Adolescents Who Do Not Endorse Risk via the Patient Health Questionnaire Before Self-Harm or Suicide

• Published in: JAMA psychiatry (Chicago, Ill.) Vol. 81; no. 7; p. 717
• Main Authors: Flores, Jean P, Kahn, Geoffrey, Penfold, Robert B, Stuart, Elizabeth A, Ahmedani, Brian K, Beck, Arne, Boggs, Jennifer M, Coleman, Karen J, Daida, Yihe G, Lynch, Frances L, Richards, Julie E, Rossom, Rebecca C, Simon, Gregory E, Wilcox, Holly C
• Format: Journal Article
• Language: English
• Published: United States 01-07-2024
• Subjects: Adolescent; Depression - epidemiology; Depression - psychology; Female; Humans; Male; Patient Health Questionnaire; Retrospective Studies; Risk Assessment; Self-Injurious Behavior - epidemiology; Self-Injurious Behavior - psychology; Suicidal Ideation; Suicide - psychology; Suicide - statistics & numerical data; United States - epidemiology; United States
• ISSN: 2168-6238
• DOI: 10.1001/jamapsychiatry.2024.0603

Given that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected.
To understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide.
This was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023.
Demographic, diagnostic, treatment, and health care utilization characteristics.
Responded "not at all" (score = 0) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide.
The study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P = .03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P = .02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P = .001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P = .007) within 90 days.
Study results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.