Universal mental health screening identifies youth at risk of suicide, ups treatment initiation

Using tools for universal mental health assessment appears to also identify adolescents who are at risk of suicide, according to a recent study. Such findings underline the potential of developing and implementing suicide-specific screening tools among the youth.

“Although done in a school versus a primary care setting, the study results support the effectiveness of suicide risk screening to increase treatment initiation for identified adolescents,” the researchers said.

The study included 12,909 high school students enrolled across 14 institutions across Pennsylvania, US. Participants were randomly assigned to undergo their usual school practice of being referred to targeted intervention if they exhibit concerning behaviours suggestive of suicide risk (n=6,346), or to receive universal mental health screening using the Patient Health Questionnaire-9 (PHQ-9; n=6,437). Any response (score >0) on item number 9 of PHQ-9 was taken as an indicator of suicide risk.

Students who were identified to be at-risk in either trial arm were referred to the Student Assistance Program (SAP), the primary mechanism by which Pennsylvania public schools address student needs. The primary outcome of interest was the percentage of students, from either trial arm, who were deemed by SAP as needing further evaluation and who eventually initiated treatment.

Overall, 718 students were deemed to be at-risk of suicide, yielding a rate of 5.6 percent. Most of these participants (n=622) were identified by PHQ-9, while only 96 were caught through targeted screening. [J Pediatr 2022;doi:10.1016/j.jpeds.2022.07.036]

Subsequently, SAP found that 143 students from the PHQ-9 arm and 16 from the targeted screening arm warranted further evaluation. Eventually, 47 and 10 students in the respective groups initiated treatment for their high suicide risk.

Fitted regression analysis confirmed that universal assessments provided a more thorough screening for suicide risk. Compared with the usual school practices of targeted intervention, undergoing PHQ-9 testing led to more than seven-times increase in the likelihood of being identified as at-risk for suicide (odds ratio [OR], 7.1, 95 percent confidence interval [CI], 5.7–8.8).

Similarly, universal screening improved the odds of identifying participants needing further evaluation by nearly eight times (OR, 7.8, 95 percent CI, 4.6–13.1). Students who took PHQ-9 were also four times more likely to initiate eventual treatment (OR, 4.0, 95 percent CI, 2.0–7.9).

“Universal screening in the school setting with the PHQ-9 helps to identify students at risk for suicide, and increases treatment initiation,” the researchers said.

However, missing data could have limited the study’s conclusions, the researchers pointed out. In cases where students were referred to external intervention services, neither the school nor SAP had any further record of their progress. In turn, this could have led the present analysis to overlook students that initiated treatment, but did so through outside, unaffiliated channels.

In addition, initiating treatment does not necessarily lead to sustained student engagement or response to intervention. Thus, the clinical impact of universal screening remains largely unelucidated.

“Future work should aim to measure the functional improvements in students identified by school-based screenings, as well as the benefits of interventions designed to enhance treatment utilization as well as disease detection,” the researchers said.