With increasing rates of suicide and mental health issues among U.S. youth, and with suicide as the second leading cause of death among people ages 10 to 34, the state of youth mental health has reached crisis proportions. For this reason, I'm gravely concerned about the impact of the recent draft recommendations of the U.S. Preventive Services Task Force (USPSTF) that found insufficient evidence for implementing screening for suicide risk among youth.
The USPSTF's methodology may be mismatched with the real-world implementation science and the scope of the problem concerning youth suicide. Clinicians and mental health professionals must have a clear understanding of the USPSTF's guidelines for reviewing evidence and arriving at a recommendation, as their approach is out of touch with recent expert recommendations on screening for youth suicide risk. The USPSTF findings may cast doubt among healthcare providers on the importance of suicide screening and preventive care.
In collaboration with our partner organization on the Blueprint for Youth Suicide Prevention and the American Academy of Pediatrics, we have identified three key weaknesses of the USPSTF draft report.
Suicide Screening Can Be Done Safely
The USPSTF calls for screening asymptomatic adolescents ages 12 to 18 years for major depressive disorder, and youth between the ages of 8 and 18 for anxiety, saying there would be a moderate benefit to each. We support this recommendation and believe the benefits would be more than moderate. On suicide risk, the USPSTF concluded there is insufficient evidence to weigh the benefits and harms of screening asymptomatic children and adolescents. However, in regards to the suicide risk, the report excluded or overlooked a number of key research studies that find universal suicide screening in pediatric medical settings validated with high sensitivity (97%) and specificity (91%), and demonstrate feasibility, accessibility by youth, parents, and clinicians, and importantly, demonstrate no evidence of harm.
Even more, while the USPSTF claims that screening will elevate stigma and anxiety, one of our recent surveys found that stigma associated with mental health and suicide has actually diminished over the past decade. From my own experience with my mental health and accessing treatment, I've seen firsthand the benefits of people coming together within families and communities to talk more openly about mental health and offer support to one another.
Asking Does Not Increase Risk
The USPSTF implies that screening youth will cause more distress, but it's been well-established that asking about suicidal thoughts does not cause harm. While there's a common misconception that asking someone if they're suicidal will put the idea in their head, asking how an individual is feeling and if they are having thoughts of suicide, in an open, caring manner has not been shown to increase risk. In fact, several studies demonstrate that not only does asking youth about suicidal thoughts not do harm, but doing so can open up opportunities for supportive care and treatment.
Depression Isn't the Only Risk Factor for Suicide
While the USPSTF recommends screening for major depressive disorder in adolescents ages 12 to 18 years, and implies that suicide risk can be detected via the presence of depression, screening for only depression misses approximately 30% of youth who are at risk of suicide. That's largely because depression isn't the only risk factor for suicide. Suicide risk is dynamic and complex, stemming from the combination of a number of factors including other mental health conditions -- such as anxiety, ADHD, and psychosis -- eating disorders, and substance use, in addition to cognitive factors like impulsivity, current and past life stressors, or trauma.
Furthermore, we know that many youth who have suicidal ideation don't spontaneously disclose their distress. Research shows that 80% of adolescents who died by suicide visited a healthcare provider within the year prior to death. Every time a pediatrician (or any clinician) screens a patient for suicide, they could potentially identify a young person who is struggling in silence.
There's Already Momentum
The concerning aspects of the USPSTF report can be distilled down into two takeaways for health professionals. First, clinicians in primary care, behavioral health, substance use care, and really any specialty area can play a critical role in identifying and supporting at-risk youth. Second, even if the determination of "insufficient evidence" holds past this current period of public comment, screening should still be implemented. In fact, health systems have already begun implementing universal suicide screening for youth in primary care, emergency departments, and of course, behavioral health settings.
We are moving in the right direction to prevent children from dying by suicide and we cannot stop this progress. A few months before the release of USPSTF's draft recommendation, the Surgeon General warned the country of a youth mental health crisis; President Biden announced a strategy aimed at addressing the mental health crisis; and AAP and Health Resources and Services Administration revised their Bright Futures program recommendations for pediatricians to routinely perform suicide screening for ages 12 and up. My organization and our partners are rolling out guidance that will equip pediatricians to implement suicide screening and care steps for youth.
It's imperative that we keep up this momentum. The task force's draft recommendations could have a counterproductive impact on how primary and preventive care is delivered, as well as a detrimental effect on which suicide preventive services are covered by insurance. Now more than ever, as mental health needs are mounting and suicide rates among youth and young adults are rising, we must implement screening and suicide preventive care at scale.
Christine Yu Moutier, MD, is chief medical officer at the American Foundation for Suicide Prevention.