46 HOW TO TREAT : SUICIDALITY IN CHILDREN AND ADOLESCENTS
46 HOW TO TREAT : SUICIDALITY IN CHILDREN AND ADOLESCENTS
14 JULY 2023 ausdoc . com . au
Severity Measure for Depression — Child Age 11 – 17 * * PHQ-9 modified for Adolescents ( PHQ-A )— Adapted
Name :____________________________________ Age : ______ Sex : Male � Female � Date :_________________
Instructions : How often have you been bothered by each of the following symptoms during the past 7 days ? For each symptom put an “ X ” in the box beneath the answer that best describes how you have been feeling .
1 . |
Feeling down , depressed , irritable , or hopeless ? |
2 . |
Little interest or pleasure in doing things ? |
3 . |
Trouble falling asleep , staying asleep , or sleeping too |
much ? |
4 . |
Poor appetite , weight loss , or overeating ? |
5 . |
Feeling tired , or having little energy ? |
6 . |
Feeling bad about yourself — or feeling that you are a |
failure , or that you have let yourself or your family |
down ? |
7 . |
Trouble concentrating on things like school work , |
reading , or watching TV ? |
8 . |
Moving or speaking so slowly that other people could |
have noticed ? |
( 0 ) Not at all
( 1 ) Several days
( 2 ) More than half the days
( 3 ) Nearly every day
Clinician Use Item score
Or the opposite — being so fidgety or restless that you were moving around a lot more than usual ? 9 . Thoughts that you would be better off dead , or of hurting yourself in some way ? Total / Partial Raw Score :
Prorated Total Raw Score : ( if 1-2 items left unanswered ) Modified from the PHQ-A ( J . Johnson , 2002 ) for research and evaluation purposes
Each item on the measure is rated on a 4-point scale ( 0 = Not at all ; 1 = Several days ; 2 = More than half the days ; and 3 = Nearly every day ). The raw scores on the nine items should be summed to obtain a total raw score and should be interpreted using this table :
Total Raw Score 0-4 None 5-9 Mild 10-14 Moderate 15-19 Moderately severe 20-27 Severe
Severity of depressive disorder or episode
If three or more items are left unanswered , the total raw score on the measure should not be used . Use this measure : ( Raw sum x 9 )
Number of items that were actually answered
Figure 4 . Modified Patient Health Questionnaire-9 .
Table 1 . Key assessment characteristics
Box 1 . Further questions
Assessment characteristic Social and contextual factors
Under the influence Intent
Conduct disorder or other behavioural disturbances
Impulsivity or other personality characteristics
Depression or other underlying mental health issues
Ever before Source : Eapen V et al 2012 43
Key considerations
Recent loss / separation , setbacks / disappointments ; bullying ; identity or social ( including social media ) issues ; family stressors ; history of trauma or abuse ; presence of any positive supports , their capacity , willingness and availability as relevant
Drug or alcohol use may increase suicidal ideation / behaviour
Detailed planning , meaning and motivation , leaving a note or making a goodbye call or social media post , taking precautions such as choosing a time and place to avoid discovery , not seeking help and continued desire to end life after the event , choosing a method with high lethality are all factors that suggest high intent and serious risk
Conduct disorder and disruptive behaviours may increase the risk
Higher levels of impulsive / risk taking behaviours are known to increase the likelihood of suicidal behaviours
Depression is the most common cause of suicidal ideation and behaviour At risk mental states include anxiety , depressive cognition , eg , hopelessness , helplessness , selfblame , guilt ; ongoing wish to die ; psychotic symptoms ; personal or family history of depression or other mental health disorders in first degree relatives including family history of suicide
Previous suicidal ideation or attempts increases the risk
• Suicidal ideas : — The presence of death wishes ; the frequency , duration , strength and any obsessional quality of suicidal ideation ; whether the ideas / urges can be controlled ; and any suicidal images , sounds or other sensory experiences ( the latter being relevant post-trauma and post-suicide attempts , one ’ s own or others ).
• Suicidal plans :
— Strength of suicidal intent ( self-rated ); any plan ( note level of detail ), beliefs about finality and lethality ; research , rehearsals ( notes , equipment , practising ) and likelihood of rescue .
• Suicidal means : — Availability , dangerousness , ease of procurement .
• Post-suicide attempt : — In addition to the above , one also considers :
• Lethality and intent : high medical lethality attempts are associated with high suicide risk ; however low lethality attempts may conceal high intent where knowledge of method lethality is limited ( eg , in younger children ); and low intent attempts can become lethal with a lethal method .
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professionals is critical .
The SUICIDE framework ( see table 1 ) outlines the key aspects that require careful exploration .
Screening for suicidality and self-harm
The belief that questioning youth
about suicidal ideas and behaviour induces suicidal ideas or behaviour
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has no empirical basis . 44 It is important to broach the topic calmly and non-judgementally . Such questioning is best embedded in the interview , in the context of depression and anxiety screening . An example of this is the widely used Patient Health Questionnaire-9 ( PHQ-9 , see figure 4 ), which has been modified for teens and for |
Aboriginal patients . Depending on the responses , ask further questions ( see box 1 ).
The wish to die strongly predicts future attempts , as does courage and competence about self-harm and previous worst-point resolved plans and preparations . Rehearsal , preventing discovery and communication beforehand are also
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important suicide predictors . Expecting repetition also predicts recurrent suicide attempts . Impulsivity and substance misuse combine to further increase the risk .
MANAGEMENT
The continuum of suicidality
ADOLESCENT self-harm comprises
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a spectrum from suicidal ideation and non-suicidal self-injury , to suicide attempts , to suicide . Self-harm behaviours ( see figure 5 ) may have a suicidal component or none and in individuals this continuum of behaviours may co-occur and suicidal intent may fluctuate , but there is a definite link between self-harm and increased risk for suicide attempts |