Increasing Adolescent Suicide Risk Identification Using the Ask Suicide Questions (ASQ)

Abstract

Problem: Suicide is the second leading cause of death in children and adolescents aged 10-19 years old in the United States and the prevalence of depression among adolescents has doubled since the start of the COVID-19 pandemic. A small, privately-owned pediatric primary care clinic in Baltimore County, Maryland noted an increase in adolescent patients presenting for sick visits with a chief complaint of depression or suicidal ideation (SI) between 2018 and 2021. Purpose: The purpose of this quality improvement project was to increase the identification of SI in adolescents at one primary care clinic through standardized screening using the Ask Suicide Questions (ASQ). The main outcome goal was to increase early referral to mental health specialists. Methods: Over a 20-week implementation period, all patients aged 10 and older seen for any well child or non-febrile sick visit were screened using ASQ. On intake, a medical assistant administered the screen following a structured script. A “yes” response to any of the four items indicated a positive screen for suicide risk, and triggered further assessment from the provider using the Brief Suicide Safety Assessment (BSSA). If active risk for suicide was identified, the patient was immediately referred to the emergency department for safety evaluation. Otherwise, the provider created an individualized plan, which included referral to a therapist. Results: 85.3% of eligible patients received ASQ screening, with six non-acute positive results. 100% of these patients received a BSSA and a referral to a mental health specialist. There were no acute positive screens. Conclusions: These results suggest that universal ASQ screening for patients aged 10 and older has increased the identification of SI in adolescents at this primary care clinic, resulting in earlier referral to mental health specialists. Providers reported satisfaction with this the implementation of ASQ screening and believe it provided valuable data. ASQ screening remains a permanent practice change at this site. Efforts to sustain the practice change include training for newly hired staff members and use of change champions.