School-Based Screening for Suicide Risk: Balancing Costs and Benefits

摘要

Objectives. We examined the effects of a scoring algorithm change on the burden and sensitivity of a screen for adolescent suicide risk. Methods. The Columbia Suicide Screen was used to screen 641 high school students for high suicide risk (recent ideation or lifetime attempt and depression, or anxiety, or substance use), determined by subsequent blind assessment with the Diagnostic Interview Schedule for Children. We compared the accuracy of different screen algorithms in identifying high-risk cases. Results. A screen algorithm comprising recent ideation or lifetime attempt or depression, anxiety, or substance-use problems set at moderate-severity level classed 35% of students as positive and identified 96% of high-risk students. Increasing the algorithm's threshold reduced the proportion identified to 24% and identified 92% of high-risk cases. Asking only about recent suicidal ideation or lifetime suicide attempt identified 17% of the students and 89% of high-risk cases. The proportion of nonsuicidal diagnosis–bearing students found with the 3 algorithms was 62%, 34%, and 12%, respectively. Conclusions. The Columbia Suicide Screen threshold can be altered to reduce the screen-positive population, saving costs and time while identifying almost all students at high risk for suicide. Adolescents commonly keep their thoughts about suicide to themselves and many suicide attempts go unrevealed to parents and other adults 1 – 4 ; furthermore, adolescents rarely seek treatment on their own. 5 , 6 Proactive screening programs for adolescent suicidality rely on the identification of the principal risk factors for completed suicide (i.e., current suicidal ideation, previous attempt behavior, and the presence of a mood, anxiety, or substance use disorder). 5 , 6 One proactive screening program, the Columbia Teen Screen program, has employed a school-based screening approach, the Columbia Suicide Screen (CSS), that involves administering a self-completion form with questions about risk factors for suicide such as suicidal ideation, prior suicide attempts, depression, anxiety, and substance use. Students who screen positive (stage 1) are then seen by a clinician for a secondary confirmatory evaluation (stage 2) and, if indicated, the student is case managed to an appropriate referral. With its original algorithm, the CSS has been shown to identify 75% of students considered to be at high risk for suicide 7 and a third of students who had unspecified mental health problems that were not already known to school professionals. 8 Criticisms that the approach generated many false positives were based on our previous reports 7 that were limited to identifying high-risk cases 9 – 11 and ignored the fact that screening for suicidal ideation and behaviors will commonly reveal nonsuicidal mental illnesses that have never been disclosed. Much of the cost of screening comes from providing confirmatory evaluations to students identified during the initial part of a 2-stage procedure. Falsely identifying students who do not have a significant mental health problem adds to the cost of screening. To minimize this problem, these costs need to be weighed against the benefits of identifying students considered to be at high risk for suicide along with those who are not deemed to be at high risk for suicide but who do have an undiagnosed but significant, impairing, and treatable mental health condition. Second-stage evaluations that fail to confirm the need for clinical referral are therefore a necessary but at times onerous burden. We report, for the first time, how varying the items and threshold of the items that determine whether an adolescent screens positive affects the accuracy and the program burden of the CSS. Our research questions were: (1) What effect does altering the scoring algorithm of the CSS have on identifying adolescents at high risk for suicide? and (2) What effect does altering the scoring algorithm of the CSS have on reducing the burden of confirmatory evaluations for a screening setting?.