Melanie Cole (Host):  Risk and protective factors can play such an important role in suicide prevention. For clinicians, identifying risk and these protective factors provides critical information to assess and manage suicide risk in individuals. Today, we’re discussing addressing teen’s suicide risk when nobody trained you for this. this is Pediatrics In Practice with Children’s Mercy of Kansas City. I’m Melanie Cole. And with me is Dr. Shayla Sullivant. She’s a Child and Adolescent Psychiatrist at Children’s Mercy Kansas City and an Associate Professor of Pediatrics at the University of Kansas City. Dr. Sullivant, it’s a pleasure to have you with us. Tell us a little bit about risk and protective factors. What are those warning signs that other providers need to be aware of?

Shayla Sullivant, MD (Guest):  Certainly. Well one of the big things we know is that many young people who are having thoughts of suicide share that with someone. It may be with a friend. Sometimes it’s with an adult but it’s more often with a friend and so, we really need young people to know that that is hugely important to reach out to an adult if they know someone that’s struggling. Another big risk factor in fact, is having access to firearms. So, the literature is really clear on this that kiddos that live in homes with firearms are not more likely to be depressed or have conditions that lead to suicide but when they are struggling, they have quick access to a method that’s very lethal. So, having that access is of particular concern.

Host:  Well then please describe for us the current regulations and recommendations for suicide risk screening in healthcare systems especially when it comes to our teens.

Dr. Sullivant:  Well this is something that’s changing quite a bit. So, the Joint Commission has identified suicide as a major point of concern and so has American Academy of Pediatrics and made recommendations that we do screen our patients for suicide risk. So, what does that look like? And what does that mean? That’s different in different locations. One of the things we’ve done at our hospital is to implement universal suicide screenings. So, we are checking in with our patients whether or not they are identified as mental health patients about thoughts of suicide, about prior suicide attempts because we know those are things that predict future suicide attempts. It is something that is expanding. I think it’s really important to have a good response whenever you choose to identify those at risk. What do you do next? And I think that is really important.

Host:  Why aren’t pediatricians trained for this?

Dr. Sullivant:  I think it’s changing. And I do think increasingly it is a focus of training. However, I think that the main focus of psychiatry training has been – one of the main areas in psychiatry of course is addressing suicide risk. The problem is that the majority of young people who die by suicide are not in mental health specific treatment. And so I think there’s kind of been this gap that the young people that need it most are not getting that care. So, I think it’s a change that needs to happen. I know I’m seeing our pediatric residents getting more education about how to identify risk and how do we do something about it. Because really, prevention is the area of specialty of pediatrics. They are so good in pediatrics at preventing problems whether it’s by telling our patients to wear bicycle helmets or seatbelts and I think this is just another horizon where we need to focus our efforts is making sure that families understand what they can do within their own homes to reduce the risk of suicide.

Host:  That’s so interesting. So, Dr. Sullivant, while we’re talking about what needs to change for this training to happen and for providers to recognize the situation and while it’s helpful to treat the primary risk factors, whether that’s depression or bipolar or substance abuse, any of those things; how important is targeting the suicide risk directly and is there a way to do that?

Dr. Sullivant:  Well targeting the suicide risk directly I think is somewhat difficult because even though we’ve had a huge increase in rates of completed suicides; predicting who is going to die by suicide is not something that our community has figured out yet. And so, we are getting better at identifying who is at elevated risk but not specifically at the individual. And so that’s why I think we need to take more of a universal approach. We just done have certain people where seatbelts when they get in their cars because we don’t know who is going to be in a car accident that day. We all wear them. And I think that’s how it needs to be with safe firearm storage that we really get the whole community on board with that because we know it’s one of the most lethal methods and if it is not an option, then our patients are more likely to be here with us tomorrow to recover.

Host:  What about in the emergency department, have there been studies on the feasibility of emergency department based suicide risk screening for adolescents that come in with maybe cutting or other injuries that might have been self-inflicted?

Dr. Sullivant:  There have been and actually at Children’s we’ve implemented the universal screening in our emergency department and we’re finding it’s one of the areas where we have the highest rates of positive screens meaning the highest rates of seeing young people that are identified as elevated risk. So, it is important because we know that many people do not come in with a chief complaint of having thoughts of suicide. They may come in with a sore throat or with an ankle injury but then when we take the time to ask them; which by the way only takes a bout a minute; then we are identifying quite a few young people. So, it’s important because then we’ve identified them, and we can potentially change the trajectory of what happens next.

Host:  Does the Joint Commission recognize that the healthcare settings, you mentioned them earlier, do they recognize that there must be an active role in the suicide prevention? How are they asking providers to achieve that objective?

Dr. Sullivant:  Well so Joint Commission is really taking quite a few steps and one of the main ones with National Patient Safety Goal number 15 is to require that general medical hospitals screen those that are in mental health treatment for suicide risk. And one of the things we’ve looked at is the fact that not everybody who needs to be in treatment is and it can take some teasing out to discern who actually is in treatment and so that’s why we’ve taken this universal screening approach. Is trying to identify risk in any patient. Joint Commission also looks at some of the modifiable environmental factors so if there are things in the environment that could be used in a completed suicide, that’s important to address as well.

So, the immediate environment is really key.

Host:  Well it certainly is. And as you are helping us to identify teens at risk, walk us through ways for addressing it and when we’re looking at ask suicide screening questions, do you feel Doctor, that adolescents will honestly respond to these questionnaires? Are parents asked to respond to these questionnaires as well?

Dr. Sullivant:  I’ve had people say well they’re not going to be honest with you. They’re not going to be truthful. And the fact is, we have a lot of patients saying yes. Yes, I’m having those thoughts or yes, I’ve tried to end my life in the past and so, we can’t of course know who we might be missing and that is the hard part of it just like any medical intervention or screening tool, they tend not to be perfect. But we certainly are capturing a higher number than we expected. So, lots of young people are saying yes, I’ve had those thoughts. I’ve had those struggles. But the parents themselves are not specifically asked the questions but we did create a brochure for the parents to educate them on the fact that it’s safe for us to ask these questions, the fact that it’s really important that the whole community be aware of this problem and that everyone has a role to play.

So, parents can learn more about how to ask these questions themselves and certainly when a parent shares concerns directly with us, we listen. Because we know that the parent is really the expert on their son or daughter and often, they have very helpful information to share. So, whenever we identify someone at risk through our screening protocol, the parent or guardian is always included in the interview because we want to get feedback from them, and we also want to provide education to them.

Host:  It’s so important. As we wrap up, Dr. Sullivant, this very important topic, how would you like other providers to establish a safety plan as a best practice approach for intervening with suicidal adolescents and reducing access as you stated earlier to lethal means of suicide among individuals with identified risk?

Dr. Sullivant:  Sure, I think it’s really important for providers to understand that they have a hugely important role. And that it’s not just about identifying risk, but what happens next. So, if we help our patients to understand what their warning signs are, what their coping skills are, who they can call in a crisis and perhaps most importantly, limiting access to the items that are used in suicide, making sure parents understand the importance of locking up their firearms, unloaded with the ammunition locked up separately, disposing of unneeded medications in the home and locking up the rest of the medications. Those interventions are not consistently utilized throughout our community and yet if they were, the research tells us it can make a huge, huge impact when it comes to outcomes with regards to suicide.

Host:  Thank you so much for such an important topic Dr. Sullivant. Thank you for sharing your expertise with us today. Do you have any final thoughts for other providers and when you feel it’s important that they refer to the specialists at Children’s Mercy Kansas City?

Dr. Sullivant:  It’s really important to just applaud the pediatricians and the primary care providers in the community because we know that they work very hard and they encounter some really challenging situations so I think they really should never hesitate to reach out. If they are running into a difficult situation, they are not sure how to handle, I enjoy the phone calls I run into. I have talked to so many docs on the phone about situations and we troubleshoot the different options and paths that they can go. It doesn’t always involve a referral. Sometimes they just want to validate that their plan is a smart plan and more often than not, it really is. So, I think reaching out is always a good idea if you have a question.

Host:  Thank you again. This has been Pediatrics in Practice with Children’s Mercy Kansas City. For more information on developmental and behavioral services at Children’s Mercy please visit www.childrensmercy.org. Please remember to subscribe, rate and review this podcast and all the other Children’s Mercy podcasts. I’m Melanie Cole.