# Facebook Live: Youth Suicide Prevention

September 19, 2023

## Transcript

**STEPHEN O’CONNOR**: Hello. Welcome, everyone. Thank you for joining us today. September is Suicide Prevention Month. And for our discussion today, we're going to focus on youth suicide prevention. My name is Stephen O'Connor, and I chief the Suicide Prevention Research Program in the Division of Services and Intervention Research at the National Institute of Mental Health, or NIMH for short. And now I'll turn it over to my colleague and co-presenter.

**LISA HOROWITZ**: Thank you, Stephen. Hello, everyone. I am Dr. Lisa Horowitz. I'm a pediatric psychologist and a senior associate scientist in NIMH's intramural research program. So suicide is a global public health problem and the second leading cause of death for young people in the United States. It is the second reason why kids die, so very serious. New NIMH-supported studies found that the COVID-19 pandemic increased the rates of youth suicide. And this wasn't an equitable increase. The impact varied by sex, age, race, and ethnicity. And what we saw were that hospital visits for mental health care increased among children and teens in the second year of the pandemic, and especially among teenage girls. So findings such as these really highlight the critical need for better ways to understand and prevent suicide in youth and teens. So these statistics are very sobering, but let's let them be a call to action. There's so much that can be done. And we are focused today on hope and action. So during the next half hour together, Stephen and I will lead a discussion on how to talk to youth about suicide risk, how to identify the risk factors and warning signs of suicide, and then NIMH-supported research on interventions and suicide prevention. We'll also take the last 10 minutes or so to take some of your questions. So please enter them under the comments, under the live stream post below, and we'll do our best to answer as many as we can before the end of our discussion.

**STEPHEN O’CONNOR**: Yeah. Thank you, Lisa. So it's important to note that during the discussion today, we cannot provide specific medical advice or referrals. Please consult with a qualified healthcare provider for diagnosis, treatment, and answers to your personal questions. If you need help finding a provider, please visit nimh.nih.gov/findhelp. And if you or someone you know is in crisis, please call or text the 988 Suicide and Crisis Lifeline** at 988. Visit 988lifeline.org for more help and information. The Lifeline provides 24/7 free and confidential support for people in distress, prevention and crisis resources for you, for your loved one, and best practices for professionals in the United States.

**LISA HOROWITZ**: So people of all genders, ages, and ethnicities can be at risk for suicide. But suicide and suicidal behavior is very complex. And there's no one single cause that makes someone die by suicide. So let's start our discussion today by identifying some of the well-studied risk factors. So the most potent risk factor is previous suicide attempt. Someone who has tried to kill themselves in the past is more likely to try to kill themselves again in the future. Having access to lethal means is a risk factor, especially young people who are aggressive, impulsive, or show signs of risky behavior have a history of bullying. People who identify as LGBTQ+ are at greater risk for suicide, people with a diagnosis, a mental illness diagnosis, and then medical illness. People with medical illness are often-- that's an often overlooked risk factor. But these are just risk factors. And most people who have these risk factors will not die by suicide because they're risk factors. And imagine yourself as a triage nurse in an emergency department. If someone came up to your desk and had the risk factors for a heart attack, let's say they had a family history of heart attack and they had high blood pressure and high cholesterol and they were obese and a smoker, when they walked up to your triage desk, you wouldn't think they were having a heart attack. But if they came up with the warning signs of a heart attack, let's say they were clutching their chest in pain and sweating profusely, you might think they're having a heart attack. So this goes for suicide as well. There's risk factors, and then there's warning signs.

**LISA HOROWITZ**: So the first warning sign is someone talking about wanting to die or kill themselves. Now this one seems very obvious, but talk about suicide is often overlooked. So it's really important to pay attention to someone when they're talking about suicide. Someone who's feeling hopeless or like they're a burden or they're trapped might be at-- that's a warning sign for suicide or acting reckless or the signs of depression, sleeping too little or too much, or increased use of drugs or alcohol, people feeling withdrawn, having severe extreme mood swings. These all might be warning signs that someone might be at imminent risk for suicide. So there's also stressful life events, and especially for young people, things like school pressures, or losing a loved one, or interpersonal stressors, things like relationship troubles, or being harassed, feeling discriminated against, or feeling great amounts of shame, maybe sometimes this happens with social media, these are all things that might contribute to being at risk for suicide, especially when they're paired with some of the risk factors.

**LISA HOROWITZ**: So what do we do about this? Well, one really important and extremely underutilized method to find out if someone is considering suicide is to ask them and ask them directly, "Are you thinking about suicide?" Now, sometimes people and especially parents worry that if you ask someone about suicide, you actually might put the idea into their head, like you might make them think about it. But this is the biggest myth about suicide. It's actually the opposite is true. It is not harmful to ask someone about suicide. There's at least four research studies showing that the best way to keep someone from killing themselves is to ask them directly, "Are you thinking of killing yourself?" And then what do you do? Then you brace for that answer because the answer might not be no. And you want to be ready to listen, to not be judgmental. You could be the only person that asks someone if they're thinking about suicide. So your question could be the first step in them getting help.

**LISA HOROWITZ**: So my research colleagues and I have come up with a simple suicide risk screening tool. It consists of four questions. It takes about 20 seconds. And the hope is that it's for the medical setting, for pediatricians and pediatric healthcare providers, that they'll start screening all young patients during their medical visits for suicide risk. So why do we think of the medical setting? Well, if you look at death registry studies, the majority of people who die by suicide - and this is not just adults; this is kids too - visit a healthcare provider months, sometimes weeks before they die. So this is an incredible opportunity to identify those people at risk and get them help. But the majority of practices don't screen for suicide risk, so the majority of temperatures go unrecognized. Now, doctors and nurses can play a really critical role in preventing teen suicide. So we came up with this tool. It's called the ASQ, the ASQ. It stands for Ask Suicide Screening Questions. It's very brief. It's been validated through research for youth, ages eight and above, and for adults as well. And it's available in multiple languages. We have an ASQ toolkit that's available, and that's organized by medical setting. We have different tools for the emergency department, for the inpatient med surge unit, and the outpatient primary care and specialty clinics.

**LISA HOROWITZ**: So for screening to be done well, we think that the nurses and the doctors should ask the parents to leave the room because kids tend to be more honest when they're in private. And if the child insists on the parent staying or the parent doesn't want to leave the room, you still can screen. And it's actually a good way to model how to talk to a young person about suicide risk. So here are the questions of the ASQ. And remember, they're meant to be very blunt, very direct. Number one, in the past few weeks, "Have you wished you were dead? Have you felt that you or your family would be better off if you were dead? In the past week, have you been having thoughts about killing yourself? And have you ever tried to kill yourself?" If the patient answers yes to any one of these four questions, you ask a fifth acuity question. "Are you having thoughts of killing yourself right now?" And again, this screening tool is meant for the medical setting. And studies reveal that screening, universal screening, screening all patients, eight and above, does not overburden your busy medical practice, that it's actually feasible and a really good way to bridge someone to mental health care. Okay, now I'll let Stephen talk about-- Stephen, why don't you talk about what happens if someone screens positive on a suicide risk screening tool?

**STEPHEN O’CONNOR**: Yeah, I can do that. Thanks, Lisa. And I think it's important to put this in context, too. I think that we know that screening alone doesn't seem like that's where this ends, right? But you have to have a really strong evidence-based approach to identify people and know how to ask these questions. And that's exactly what this tool is that Lisa and her colleagues have developed. So there's a difference between screening and assessment. The idea behind a screener is to identify people who need further evaluation. Once you identify who needs further evaluation, then it's a process of gathering more information about what they're experiencing. So part of the toolkit that you can find on the NIMH website, where you can find the ASQ tool, is a brief suicide safety assessment. The safety assessment, essentially, it's an opportunity to gather more information about someone's suicide intensity. So what's the frequency of suicidal thoughts that they're having? Are there plans, if any? It also gives you opportunity to ask about history of suicide behavior, like Lisa was mentioning. Then you can also learn about any social stressors that people might be having, and also their forms of support. All that information can be really helpful to basically determine what's the level of care that someone needs at this moment in time? Do they need a higher acuity of care because they have more suicide intensity at this time? And if that's the case, that's a person that might need to go to a setting where they can offer immediate emergency care.

**STEPHEN O’CONNOR**: But like Lisa was saying, the vast majority of people who would endorse or report having a suicidal thought are not actually in a crisis or an emergency situation. So the assessment is really key at determining the level, the intensity of intervention that's necessary. You wouldn't want to just decide that based upon what you learned from the screener alone. And all that information is available on the NIMH website. So that's all really useful. And in the spirit of the hope and recovery that Lisa described, we do know that the majority of people who survive a suicide attempt will never go on to make another suicide attempt, that they will live happy, healthy, very productive lives. And that doesn't necessarily define their identity or what is available to them moving forward. But what we want to do is be able to have-- we want for clinicians to be able to have these discussions in a collaborative way that's not traumatizing to patients and to their families and makes them part of the process too in deciding what level of care and what care is going to look like. So those are the differences between a screener and assessment. So you kind of think about this continuum, what happens after you've identified someone and maybe you've understood now what their level of risk is, well, then you start thinking about, well, what are some approaches we could use to reduce your risk right now in the near term?

**STEPHEN O’CONNOR**: So one of the best approaches for that is called safety planning. Safety planning intervention consists of really six different elements, helping people identify what their personalized warning signs are, and then helping identify in advance internal coping strategies, things that you could do to sort of survive that dark moment, and then places that you can go that are going to be protective for you, people you can reach out to for extra support, professional help that you can access if you felt unsafe or if you needed extra assistance, including 988, and then really importantly, creating a safe living environment. And by that, really kind of emphasizing the practice of lethal means safety. So if there are firearms that are in the house, making sure that those are safely stored, if there are medications in the house, also making sure that those are safely stored. This is really important because 90% of suicide attempts that involve a firearm result in fatality. It's really hard to survive suicide attempts that involve a firearm. And the lethality rate is not as high for overdose, but it can still be a lethal action. It can lead to hospitalization. And in general, it's something that can be prevented. So the same lethal means safety strategies apply across the board there.

**STEPHEN O’CONNOR**: And then finally, I guess what I'd like to highlight is that the safety plan intervention, it can really help keep people safe, keep them from having to receive emergency services. But at the same time, there are interventions and therapies that have been shown to reduce the risk of suicide attempts. We have funded some of those at NIMH. And it seems like the ones that are the most effective are focused on helping youth develop skills to regulate emotions and to tolerate distress. There's one treatment in particular that's called dialectical behavior therapy that seems like it's very effective at reducing suicide attempts in youth that are maybe transitioning out of a higher level of care, coming from the hospital, going back into the community, and for youth that have diagnoses of bipolar disorder as well. So that makes a lot of sense why if you help youth learn emotion regulation skills and distress tolerance, why that would be helpful, because in general, whenever people get upset, they have a hard time with problem-solving. And there's also immense emotional pain and suffering that is happening simultaneously.

**STEPHEN O’CONNOR**: So helping people learn skills to better manage emotions, learn how to validate your emotion, understand what it represents, use it to inform your decision-making, all those things can help reduce the likelihood of a suicide attempt. So yeah, that's the good news, is that we actually have these evidence-based practices that when utilized, they can help reduce risk. Medications might also be an option for youth. There's no data specifically that's going to suggest that a certain drug is going to help reduce the likelihood of a suicide attempt in youth, but it might be part of a more comprehensive treatment plan because as Lisa was describing earlier, people who experience suicide ideation, they might have different forms of mental illness. They might have substance use concerns. So a medication, some instances can be helpful. We also know that psychotherapy can be helpful to address those problems as well. Okay.

**LISA HOROWITZ**: Thank you, Stephen. Why don't we use the rest of the time now to answer some of the questions?

**STEPHEN O’CONNOR**: Yeah, sure. Yeah, so thank you all for posting some questions. I see one here. It's kind of related to using the ASQ. So do you think that the ASQ would be administered by a parent? Would it be possible to use that in the school setting? Could you just kind of talk about who and where this would be utilized?

**LISA HOROWITZ**: Sure, good questions. Because I often get asked by parents, "Should I use the screening tool, the ASQ on my kids?" And the ASQ was really developed as a conversation starter for healthcare providers, right, in the medical setting. But as a parent, you don't need a screening tool. You have the benefit of having a relationship with your child. So you just have to start the conversation. And everyone should know that starting this conversation is very awkward. And tonight, when you're brushing your teeth, I want you to look in the mirror and picture yourself saying to your child or your friend or someone you're worried about, "Are you having thoughts about killing yourself?" You can start with, "You haven't been acting like yourself lately, or you seem really down. I'm worried about you." And then you can ask straight out, "Are you thinking of killing yourself?" And then when you're looking in the mirror, I want you to brace yourself for how to answer that. What do people want from you when they're talking about suicide? They don't want you to panic. They don't want you to judge them. They want you to listen. And you don't have to fix it. You would just be the bridge to getting them help. So starting the conversation in the same way you would talk with your kids about drinking and drugs and smoking and safe sex, talking about suicide and asking them about their thoughts about it is really important. You can even say, "I saw this Facebook Live today, and they were talking about youth suicide. I just want to check in with you. Do you ever think about that?" Those are all really important conversations to have.

**STEPHEN O’CONNOR**: Yeah, great. How would you use the ASQ in the school setting, do you think?

**LISA HOROWITZ**: Yeah, so schools are where kids are, where we find kids, right? So schools are a really important place for suicide prevention. And you can use the ASQ in a school nurse's office. There's also programs that go into schools, programs like SOS, Signs of Suicide, Sources of Strength, that go in and train. They do peer training with the kids, parent training, teacher training, coaches, and they teach people how to implement suicide prevention. But the screening tool, probably best used in the school nursing office when you see kids showing up for medical concerns. Okay. Stephen, I think this next question we received would be good for you to answer. What research is NIMH currently supporting to address this increased suicide rate in youth?

**STEPHEN O’CONNOR**: Yeah, that's a really great question. I mean, NIMH has made really historic investments in advancing research on suicide prevention for youth. So we have funded a number of very large studies involving thousands of youth that are presenting to emergency departments, and they are at elevated risk for suicide, so testing approaches for assessment and for intervention and ongoing support. We also have a number of what we call pilot studies, which are really there to, I think, seed the field in terms of the many different needs that we have in youth suicide prevention. So some of those take place in schools. Some of them are focused on primary care settings. Others are focused on other community settings or emergency departments, inpatient psychiatry units, outpatient community mental health. So just kind of across the board, what we want to do is we want to make sure that we have studies that are representative of all of the diversity of youth and trying to figure out, realistically, who can deliver these approaches that we know can be lifesaving, and how do we make sure that they're delivered with really good quality? So we literally have tens of millions of dollars invested just in this fiscal year alone in a variety of studies that are going to help inform what the best version of intervention looks like for youth suicide prevention.

**LISA HOROWITZ**: Yeah, no doubt that those studies are going to be impactful. Okay. There's another question here that asks, what other populations has the ASQ been tested on or in? And so we did do multi-site studies that the ASQ can be used with adults for suicide risk screening so that medical settings can just use one tool for youth and adults. And what about kids with neurodevelopmental disorders like autism? So that's a great question. And actually, there's some research showing that kids with neurodevelopmental disorders may be at greater risk for suicide. And so there is a study right now where we are testing and validating the ASQ through research at Kennedy Krieger Institute at Johns Hopkins and looking at how the ASQ performs in kids with neurodevelopmental disorders, that there are hospitals who treat kids with neurodevelopmental disorders that are already using the ASQ. And in fact, Kennedy Krieger has given over 30,000 ASQs, and it seems to be working very well in that population.

**STEPHEN O’CONNOR**: Great. There's a question here about LGBTQ youth suicide risk. Do we understand why that is? I think one of the main reasons we think that that occurs is just because of the experience of stress that people from that community experience. There's nothing inherent about being a sexual gender minority that should place you at elevated risk for suicide. But we know that there's a lot of stress directed at those folks just based upon their own sexual and gender identity. And so it's really important to be able to make sure that we offer services that are effective for that group in particular. And that if there are any barriers that get in the way of them receiving the very best care, that we understand the best strategies for addressing what those barriers are. So that's kind of more of a systems-based approach.

**LISA HOROWITZ**: Yeah, that's really important. I'm glad somebody asked about that. There's also a question from a pediatrician asking, what about suicide risk screening when you don't have any access to mental health care for their patients? Should you still screen? And there are three things that pediatric healthcare providers can do immediately. So a young person, if they're thinking about suicide risk, they're thinking about it whether or not you ask them or not, right? So once you find out someone's at risk for suicide, you can do these things that Stephen talked about. You can do safety planning. You can do lethal means safety counseling. And you can provide resources like 988, the Crisis Text Line, the Suicide Lifeline, the Trans Lifeline. There's a lot of resources. So there are things you can do. No one should feel like, "Well, I shouldn't ask because there's nothing I can do." Even just the asking could be an intervention.

**STEPHEN O’CONNOR**: Yeah, yeah. And there's a question about, any advice for kids who are quiet or struggle to talk about their mental health, resources where they could talk to people anonymously or one-on-one. It's confidential when you contact 988. So that's a bit more of a crisis lifeline, but you don't have to be suicidal in order to contact 988. So number one, 988 is sort of thought of as kind of an open front door to thinking about engaging and receiving mental health services. So that's really how they're looking at it. You should never receive any kind of negative response. If you contact 988, you say that you're kind of struggling and you're just looking for some support, I think that they're there to help. There are also a few youth resources that are available. For instance, I know that the Trevor Project has kind of a peer-based network that's really there to help engage folks, sexual gender minority status, who are just questioning anything. And you can call chat or text at any time, and they're available. Then there is also a separate crisis line, right, where if you are in crisis, that you can receive specific care as well. There's something called Youth Line that I've learned about recently that is really staffed by youth peers that are the ones that are answering the calls, chats, and texts to their crisis line. Again, that's a kind of a crisis line setting. But it's a situation where I think you're seeing these programs are saying, yeah, maybe we need to think about staffing in a way that's really going to appeal to youth and where they're going to feel comfortable sharing their experiences.

**LISA HOROWITZ**: Okay, and then there's a question about mental illness connection to suicide risk and things like alcohol use disorder and substance use disorder. And yes, alcohol use disorder and substance use disorder are-- there's definitely studies showing that people struggling with substances are at greater risk for suicide. When the American Academy of Pediatrics and Bright Futures came out with a recommendation that all kids ages 12 and above should be screened for suicide risk alongside screening for depression risk, there was some thought that depression screening and suicide risk screening must be the same thing. So I want to make sure we say they are very different things. It's really important to screen for depression because that's even more prevalent than suicide risk. And so you use depression screeners to screen for depression.

**LISA HOROWITZ**: But if you want to identify people at risk for suicide, it's really important to use suicide risk screening tools, things like the ASQ because not everybody who is at risk for suicide is depressed. People who are depressed might be at risk for suicide, but there's other mental illnesses that people struggle with that have a higher risk for suicide, like depression, ADHD in kids, anxiety, PTSD, and again, alcohol use disorder, substance use disorder. So I think that we've reached the end of our discussion today. Thank you all so much for joining us and for your attention and for all your important questions. Again, if you or someone you know is in crisis, please call or text 988, the Suicide and Crisis Lifeline, or visit 988lifeline.org** for more help and information. And for more information about everything we discussed today, please visit nimh.nih.gov/suicideprevention. Thank you, Stephen.

**STEPHEN O’CONNOR**: Okay. Thank you, Lisa. And thank you everyone for tuning in. Stay well.