DOH provider alert regarding increased concern of suicide risk in youth during COVID-19

The Washington State Department of Health (DOH) recently released the following provider alert regarding increased concern of suicide risk in youth during COVID-19.

Actions Requested

  • Screen patients for suicide risk, particularly children, teens, and young adults. See the Screening section below for more information.
  • Share information and resources with patients and their families on crisis support, suicide warning signs, and suicide risk factors. See the Resources section below for more information.

Background
A convergence of factors may be leading to an increased risk of suicide attempts, suicidal ideation, and psychological distress among youth in Washington, including:

  • The extended disillusionment phase1 of disaster for the COVID-19 pandemic, which is typically the disaster phase with the greatest behavioral health impacts.
  • Other effects related to the pandemic, such as disruption of two academic years, economic impacts, and social isolation.
  • Seasonal changes, such as reduced daylight hours and winter weather conditions.
  • Nationally, the Centers for Disease Control and Prevention (CDC) estimates that one in four people under age 18 have struggled with suicidal thoughts since the beginning of the pandemic.2 Moreover, over twice as many adults reported having serious thoughts of suicide in the previous 30 days in June 2020 (10.7%) compared to the previous 12 months in 2018 (4.3%).2 Rates were particularly high among certain populations, including young adult respondents aged 18–24 (25.5%), Hispanic respondents (18.6%), Black respondents (15.1%), and essential workers (21.7%).2 As a result, the CDC recommends community-level intervention and prevention to address this concern.1

Screening
We recommend using the National Institute of Mental Health’s Ask Suicide-Screening Questions (ASQ)
Screening Tool
for patients ages 10–24.3 For example, ask patients if they have:

  1. Current or recent suicidal ideation.
    a. Determine the frequency, intensity, and duration of suicidal thoughts.
  2. Past suicidal ideation or attempts.
    a. Assess historical patterns of behavior to help determine risk.
  3. A plan.
    a. Determine timing, location, and lethality.
  4. The means or access to carry out the plan.
    a. Ask about availability of means (i.e., types of harm) to complete suicide, such as drowning,
    cutting, poisoning, jumping, etc.
    b. Ask about access to methods to complete suicide, such as medications, household materials
    (e.g., bleach, poisons, rope, or cleaning agents), or firearms.
  5. The intention to carry out the plan.
    a. Explore how they envision carrying out their plan, and to what degree they believe the plan
    to be lethal versus harmful.
  6. Protective factors.
    a. Ask about connectedness to family, friends, community, and culture.
    b. Assess skills, including the ability to cope, problem solve, or engage in conflict resolution.
    c. Determine access to medical and mental healthcare.

Prepare for Screening and Supporting Patients and Families
Having information readily available and accessible will help providers advise young people who are
struggling with suicidal thoughts or actions and their families. Parents may need counseling on safety
planning and should be provided information and contact numbers on how to access crisis outreach, if
needed. Contact information and resources for providers, patients, and families are listed on the
following pages in the Resources section.

The COVID-19 pandemic has created difficulty in accessing behavioral health care, as behavioral health
providers are seeing a surge in new patients. Parents should be counseled that it may take some time
before their child can get into treatment, and it may be helpful to discuss interim planning with them.
For example, an option can be offering follow-up appointments as a way of monitoring and supporting
until the patient can begin behavioral health treatment.

Sometimes young people in crisis may not agree to treatment. Parents should be provided information
on how involuntary treatment works in Washington, including the need for a designated crisis
outreach provider to assess and make the determination. Inform yourself about these processes and
gather contact information for designated crisis responders. Additionally, provide counseling and
information for parents on safety planning and actions for reducing access to methods of self-harm in
their homes.

To help increase emotional health, we encourage everyone to work on building resilience. Whenever
possible, encourage patients and clients to access their support network for assistance, and consider
facilitating that connection with the patient’s permission. For additional tips on building resilience,
please see The Ingredients of Resilience handout.

Suicide Warning Signs
Everyone can play a role in suicide prevention. Know the suicide warning signs:

  • A history of suicide attempt(s)
  • Current talk of suicide or making a plan
  • Strong wish to die or a preoccupation with death
  • Giving away prized possessions
  • Signs of depression, such as moodiness, hopelessness, or withdrawal
  • Increased alcohol and/or other substance use
  • Hinting at not being around in the future or saying goodbye

Suicide Risk Factors
Ask patients about the following risk factors for suicide:

  • Unsecured firearms
  • Recent loss or trauma
  • Accessible medications or substances in the home
  • Social isolation
  • Hopelessness for the future

Although there is stigma around discussing suicide, research shows it is best to ask about suicide
directly
. Ask patients candidly if they have had thoughts or feelings about suicide and if they are a
danger to themselves. Asking about suicide does not increase risk and, in fact, increases safety.

Resources
For Providers:

For Patients and Families:

1 For a description of each phase in the disaster timeline, refer to page 5 of the COVID-19 Behavioral Health Group Impact Reference Guide (https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/BHG-COVID19BehavioralHealthGroupImpactReferenceGuide.pdf).
2 Centers for Disease Control and Prevention. (2020, August 14). Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm
3 National Institute of Mental Health. (2020). NIMH Ask Suicide-Screening Questions (ASQ) Toolkit.
https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/asqtool/
screening_tool_asq_nimh_toolkit_155867.pdf.

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