The Acceptability and Next Steps With the CASSY Suicide Screening Tool

In the conclusion of this video series, Cheryl King, PhD, professor in the Departments of Psychiatry and Psychology and Director of the Youth Depression and Suicide Prevention Program at the University of Michigan, Ann Arbor, discusses the acceptability to both parents and youth for this screening tool, next steps in implementation, as well as the stigma of suicidal ideation in youth. Dr King touches on underlying mental health conditions, such as major depressive disorder, schizophrenia, and bipolar disorder, which can be identified using the CASSY screening tool.

In Part 1 and Part 2, Dr King discussed the importance of developing the CASSY suicide screening tool for youth in emergency departments and the key research studies that laid the groundwork for the CASSY to be implemented.

Read the transcript:

Cheryl King:  Now, what do we know about the acceptability of screening teens for suicide risk to parents and to teens, keeping in mind that they come into the emergency department not with a mental health concern, not with a behavioral health concern. They may be there for a sports injury or for influenza with a high fever.

Working together with one of my doctoral students, Roisin O'Mara, a number of years ago, we asked parents and teens independently, "What they thought about screening for a number of behavioral health concerns when they come in to a general medical or pediatric emergency department?" We did a fairly brief survey.

One side of the page, we asked them what they thought about screening for depression, anxiety, eating problems, drug use, suicide risk, dating violence? There are eight or nine different things we're asking about. What's the acceptability? Would you complete a screen today if it was offered? What are your attitudes toward it?

What we learned was that it was definitely acceptable to screen for these things. Most parents and teens thought it was at least average acceptability. The majority thought it was very or highly acceptable. Their attitudes were very positive. Somewhat fewer would take it today if offered, but they thought it was a good idea and acceptable.

The other finding that came out of this, was that for the teens, there was a significant difference between the things on the list. The teens were most favorable about screening for suicide risk. Significantly more favorable about doing that than screening for any of the other items, which they didn't see as critically important when they're coming in to a general medical emergency department.

The parents, on the other hand, thought it was significantly more important to screen for two of the items, suicide risk and drug abuse. You get an idea this was seen as acceptable. That's obviously important when you bring a new practice into a healthcare setting.

Most of our healthcare settings have as one of our values that patients and families come first. We want to listen to, hear their input, and take that into account before we put into place any new practices.

Now, what are the next steps with the CASSY screen and how might it be used? We developed it in, and obviously, very much for general medical emergency departments, which include pediatric emergency departments, but it could potentially be used in other settings. It hasn't been studied in them yet. We don't have as much data.

It could certainly be used in an outpatient clinic, where people are being treated for mental health concerns, disorders, psychiatric clinics, community-based clinics, private practice clinics. It also may have a lot of potential in schools. Again, it could be studied further, but it's a very promising screen.

It's not for any narrow group of youth with mental health concerns. It's important to keep in mind that youth at risk for suicide are highly heterogeneous. There are many different risk profiles and combinations of risk factors.

These range from psychiatric conditions, such as major depressive disorder, bipolar disorder, or schizophrenia in young adults, almost every psychiatric condition, mental health condition, certainly including alcohol and substance misuse, place people, including youth, at elevated risk, but so do many other factors.

Histories of trauma, bullying, victimization, feeling that one doesn't belong at the school or in the family, a lack of identity affirmation, problems with behavioral control, and disinhibition, and aggression, and fighting. There's many factors.

Whereas one youth at risk, may be severely depressed, may be isolated, withdrawn, or disconnected, feeling disconnected, another person at risk may be very connected. Also, highly aggressive having a struggle to manage strong ever-changing emotions, maybe angry outbursts, really different profiles of risk.

We want to keep that in mind and realize that suicide risk cuts across youth with a full range of mental health concerns. We would want to screen for suicide risk, not only in a general medical emergency sample of youth coming in for other reasons, but youth who are coming in with mental health concerns, too.

Now, to wrap up with some final comments about this computerized adaptive screen for suicidal youth, the CASSY. We want to keep in mind that it's personalized and adaptive, which probably accounts for its relatively high classification accuracy in terms of risk for suicide attempt within three months. It's also brief and easy to administer.

It's administered on a tablet like an iPad, and it takes less than two minutes to administer. Each youth will be presented a number of questions and they're just clicking yes/no, to anywhere from say, 5 to 15 or so questions. It's a fairly brief and rapid screen.

It does give us the potential to recognize possible risk for a suicide attempt in youth where this risk has never been recognized or acknowledged before. Some youth share these concerns. Many youth do not. Why? It could be shame. It could be they're afraid people will overreact. They'll lose some freedoms. They'll be hospitalized, they don't want to be.

It could be because they're at such high risk, they don't want to tell anyone about it. For different reasons, including that day that you ask, they may not be. It's been underlying. It comes and goes.

It's good that we screen when they come in and try to recognize this risk in larger numbers of youth so we can take the steps with them, with their families, that may make a difference in their trajectory going forward. Help them to live a fuller life, a better quality of life, and prevent suicide attempts and potentially death by suicide.

Thank you very much for taking the time to learn about the new and promising CASSY screening tool today.

Cheryl King, PhD, is a professor in the Departments of Psychiatry and Psychology and Director of the Youth Depression and Suicide Prevention Program at the University of Michigan. Her research focuses on the development of evidence-based practices for suicide risk screening, assessment, and intervention. She has provided leadership for multiple NIMH-funded projects, including Emergency Department Screen for Teens at Risk for Suicide, which aims to develop a suicide risk screen that can be disseminated nationwide, and 24-Hour Risk for Suicide Attempts in a National Cohort of Adolescents. A clinical psychologist, educator and research mentor, Dr. King has served as Director of Psychology Training and Chief Psychologist in the Department of Psychiatry, and has twice received the Teacher of the Year Award in Child and Adolescent Psychiatry. She is the lead author of Teen Suicide Risk: A Practitioner Guide to Screening, Assessment, and Management. In addition, Dr. King has provided testimony in the U.S. Senate on youth suicide prevention and is a Past President of the American Association of Suicidology, the Association of Psychologists in Academic Health Centers, and the Society for Clinical Child and Adolescent Psychology. She is a current member of the National Advisory Mental Health Council.