Preventing Youth Suicide:Preventing Youth Suicide:Does Access to Care Matter?Does Access to Care Matter?

John V. Campo, MD

Nationwide Children’s Hospital

Ohio State University Medical CenterEmail John.Campo@nationwidechildrens.org

04/18/23 2

ObjectivesObjectives

To review pediatric suicide as a preventable public health problem

To explore the relationship between suicide and access to care

To discuss a few novel efforts designed to improve access to care for youth at risk

04/18/23 3

Suicide and Access to CareSuicide and Access to CareMain PointsMain Points

Youth suicide rate ↑ since 2004 Suicide risk associated with psychiatric

disorder, especially mood disorder Suicide risk negatively correlated with

access to quality mental health care Improving access to effective care has

potential to reduce youth suicide risk

04/18/23 4

Pediatric SuicidePediatric SuicideA Public Health ChallengeA Public Health Challenge 3rd leading cause death ages 15-24 yrs

– Only accidents and violence kill more…– Among top ten causes of death worldwide

U.S. deaths for ages 15-24 years (2006)– 4,189 deaths due to suicide

– More than following causes COMBINED • Cancer (1644) + cardiovascular disease (1376) +

stroke (210) + HIV (206) + influenza and pneumonia (184) + diabetes (165) + septicemia (139) + asthma (135) + meningitis (47)

04/18/23 5

Pediatric SuicidePediatric SuicideA Public Health ChallengeA Public Health Challenge After a decade of decline, the U.S.

youth suicide rate ↑’ed ~20% in 2004– Responsible for > 300 additional deaths– Only ↑’ing cause of pediatric death

Increase appears to be persistent

Bridge et al. JAMA 2008; 300(9):1025-1026

04/18/23 6

Copyright ©2008 BMJ Publishing Group Ltd.

Bridge et al. JAMA 2008; 300(9):1025-1026

04/18/23 7Bridge et al. JAMA 2008; 300(9):1025-1026

Annual Rate of SuicideU.S. Males and Females Aged 10 to 19 Years

1996 through 2005*

04/18/23 8

Pediatric SuicidePediatric Suicide A Public Health Challenge A Public Health Challenge (cont.)(cont.)

Prevalence of suicidal ideation – ~ 15% of U.S. high school students annually

Prevalence of suicide attempts– ~7% of U.S. high school students annually

15 to 24 year age range vulnerable – Age of ↑ risk for mood and other disorders, – May “fall between the cracks” of the health

system (transition to adulthood…)• Important to campus suicide prevention efforts

04/18/23 9

Pediatric SuicidePediatric SuicidePsychiatric Disorder and RiskPsychiatric Disorder and Risk Untreated psychiatric disorder the

most substantial remediable risk factor– ~90% of completers have a psychiatric d/o– Risk especially strong for mood disorders

• Depression the main predictor of suicidal ideation

• Depression ↑ risk of completion and attempts– 2-7% of MDD youth complete suicide later in life – 40-80% of attempters suffer from depression

• Bipolar disorder, particularly mixed, confers ↑ risk

– Comorbidity, chronicity, severity ↑ risk

04/18/23 10

Pediatric Suicide Pediatric Suicide Depression and Suicide RiskDepression and Suicide Risk

Odds Ratio

Suicide completionBrent et al., 1999 7.5 - 12.9Shaffer et al., 1996 16 - 20

Suicide attempt

Andrews et al., 1992 12.0 - 14.7Beautrais et al., 1996 27.3

04/18/23 11

Pediatric SuicidePediatric SuicideAdult Pharmacotherapy RCTsAdult Pharmacotherapy RCTs Meta-analyses of antidepressant

RCTs have not shown clear protective effects

Persuasive meta-analytic evidence that lithium reduces suicide risk in adults

Some evidence that clozapine reduces suicide risk in adults with schizophrenia

04/18/23 12

Forest Plot Showing Meta-Analysis of Suicides Plus Deliberate Self-Harm in Randomized Trials Comparing

Lithium with Placebo or Active Comparators

Cipriani et al., 2005

04/18/23 13

Pediatric SuicidePediatric SuicideAdult Psychotherapy RCTsAdult Psychotherapy RCTs Dialectical Behavior Therapy

– Reduced rate of repeat suicide attempts in adults who attempted suicide

Cognitive Behavioral Therapy– Some evidence that CBT may reduce suicide

attempts and suicidal behaviors– May be most effective when includes specific

elements focused on reducing suicidality

04/18/23 14

Pediatric SuicidePediatric SuicidePediatric RCTsPediatric RCTs Few pediatric RCTs specifically address

suicide as an outcome– Suicidal youth often excluded from RCTs– Mixed results for psychotherapy studies– TADS and TORDIA studies showed reductions

in suicidality for all groups• TADS showed greatest reduction in suicidality in

fluoxetine + CBT group• TORDIA study found no meaningful differences

between groups

04/18/23 15

Pediatric SuicidePediatric SuicidePharmacoepidemiologic StudiesPharmacoepidemiologic Studies Coincident ↓ pediatric suicide rates with ↑

SSRI prescribing since late 1990s– Similar findings in US and Europe– Geographic trends for ↓ suicide with ↑ Rx– 1% ↑ in adolescent antidepressant use associated with

a ↓ of 0.23 suicide per 100 000 adolescents per year • Olfson et al., Arch Gen Psychiatry 2003

Longer antidepressant Rx may reduce suicide risk– Rx > 180 days vs. Rx < 55 days

Studies of completed suicide– < 10% completed suicides who had been prescribed

antidepressants + at autopsy

04/18/23 16

Pediatric SuicidePediatric SuicidePrimary Care Based StudiesPrimary Care Based Studies Primary care based education for PCCs in

recognition and management of depression may be a very promising approach – PROSPECT study

• Collaborative care for depressed suicidal elders was more effective than TAU for reducing suicidality

– Gotland study • Improved PCC ability to treat depression resulted in

decreased suicide rate

– Youth Partners in Care (Asarnow et al. 2005)• Suggest that improved treatment of adolescent depression in

primary care may reduce suicidality risk

04/18/23 17

Pediatric SuicidePediatric SuicideOther InterventionsOther Interventions Promising interventions include

those maintaining long term contact with at risk individuals and offering psychoeducation– Use of technology as simple as the

telephone may be especially helpful

04/18/23 18

Pediatric SuicidePediatric SuicidePopulation Based StudiesPopulation Based Studies Negative correlation between suicide

rate and access to health and MH services

• Tondo et al., J Clin Psychiatry 2006

Type of service availability matters– Multifaceted services protective– > outpatient to inpatient ratio advantageous– 24 hour emergency services useful

• Pirkola et al., Lancet 2009

Rural residence associated with risk

04/18/23 19

Pediatric SuicidePediatric SuicideTreatment RealitiesTreatment Realities Most youth at risk for suicide

receive inadequate treatment or no treatment – Only 7 to 20% of suicide completers had seen a

MH profession in prior 1 to 3 months– Antidepressants rarely found in toxicological

studies after completed youth suicides– Some studies correlate low SSRI prescription

rates with higher rates of youth suicide• Gibbons et al., Am J Psychiatry 2006, Olfson et al., Arch

Gen Psychiatry 2003

04/18/23 20

The Access to Care ChallengeShortage of Pediatric Psychiatrists* Current US average is 8.7 pediatric

psychiatrists per 100,000 youth– Range 3.1 (Alaska) to 21.3 (Massachusetts)– Estimated need ~ 14.4 per 100,000– Ohio ranks 30th (6.7 per 100,000)

Number of training programs is decreasing and number of trainees static

Average age of practitioners increasing Shortage will grow worse at current

levels of training and support

* Thomas and Holzer, JAACAP 2006

04/18/23 21

Child and Adolescent PsychiatryChild and Adolescent PsychiatryNumber per county in U.S. (2009) Number per county in U.S. (2009)

04/18/23 22

Child and Adolescent PsychiatryChild and Adolescent PsychiatryOhio Rate per 100,000 youth (2009) Ohio Rate per 100,000 youth (2009)

04/18/23 23

Meeting the NeedTransformational Change

To improve access to care To improve care quality To challenge stigma To improve efficiency of care

04/18/23 24

Access to Effective TreatmentAccess to Effective TreatmentNeed for a System of CareNeed for a System of Care Stepped care

– Different levels of care depending on type of disorder, its severity, complexity, and/or persistence in the face of intervention• Primary care/general medical care• Outpatient specialty MH care• Intermediate specialty MH care• Acute inpatient psychiatric care• Long term residential treatment

– Collaboration across disciplines the key

04/18/23 25

Pediatric SuicidePediatric SuicideThe Relevance of Primary CareThe Relevance of Primary Care

The primary care setting may prove to be critical to meaningful prevention– 80% of completers had contact with a

primary care clinician in the prior year– 40-60% had contact with PCC in prior month – Shortage of pediatric mental health

professionals is deep and persistent– Treatment of geriatric depression in primary

care demonstrated to ↓ suicide risk

04/18/23 26

Pediatric SuicidePediatric SuicideIdentifying At Risk YouthIdentifying At Risk Youth Medical Settings

– Primary Care– Specialty Care– Emergency Departments/Crisis Centers– Hospitals

Schools Juvenile Justice/Courts Child Welfare Settings

04/18/23 27

Suicidality Screening in Primary CareSuicidality Screening in Primary CareHealth eTouchHealth eTouch

Developed by Drs. Bill Gardner and Kelly Kelleher and colleagues

Portable with little space requirement Automatically scored and stored Little imposition on office work flow Confidential and secure Potential to integrate with EMR

04/18/23 28

Youths are given the tablet in the primary care waiting room.

04/18/23 29

A stylus is used to select responses to multiple-choice questions. For privacy, the system moves to the next question as soon as a response is entered.

04/18/23 30

Report is clipped to patient’s chart so that it is available to the clinician during the visit.

04/18/23 31

Health eTouch Screening Results

20%

17%

15%

8%

5%

0%

5%

10%

15%

20%

25%

Depression Suicidality Tobacco,Alcohol,

Marijuana

Alcohol Marijuana

High levels of mental and behavioral risk found in patients at nine urban primary care clinics serving a predominantly Medicaid population.

04/18/23 32

The clinician can follow-up on issues identified by screening. The report form includes contact information for referrals to enhance efficiency.

04/18/23 33

Access to Effective TreatmentAccess to Effective TreatmentUse of Novel TechnologiesUse of Novel Technologies Health eTouch

– Screening– Case finding– Assessment

Decision support for PCCs Access to informal psychiatry consultation

Telepsychiatry (Rural areas especially) Interactive voice response technology

– PhaST study

04/18/23 34

Pharmaceutical Safety Tracking PhaST

Study funded by AHRQ (Gardner, PI) In wake of “Black Box Warning”

– FDA recommends intensive f/u monitoring• Weeks 1, 2, 3, 4, 6, 8, then monthly until stable• No research support for recommendation• Infeasible for clinicians and families

– Pediatric antidepressant prescriptions ↓ Need for feasible safety monitoring

04/18/23 35

Pharmaceutical Safety Tracking PhaST (cont.) Interactive voice response technology (IVR)

– “Robotic phone calls” Medication AEs monitored on FDA schedule 8 questions answered using phone pad Positive response triggers study clinician call AEs classified as routine, urgent, or emergent Prescribing physician contacted accordingly

and/or emergency response activated

04/18/23 36

Pharmaceutical Safety Tracking PhaST (cont.)

PHASTRegistry

MD

Other ClinicalDatabases

Family IVR Telephone Robot

CATI & Triage

WorkstationPHASTNurse

Waiting RoomComputers

ReportsData

Questions

Answers

The PhaSTSystem

04/18/23 37

Pediatric SuicidePediatric SuicidePrevention StrategiesPrevention Strategies Effective treatment for psychiatric d/os

– Consensus is growing that untreated psychiatric disorders are the most substantial remediable risk factor for suicide

Reduce access to lethal means Screening to identify high risk individuals Education and awareness programs Influence media reports of suicide

04/18/23 38

Pediatric SuicidePediatric SuicideSelected ReferencesSelected References Bridge JA, Greenhouse JB, Weldon AH, Campo JV,

Kelleher KJ. Suicide trends among youths aged 10 to 19 years in the United States, 1996-2005. JAMA 2008; 300(9):1025-1026.

Campo JV. Youth suicide prevention: Does access to care matter? Current Opinion in Pediatrics 2009; 21:628-634.

Campo JV. Suicide prevention: time for ‘zero tolerance’ [Editorial]. Current Opinion in Pediatrics 2009; 21:611-612.

 

39

Nationwide Children’s Hospital Nationwide Children’s Hospital Physician Decision SupportPhysician Decision Support

•During business hours (M–F, 8 am – 5 pm)•Page (614) 690-1887 or Call (614) 355-8080

•Select option 2 for doctor’s office, then 2 •Email

BHDecisionSupport@NationwideChildrens.org •For urgent questions after hours,

•Call (614) 722-2000 - ask for psychiatrist on-call