Adolescents Who Do Not Endorse Risk via the Patient Health Questionnaire Before Self-Harm or Suicide

Author:

Flores Jean P.1,Kahn Geoffrey2,Penfold Robert B.3,Stuart Elizabeth A.1,Ahmedani Brian K.2,Beck Arne4,Boggs Jennifer M.4,Coleman Karen J.56,Daida Yihe G.7,Lynch Frances L.8,Richards Julie E.3,Rossom Rebecca C.9,Simon Gregory E.3,Wilcox Holly C.1

Affiliation:

1. Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

2. Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, Michigan

3. Kaiser Permanente Washington, Seattle

4. Kaiser Permanente Colorado, Aurora

5. Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena

6. Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California

7. Kaiser Permanente Hawaii, Honolulu

8. Kaiser Permanente Northwest, Portland, Oregon

9. HealthPartners Institute, Minneapolis, Minnesota

Abstract

ImportanceGiven that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected.ObjectiveTo understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide.Design, Setting, and ParticipantsThis was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023.ExposuresDemographic, diagnostic, treatment, and health care utilization characteristics.Main Outcome(s) and Measure(s)Responded “not at all” (score = 0) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide.ResultsThe study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P = .03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P = .02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P = .001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P = .007) within 90 days.Conclusions and RelevanceStudy results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.

Publisher

American Medical Association (AMA)

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