., Bitsko, R. H., Blumberg, S. J., et al. (2013). Mental health surveillance among children—United States, 2005-2011. Centers for Disease Control and Prevention.
- Sheftall, A. H., Asti, L., Horowitz, L. M., Felts, A., Fontanella, C. A., Campo, J. V., & Bridge, J. A. (2016). Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics, 138(4), e20160436. doi:10.1542/peds.2016-0436
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