1. What is the decision or change (e.g., clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?
We plan to develop a clinical practice guideline on the management of suicidal thoughts and behaviors in children, adolescents, and young adults. A systematic review by AHRQ would be instrumental to the development of this guideline, providing a comprehensive, up-to-date review of the available literature.
The clinical practice guideline will include efficacy and comparative effectiveness recommendations for managing suicidal thoughts and behaviors in children, adolescents, and young adults (ages approximately 11-24). It will also include recommendations for future research in this area and implementation considerations for the recommendations such as equity, diversity, and inclusion and anti-racism issues.
Interventions would ideally include psychological, pharmacological, and complementary and integrative health including efficacy and comparative effectiveness among the interventions as data is available.
Outcomes of interest include symptom reduction such as decrease in suicidal thoughts and behaviors, quality of life, co-morbid depression and anxiety, school outcomes, adverse events, and dropout.
Questions of interest include:
• What is the efficacy and comparative effectiveness of psychological, pharmacological, and complementary and integrative health interventions for suicidal thoughts and behaviors in children, adolescents, and young adults?
o Do these findings vary by demographic factors such as age, race, ethnicity, sex, gender, and sexual orientation?
• What are potential harms of any of psychological, pharmacological, and complementary and integrative health interventions for suicidal thoughts and behaviors in children, adolescents, and young adults?
o Do these findings vary by demographic factors such as age, race, ethnicity, sex, gender, and sexual orientation?
• Contextual question: What are the components of effective psychological treatments
(e.g., frequency or intensity of therapy and/or aspects of the therapeutic modality)?
• Contextual question: What role do social determinants of health and in particular racism and health equity play in the above findings regarding interventions?
2. Why are you struggling with this issue?
The United States is experiencing a youth mental health crisis, with the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association declaring a national emergency in child and adolescent mental health in late 2021.
Suicide is the second leading cause of death among children (aged 10-14 years) and adolescents/young adults (aged 15-24 years) across all races and both sexes (National Center for Health Statistics, 2019). During 2019, 18.8% of high schoolers (aged 14-18 years) “seriously considered attempting suicide,” 15.7% “made a suicide plan,” and 8.9% “had made a suicide plan” (Ivey-Stephenson et al., 2020). In children ages 10-14, suicide nearly tripled from 2007 to 2017 (2.5) (Curtin & Heron, 2019).
Health disparities in suicidal ideation and behavior also exist in children and adolescents. Significant racial differences regarding high schoolers’ suicidal ideation and behaviors exist, particularly in males (white: 13.8%, Black: 10.7%, Hispanic: 11.4%) (Ivey-Stephenson et al., 2020). There is also a higher prevalence of suicidal ideation and behaviors in high schoolers who identify as Lesbian, Gay, or Bisexual (46.8%) versus their heterosexual counterparts (11.4%; Ivey-Stephenson et al., 2020). Suicide attempt injury was also more prevalent in Black adolescent boys than girls (Lindsey et al., 2019). There has also been an increase in suicide related emergencies in girls with and without a history of psychiatric diagnoses during the COVID-19 pandemic (Ridout et al., 2021).
Given this public mental health crisis among youth, a clinical practice guideline on this topic is urgently needed in the United States. However, to our knowledge, within the last five years, there are only three current clinical practice guidelines/resource guides on the assessment/management/prevention of suicidality in children, adolescents, and young adults that have been published in the English language (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020; Kennebeck & Bonin, 2020; National Institute for Health and Care Excellence [NICE], 2018), as follows:/
• Kennebeck & Bonin (2020; UpToDate) provides guidance on evaluating and managing suicidal ideation and behavior in children and adolescents. It is available in the UpToDate database, a clinical decision support system used in healthcare settings. It is updated periodically as new evidence becomes available and their peer review process is complete.
• NICE (2018) includes recommendations on preventing suicide in community and custodial settings for all ages. The NICE (2018) guidance focuses mostly on preventing suicide from occurring and does not address specific psychotherapy treatments for children and adolescents with SIBs. It also addresses recommendations for supporting people bereaved or affected by a suspected suicide.
• SAMHSA (2020) provides an evidence-based resource guide on suicidal ideation, self-harm, and suicide attempts among youths. It recommends provision of dialectical behavior therapy, attachment-based family therapy, multisystemic therapy-psychiatric, safe alternatives for teens and youth, integrated cognitive behavioral therapy, and youth-nominated support team version II. SAMHSA (2020) also lists examples of suicide treatment programs throughout the country and shows how the listed interventions could be adapted for particular populations (e.g., Indian Health Service).
Of these three guidelines, one focuses on prevention instead of treatment and one is a resource guide as opposed to a true clinical practice guideline. Only one appears to broadly cover a similar focus, however, it has some differences in scope and also in the composition of the writing group. APA’s guideline development panels are multidisciplinary and also include patients as full members of the panel, following the former Institute of Medicine’s (now National Academy of Medicine’s) 2011 standards for clinical practice guideline development. This further highlights the critical need for APA to develop a clinical practice guideline in this area as well as the tremendous help that a systematic review by AHRQ would provide to this effort.
3. What do you want to see changed? How will you know that your issue is improving or has been addressed?
Ideally, there would be no suicide among children and adolescents. However, given the current youth mental healt h crisis, there is an urgent public health need for a clinical practice guideline on treating suicidal thoughts and behaviors in children, adolescents, and young adults. A systematic review on this topic by AHRQ would greatly facilitate the development of this guideline.
4. When do you need the evidence report?
Saturday, 06/01/2024
5. What will you do with the evidence report?
We plan to develop a clinical practice guideline on this topic. A systematic review by AHRQ would greatly enhance our ability to produce an up-to-date guideline on this critically important topic. Not only would it facilitate the guideline development panel’s ability to produce efficacy and comparative effectiveness recommendations for treatment based on the most current evidence, it would also greatly increase the panel’s ability to provide recommendations for future research needed given the comprehensive literature review it would have.
We plan to develop a clinical practice guideline on this topic. If this topic is accepted by AHRQ for a systematic review, we can coordinate the timing for seating the guideline development panel to coincide with when the report would be available, either in draft or final form. Ideally, we would like to begin the guideline development process in the next one to two years given the public health significance of this topic.
Results from this report would also be disseminated to our organization’s membership, which includes nearly 131,000 researchers, educators, clinicians, consultants, and students. This information can help guide the practice of clinicians as well as the training of students.
Once the clinical practice guideline is finalized, it will be placed on APA’s website as well as submitted to the ECRI guidelines clearinghouse and we will include links to access the review along with the guideline.
Last, but not least, it is our sincere hope to be able to collaborate with another organization such as the American Academy of Pediatrics or the American Academy of Child & Adolescent Psychiatry on the development of this clinical practice guideline. If this collaboration comes to fruition, this evidence report would also be used by the other organization and ideally disseminated to their members as well.
Supporting Documentation
References: Management of Suicidal Thoughts in Children and Adolescents (PDF, 98 KB)
Optional Information About You
What is your role or perspective? Professional society
If you are you making a suggestion on behalf of an organization, please state the name of the organization. American Psychological Association
May we contact you if we have questions about your nomination? Yes
