Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments

Rates of suicidal ideation, suicide attempts, and suicide have increased among adolescents over the past 15 years, with a sharp increase among Black and Hispanic youths.

Moreover, there has been an increase in presentations to pediatric emergency departments for adolescent suicidal behavior that has accelerated since the onset of the COVID-19 pandemic. A growing consensus contends that screening patients in emergency departments for suicidal risk is an important component of effective adolescent suicide prevention. Patients presenting to the emergency department are more likely than the general population to be at risk for suicide, and youths who have completed suicide were nearly seven times more likely than their peers to have visited an emergency department within 30 days prior to their death. 

A team of scientists led by Cheryl King, PhD (University of Michigan), Jackie Grupp-Phelan, MD, MPH (University of California, San Francisco), and David Brent, MD (University of Pittsburgh Distinguished Professor of Psychiatry, Pediatrics, Epidemiology, and Clinical and Translational Science and Endowed Chair in Suicide Studies), compared two instruments for the prediction of suicidal behavior among 2,740 adolescents seen in emergency departments: the Ask Suicide-Screening Questions (ASQ) instrument and the Computerized Adaptive Screen for Suicidal Youth (CASSY). The ASQ consists of four yes-or-no items that assess recent suicidal ideation, burdensomeness, and lifetime suicidal behavior; a “yes” answer or a nonresponse to any of these items results in a positive screening result for suicide risk. The CASSY is an adaptive screen based on the use of multidimensional item response theory model combined with a prediction model and is designed to measure interrelated domains of suicide risk. Its outcome score provides the probability of a suicide attempt within the subsequent three months.

Recently published in JAMA Network Open, the findings from this longitudinal study showed that both ASQ and CASSY demonstrated strong predictive validity and similar sensitivity and specificity in predicting future suicide attempts. The ASQ and the CASSY showed similar performance for Black, Hispanic, and White youths. Both ASQ and CASSY performed similarly among patients with physical symptoms; the CASSY more accurately predicted suicide attempts for those with psychiatric symptoms. 

“Both of these measures show very good performance in the prediction of suicide attempts in adolescents presented to pediatric emergency departments,” said Dr. Brent, lead author of the study. “The advantages of the ASQ are that it is free, already widely utilized, and very brief. The advantages of the CASSY are greater accuracy in those with behavioral health complaints, and that the site can adjust the sensitivity and specificity to meet the needs of a particular site. However, the CASSY requires a computer interface and is not free.”

Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments
Brent DA, Horowitz LM, Grupp-Phelan J, Bridge JA, Gibbons R, Chernick LS, Rea M, Cwik MF, Shenoi RP, Fein JA, Mahabee-Gittens EM, Patel SJ, Mistry RD, Duffy S, Melzer-Lange MD, Rogers A, Cohen DM, Keller A, Hickey RW, Page K, Casper TC, King CA.
JAMA Network Open. 2023;6(2):e2255986. doi:10.1001/jamanetworkopen.2022.55986  

Conflict of Interest Disclosures: Dr. Brent, Dr. Grupp-Phelan, Dr. King, and Dr. Gibbons have intellectual property interests in the CASSY; Dr. Gibbons receives revenue from Adaptive Technology, which can license the CASSY.