Preventing Youth Suicide:
Does Access to Care Matter?
John V. Campo, MD
Nationwide Children’s Hospital
Ohio State University Medical Center
Email John.Campo@nationwidechildrens.org
Objectives

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To review pediatric suicide as a
preventable public health problem
To explore the relationship between
suicide and access to care
To discuss a few novel efforts designed
to improve access to care for youth at
risk
4/8/2015
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Suicide and Access to Care
Main Points
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Youth suicide rate ↑ since 2004
Suicide risk associated with psychiatric
disorder, especially mood disorder
Suicide risk negatively correlated with
access to quality mental health care
Improving access to effective care has
potential to reduce youth suicide risk
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Pediatric Suicide
A Public Health Challenge

3rd leading cause death ages 15-24 yrs
– Only accidents and violence kill more…
– Among top ten causes of death worldwide

U.S. deaths for ages 15-24 years (2006)
– 4,189 deaths due to suicide
– More than following causes COMBINED
• Cancer (1644) + cardiovascular disease (1376) +
stroke (210) + HIV (206) + influenza and
pneumonia (184) + diabetes (165) + septicemia
(139) + asthma (135) + meningitis (47)
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Pediatric Suicide
A Public Health Challenge

After a decade of decline, the U.S. youth
suicide rate ↑’ed ~20% in 2004
– Responsible for > 300 additional deaths
– Only ↑’ing cause of pediatric death
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Increase appears to be persistent
Bridge et al. JAMA 2008; 300(9):1025-1026
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4/8/2015
Copyright ©2008 BMJ Publishing Group Ltd.
Bridge et al. JAMA 2008; 300(9):1025-1026
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Annual Rate of Suicide
U.S. Males and Females Aged 10 to 19 Years
1996 through 2005*
4/8/2015
Bridge et al. JAMA 2008; 300(9):1025-1026
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Pediatric Suicide
A Public Health Challenge (cont.)

Prevalence of suicidal ideation
– ~ 15% of U.S. high school students annually

Prevalence of suicide attempts
– ~7% of U.S. high school students annually

15 to 24 year age range vulnerable
– Age of ↑ risk for mood and other disorders,
– May “fall between the cracks” of the health
system (transition to adulthood…)
• Important to campus suicide prevention efforts
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Pediatric Suicide
Psychiatric Disorder and Risk

Untreated psychiatric disorder the most
substantial remediable risk factor
– ~90% of completers have a psychiatric d/o
– Risk especially strong for mood disorders
• Depression the main predictor of suicidal ideation
• Depression ↑ risk of completion and attempts
– 2-7% of MDD youth complete suicide later in life
– 40-80% of attempters suffer from depression
• Bipolar disorder, particularly mixed, confers ↑ risk
– Comorbidity, chronicity, severity ↑ risk
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Pediatric Suicide
Depression and Suicide Risk
Odds Ratio
Suicide completion
Brent et al., 1999
Shaffer et al., 1996
7.5 - 12.9
16 - 20
Suicide attempt
Andrews et al., 1992
Beautrais et al., 1996
4/8/2015
12.0 - 14.7
27.3
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Pediatric Suicide
Adult Pharmacotherapy RCTs
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Meta-analyses of antidepressant RCTs
have not shown clear protective effects
Persuasive meta-analytic evidence that
lithium reduces suicide risk in adults
Some evidence that clozapine reduces
suicide risk in adults with schizophrenia
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Forest Plot Showing Meta-Analysis of Suicides Plus
Deliberate Self-Harm in Randomized Trials Comparing
Lithium with Placebo or Active Comparators
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Cipriani et al., 2005
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Pediatric Suicide
Adult Psychotherapy RCTs
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Dialectical Behavior Therapy
– Reduced rate of repeat suicide attempts in
adults who attempted suicide
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Cognitive Behavioral Therapy
– Some evidence that CBT may reduce suicide
attempts and suicidal behaviors
– May be most effective when includes specific
elements focused on reducing suicidality
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Pediatric Suicide
Pediatric RCTs

Few pediatric RCTs specifically address
suicide as an outcome
– Suicidal youth often excluded from RCTs
– Mixed results for psychotherapy studies
– TADS and TORDIA studies showed
reductions in suicidality for all groups
• TADS showed greatest reduction in suicidality in
fluoxetine + CBT group
• TORDIA study found no meaningful differences
between groups
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Pediatric Suicide
Pharmacoepidemiologic Studies
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Coincident ↓ pediatric suicide rates with ↑ SSRI
prescribing since late 1990s
– Similar findings in US and Europe
– Geographic trends for ↓ suicide with ↑ Rx
– 1% ↑ in adolescent antidepressant use associated with a ↓ of
0.23 suicide per 100 000 adolescents per year
• Olfson et al., Arch Gen Psychiatry 2003
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Longer antidepressant Rx may reduce suicide risk
– Rx > 180 days vs. Rx < 55 days
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Studies of completed suicide
– < 10% completed suicides who had been prescribed
antidepressants + at autopsy
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Pediatric Suicide
Primary Care Based Studies
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Primary care based education for PCCs in
recognition and management of depression may
be a very promising approach
– PROSPECT study
• Collaborative care for depressed suicidal elders was more
effective than TAU for reducing suicidality
– Gotland study
• Improved PCC ability to treat depression resulted in
decreased suicide rate
– Youth Partners in Care (Asarnow et al. 2005)
• Suggest that improved treatment of adolescent depression in
primary care may reduce suicidality risk
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Pediatric Suicide
Other Interventions

Promising interventions include those
maintaining long term contact with at risk
individuals and offering psychoeducation
– Use of technology as simple as the telephone
may be especially helpful
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Pediatric Suicide
Population Based Studies

Negative correlation between suicide rate and
access to health and MH services
• Tondo et al., J Clin Psychiatry 2006

Type of service availability matters
– Multifaceted services protective
– > outpatient to inpatient ratio advantageous
– 24 hour emergency services useful
• Pirkola et al., Lancet 2009

Rural residence associated with  risk
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Pediatric Suicide
Treatment Realities

Most youth at risk for suicide receive
inadequate treatment or no treatment
– Only 7 to 20% of suicide completers had seen a
MH profession in prior 1 to 3 months
– Antidepressants rarely found in toxicological
studies after completed youth suicides
– Some studies correlate low SSRI prescription
rates with higher rates of youth suicide
• Gibbons et al., Am J Psychiatry 2006, Olfson et al., Arch
Gen Psychiatry 2003
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The Access to Care Challenge
Shortage of Pediatric Psychiatrists*
Current US average is 8.7 pediatric
psychiatrists per 100,000 youth
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–
–
–
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Range 3.1 (Alaska) to 21.3 (Massachusetts)
Estimated need ~ 14.4 per 100,000
Ohio ranks 30th (6.7 per 100,000)
Number of training programs is decreasing
and number of trainees static
Average age of practitioners increasing
Shortage will grow worse at current levels
of training and support
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* Thomas and Holzer, JAACAP 2006
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Child and Adolescent Psychiatry
Number per county in U.S. (2009)
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Child and Adolescent Psychiatry
Ohio Rate per 100,000 youth (2009)
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Meeting the Need
Transformational Change
To improve access to care
 To improve care quality
 To challenge stigma
 To improve efficiency of care

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Access to Effective Treatment
Need for a System of Care
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Stepped care
– Different levels of care depending on type
of disorder, its severity, complexity, and/or
persistence in the face of intervention
•
•
•
•
•
Primary care/general medical care
Outpatient specialty MH care
Intermediate specialty MH care
Acute inpatient psychiatric care
Long term residential treatment
– Collaboration across disciplines the key
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Pediatric Suicide
The Relevance of Primary Care

The primary care setting may prove to be
critical to meaningful prevention
– 80% of completers had contact with a
primary care clinician in the prior year
– 40-60% had contact with PCC in prior month
– Shortage of pediatric mental health
professionals is deep and persistent
– Treatment of geriatric depression in primary
care demonstrated to ↓ suicide risk
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Pediatric Suicide
Identifying At Risk Youth
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Medical Settings
– Primary Care
– Specialty Care
– Emergency Departments/Crisis Centers
– Hospitals
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Schools
Juvenile Justice/Courts
Child Welfare Settings
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Suicidality Screening in Primary Care
Health eTouch
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Developed by Drs. Bill Gardner and Kelly
Kelleher and colleagues
Portable with little space requirement
Automatically scored and stored
Little imposition on office work flow
Confidential and secure
Potential to integrate with EMR
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Youths are given the tablet in the
primary care waiting room.
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A stylus is used to select responses to
multiple-choice questions. For privacy,
the system moves to the next question
as soon as a response is entered.
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Report is clipped to patient’s chart so that it is
available to the clinician during the visit.
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Health eTouch Screening Results
25%
20%
20%
17%
High levels of mental and behavioral risk
found in patients at nine urban primary
care clinics serving a predominantly
Medicaid population.
15%
15%
10%
8%
5%
5%
0%
Depression
4/8/2015
Suicidality
Tobacco,
Alcohol,
Marijuana
Alcohol
Marijuana
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The clinician can follow-up on issues identified by
screening. The report form includes contact
information for referrals to enhance efficiency.
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Access to Effective Treatment
Use of Novel Technologies
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Health eTouch
– Screening
– Case finding
– Assessment
 Decision support for PCCs
 Access to informal psychiatry consultation
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Telepsychiatry (Rural areas especially)
Interactive voice response technology
– PhaST study
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Pharmaceutical Safety Tracking
PhaST
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Study funded by AHRQ (Gardner, PI)
In wake of “Black Box Warning”
– FDA recommends intensive f/u monitoring
• Weeks 1, 2, 3, 4, 6, 8, then monthly until stable
• No research support for recommendation
• Infeasible for clinicians and families
– Pediatric antidepressant prescriptions ↓

Need for feasible safety monitoring
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Pharmaceutical Safety Tracking
PhaST (cont.)
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Interactive voice response technology (IVR)
– “Robotic phone calls”
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Medication AEs monitored on FDA schedule
8 questions answered using phone pad
Positive response triggers study clinician call
AEs classified as routine, urgent, or emergent
Prescribing physician contacted accordingly
and/or emergency response activated
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Pharmaceutical Safety Tracking
PhaST (cont.)
CATI & Triage
D
we
rs
PHAST
Nurse Workstation
at
a
Da
ta
An
s
Qu
e
sti
on
s
Other Clinical
Databases
Questions
PHAST
Registry
Data
Answers
Family
IVR Telephone Robot
Qu
e
An
s
sti
we
4/8/2015
Reports
MD
Da
on
s
ta
The PhaST
System
rs
Waiting Room
Computers
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Pediatric Suicide
Prevention Strategies

Effective treatment for psychiatric d/os
– Consensus is growing that untreated
psychiatric disorders are the most
substantial remediable risk factor for suicide

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Reduce access to lethal means
Screening to identify high risk individuals
Education and awareness programs
Influence media reports of suicide
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Pediatric Suicide
Selected References
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Bridge JA, Greenhouse JB, Weldon AH, Campo
JV, Kelleher KJ. Suicide trends among youths aged
10 to 19 years in the United States, 1996-2005.
JAMA 2008; 300(9):1025-1026.
Campo JV. Youth suicide prevention: Does access
to care matter? Current Opinion in Pediatrics 2009;
21:628-634.
Campo JV. Suicide prevention: time for ‘zero
tolerance’ [Editorial]. Current Opinion in Pediatrics
2009; 21:611-612.
4/8/2015
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Nationwide Children’s Hospital
Physician Decision Support
•During business hours (M–F, 8 am – 5 pm)
•Page (614) 690-1887 or Call (614) 355-8080
•Select option 2 for doctor’s office, then 2
•Email
BHDecisionSupport@NationwideChildrens.org
•For urgent questions after hours,
•Call (614) 722-2000 - ask for psychiatrist on-call
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