The U.S. Centers for Disease Control (CDC) reports that in 2017, the most recent year for which numbers are available, suicide was the second leading cause of death for teenagers, exceeded only by accidental injury. Studies show that most teens who attempt or complete suicide have visited a primary care provider within the previous month.
Healthcare providers have to understand the warning signs of suicidal thoughts and behavior in teens—and family practice nurses, who have a significant amount of contact with patients, are on the front line of this effort.
To be effective in this role, family nurse practitioners (FNPs) must have specialized knowledge and training regarding suicide screening and prevention. Such knowledge can be obtained through academic programs, such as Duquesne University’s online MSN program, which offers a Psychiatric-Mental Health Nurse Practitioner track.
Also offering Post-Master’s Certificate programs to meet the needs of all healthcare providers, Duquesne’s online master’s in nursing helps students pursuing MSN careers to understand adolescent suicide risk factors.
Simple Screening
Basic suicide screening is the first step in the identification process. To help in this task, the National Institute of Mental Health (NIMH) has developed a resource called the Ask Suicide-Screening Questions (ASQ) Toolkit. The backbone of the toolkit is a set of four questions that take less than 20 seconds to ask. One NIMH study showed that a “yes” answer to any one of these questions identified 97 percent of youth at risk for suicide:
- In the past few weeks, have you wished you were dead?
- In the past few weeks, have you felt that you or your family would be better off if you were dead?
- In the past week, have you been having thoughts about killing yourself?
- Have you ever tried to kill yourself? If yes, how and when?
If the patient answers “yes” to any of them, the FNP should ask a fifth question:
- Are you having thoughts of killing yourself right now? If yes, describe.
Results of the ASQ screen fall into three categories:
Negative.
If the patient answers “no” to the first four questions, the fifth question is not necessary, and the screen is considered negative. No further action is required.
Non-acute positive.
If the patient answers “yes” to at least one of the first four questions, but “no” to the fifth, the screen is considered non-acute positive. The patient should be given a brief suicide safety assessment before being allowed to leave. The FNP must notify the patient’s primary care provider (if not the FNP) of the positive screen.
Acute positive.
If the patient answers “yes” to at least one of the first four questions and “yes” to the fifth, the screen is considered acute positive. The patient requires an immediate, full mental health assessment and may not leave the premises. The patient should be kept in sight, all dangerous objects should be removed from the room, and the primary care physician (if not the FNP) must be notified immediately.
The NIMH stresses that an important part of using the basic ASQ screen is having a plan in place for patients who screen positive. The full ASQ Toolkit contains resources to help providers with this task, greatly increasing the chances that at-risk teens will receive the help they need.
Expanded Training
In addition to using simple tools such as the ASQ screen, FNPs may wish to consider more extensive, formalized training in suicide awareness and prevention. Many providers feel that the gold standard is a program called Applied Suicide Intervention Skills Training (ASIST). This two-day workshop covers a great deal of ground and teaches providers how to:
- Recognize that people are impacted by their own and society’s attitudes about suicide
- Discuss suicide with at-risk teens in a direct manner
- Identify red flags and form a plan related to them
- Intervene with a teen at acute risk of suicide
- Provide a list of resources to at-risk teens, including themselves
- Commit to improving community resources and networking
- Understand that suicide prevention is about more than just suicide intervention; it includes helping at-risk teens to find positive solutions to the problems they face
Dr. Laura Shannonhouse, assistant professor in the department of counseling and psychological services at Georgia State University, is a fan of the ASIST model. “It’s actually the only suicide training that’s evidence-based,” she says in an Atlanta Journal-Constitution article. “It’s worth its weight in gold. If you’re a nurse, it takes all the fear out of talking about suicide.”
Points to Remember
Besides using general screening tools, nursing organizations offer a variety of additional recommendations to help FNPs in preventing teen suicide. In a recent article, the Atlanta Journal-Constitution compiles the main recommendations into several key points:
- Be aware of risk factors. FNPs should be educated about the risk factors for teen suicide, such as substance abuse, isolation, grief, mental health issues, or being the victim of abuse or violence.
- Build collaborative relationships. Good provider/patient relationships will make it easier for at-risk youth to open up to you.
- Understand that talking helps. Many nurses are afraid that talking about suicide will increase its likelihood, but studies show that this is not the case. At-risk teens want and need to talk.
- Ask for backup. Never be afraid to call in mental health professionals if further evaluation seems warranted.
- Create a safety plan. Work with other professionals and the patient to create a safety plan that helps the patient manage his or her situation.
- Take preventive steps. A patient who has a suicide plan must not be left alone. Take all steps necessary to ensure the patient’s safety.
None of these steps are difficult—but to take them, the FNP must first be aware that a teen is at risk. The seconds it takes to evaluate every patient are well spent if it keeps a single young person alive.