24. The Comparative Effectiveness of Suicide Risk Screening Among Adolescents: A Secondary Analysis of the SHIELD Randomized Clinical Trial

Suicide is the second leading cause of death among US adolescents, with rates increasing by over 50% in the past decade. The SHIELD randomized clinical trial evaluated the effectiveness of school-based major depressive disorder (MDD) screening. This secondary analysis focused on suicide risk assessment to increase initiation of mental health treatment. MDD screening in SHIELD utilized the Patient Health Questionnaire-9 (PHQ-9). Though not a formal suicide risk assessment tool, PHQ-9 item #9 considers suicide risk. During the SHIELD trial, positive responses to item #9 placed the greatest burden on schools for urgent/emergent evaluation. Our objective was to determine whether the PHQ-9 increased identification of and treatment initiation for increase suicide risk. Students in 14 Pennsylvania high schools were randomized by grade to either: 1) usual school practice of targeted referral for behaviors prompting concern for suicide risk or 2) universal screening using the PHQ-9 with any response >0 to item #9 regarding suicide risk considered positive. Students identified in either arm were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. SAP includes trained professionals that utilize a team process to gather and review referral data. SAP determined follow-up recommendations. Study groups were compared using mixed effects logistic regression. To simulate use of a PHQ-8, which excludes item #9, responses on item #9 were compared to positive scores on the PHQ-8. Participants included 12,909 students with 6,473 (50.1%) randomized to universal screening. Students were 46% female and 43% Hispanic or non-Hispanic Black. Seven of 14 schools were urban with a median size of 370 students. Adolescents in the universal screening arm had 7.1 times higher odds (95% CI 5.7-8.8) of being identified as at-risk for suicide, 7.8 times higher odds (95% CI 4.6-13.1) of confirmed follow-up needs, and 4.0 times higher odds (95% CI 2.0-7.9) of initiating mental health treatment. Using a PHQ-8 screen potentially missed 30.2% of at-risk students (positive response to PHQ-9 item #9, but negative on the PHQ-8). Even with a MDD screening tool, which is not optimized for suicide risk assessment, universal screening increased identification of and treatment initiation for suicide risk among identified adolescents. This both confirms the value of this approach and suggests a suicide-specific risk assessment may have even greater impact on treatment engagement of at-risk youth.