Suicidality Screening: Ensuring Providers Do Not Miss Adolescents at High Risk through Clinical Decision Support

Abstract

Background

Major depression in adolescents is recognized as a serious psychiatric illness and a risk factor for suicide. It is important for providers to screen for depression and suicidality and have clinical decision support (CDS) for evaluation, risk assessment, and initial management. Our efforts focused on leveraging the electronic health record (EHR) to ensure that high-risk adolescents received appropriate interventions before leaving the office.

Objectives

This study aims to improve notification of positive adolescent depression and suicide risk screening results. Subaims include (1) designing and optimizing CDS alerts for severe depression and/or acute lethality; and (2) increasing visibility for different EHR users to avoid the near misses.

Methods

We implemented several iterations of an interruptive alert after a positive mental health screening for patients aged 12 to 20 years seen in primary care and subspecialty rheumatology clinics between 2016 and 2023. Screening started with the Patient Health Questionnaire (PHQ) and Ask Suicide-Screening Questions (ASQ) on paper, and later via tablets.

Results

There were 76,919 visits during the study period, of which 50,502 (66%) completed PHQ screening. Rates of PHQ screening increased throughout the study period. Of the ASQ screenings completed, alerts were fired for 2,355 nonacute positive and 411 acute positive. In most cases, all alerts fired were more than once. Providers and clinicians receiving alerts (physicians, nurse practitioners, social workers, and psychologists) acknowledged 63 to 96% of alerts and cancelled 6 to 70% of alerts. We revised the initial alert identifying lethality to include separate alerts for major depressive symptoms and suicide risk. Iterations also included an icon on the clinic schedule and incorporated guidance on appropriate actions.

Conclusion

By creating multiple types of alerting within different workflows, we improved notification and increased next-step visibility, leveraging decision support for patients screening positive for depression and suicidality.

Keywords

depression - suicide - mental health - clinical decision support - adolescent health

Protection of Human and Animal Subjects

This study was approved by the Nationwide Children's Hospital Institutional Review Board, STUDY00003743.

Publication History

Received: 31 December 2024

Accepted: 17 April 2025

Article published online:
22 August 2025

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