Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Multicenter Study
. 2023 Feb 1;6(2):e2255986.
doi: 10.1001/jamanetworkopen.2022.55986.

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

David A Brent  1   2 , Lisa M Horowitz  3 , Jacqueline Grupp-Phelan  4 , Jeffrey A Bridge  5   6 , Robert Gibbons  7   8   9   10 , Lauren S Chernick  11 , Margaret Rea  12 , Mary F Cwik  13 , Rohit P Shenoi  14 , Joel A Fein  15 , E Melinda Mahabee-Gittens  16 , Shilpa J Patel  17   18   19 , Rakesh D Mistry  20 , Susan Duffy  21 , Marlene D Melzer-Lange  22 , Alexander Rogers  23   24 , Daniel M Cohen  25 , Allison Keller  26 , Robert W Hickey  27 , Kent Page  28 , T Charles Casper  28 , Cheryl A King  29   30 ; Pediatric Emergency Care Applied Research Network (PECARN)
Collaborators, Affiliations
Multicenter Study

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

David A Brent et al. JAMA Netw Open. .

Abstract

Importance: Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool.

Objective: To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata.

Design, setting, and participants: The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023.

Main outcomes and measures: This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA.

Results: Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively).

Conclusions and relevance: This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Brent reported receiving grants from the National Institute of Mental Health (NIMH) (supported the development of intellectual property for the BRITE app, the As Safe As Possible intervention, the Computerized Adaptive Screen for Suicidal Youth [CASSY] measure, a suicide risk machine learning algorithm, and the Screening Wizard screening tool), the American Foundation for Suicide Prevention (AFSP), Once Upon a Time Foundation, and The Beckwith Institute; royalties from Guilford Press, eRT Inc from the electronic self-rated version of the Columbia Suicide Severity Rating Scale, and UptoDate; personal fees from Healthwise; honoraria from the Klingenstein Third Generation Foundation for scientific board membership and grant review; and serving as a member of the AFSP scientific board outside the submitted work. Dr Horowitz reported being a co-creator of the Ask Suicide-Screening Questions. Dr Bridge reported serving as a member of the scientific advisory board for Clarigent Health outside the submitted work. Dr Gibbons reported being a founder of Adaptive Testing Technologies outside the submitted work. Dr Chernick reported receiving grants from Columbia University during the conduct of the study. Dr Shenoi reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Mahabee-Gittens reported receiving grants from the National Institute of Environmental Health Sciences outside the submitted work. Dr Patel reported receiving grants from the NIMH during the conduct of the study. Dr Cohen reported grants from the NIH during the conduct of the study. Mr Page reported receiving grants from the NIH during the conduct of the study. Dr Casper reported receiving grants from the NIMH and the Health Resources and Services Administration during the conduct of the study. Dr King reported receiving personal fees from the AFSP; holding equity in Oui Therapeutics and Vytyl Health Management Inc; and sharing intellectual property rights for the Computerized Adaptive Screen for Suicidal Youth. No other disclosures were reported.

Figures

Figure.
Figure.. Flow Diagram of Study Participation
ASQ indicates Ask Suicide-Screening Questions; CASSY, Computerized Adaptive Screen for Suicidal Youth.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Kalb LG, Stapp EK, Ballard ED, Holingue C, Keefer A, Riley A. Trends in psychiatric emergency department visits among youth and young adults in the US. Pediatrics. 2019;143(4):e20182192. doi:10.1542/peds.2018-2192 - DOI - PMC - PubMed
    1. Xiao Y, Cerel J, Mann JJ. Temporal trends in suicidal ideation and attempts among US adolescents by sex and race/ethnicity, 1991-2019. JAMA Netw Open. 2021;4(6):e2113513. doi:10.1001/jamanetworkopen.2021.13513 - DOI - PMC - PubMed
    1. Lindsey MA, Sheftall AH, Xiao Y, Joe S. Trends of suicidal behaviors among high school students in the United States: 1991-2017. Pediatrics. 2019;144(5):e20191187. doi:10.1542/peds.2019-1187 - DOI - PMC - PubMed
    1. Bridge JA, Horowitz LM, Fontanella CA, et al. . Age-related racial disparity in suicide rates among US youths from 2001 through 2015. JAMA Pediatr. 2018;172(7):697-699. doi:10.1001/jamapediatrics.2018.0399 - DOI - PMC - PubMed
    1. American Academy of Pediatrics . Suicide: blueprint for youth suicide prevention. Accessed October 25, 2022. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/

Publication types