Emergency Department Screen for Teens at Risk of Suicide (ED-STARS): Design and Potential Policy Implications

Introduction: Suicide is the 2nd leading cause of death among youth ages 12 to 17 in the United States. However, most youth at high risk for suicide go unrecognized and untreated, and for half of adolescent suicides, the first suicide attempt is fatal. This multi-site project includes two, sequential studies with the overall goal of identifying youth at risk for suicide in the Emergency Department (ED). The screening and triage of at-risk youth in healthcare settings are key strategies of the National Strategy for Suicide Prevention to reduce adolescent suicide. This study is highly innovative because it will develop and test a computerized adaptive screen (CAS), which results in individualized sequences of screening questions conditional on previous responses; and it will test a wide range of acute suicide risk indicators for possible inclusion in the CAS. In addition, this project will test the incremental value of the Implicit Association Test (IAT), which is important as many at-risk youth may deny suicidal thoughts.

Methods: In Study 1, we will implement a universal suicide risk assessment using a broad range of risk factors with approximately 6,750 youth, ages 12 to 17, who present to participating EDs. We will follow-up a subsample of 30% of these youth, enriched for suicide risk factors, at 3 and 6 months. Based on the risk data gathered, we will develop and calibrate a Computerized Adaptive Screen (CAS) to accurately predict suicide attempt. In Study 2, we will recruit a new sample of approximately 2,000 youths (stratified by suicide risk factors), administer the CAS and Ask Suicide-Screening Questions (ASQ), and follow-up at 3 months with interviews and medical chart reviews. In Study 2 we aim to validate the specificity and sensitivity of the CAS and ASQ for predicting suicide attempts, and to evaluate the performance of the Implicit Association Test (IAT). The study will be conducted in the Pediatric Emergency Care Applied Research Network (PECARN) and at the Whiteriver PHS Indian Hospital ED.  

CONCLUSION: The optimal screen developed in this collaborative project will have the potential to be disseminated nationwide to enhance the capacity of emergency departments to identify and effectively triage youth at acute risk for suicide attempts. Regarding potential policy implications, the CAS screening strategy is expected to be brief and highly feasible, to require computer-based screening, and to yield useful clinical triage information.