Chronicity of Suicidality: Youth Suicide Prevention in Primary Care

Abstract

Youth suicide and suicidality are significant public health concerns, with rates continuing to rise. Suicidality can be chronic, requiring ongoing management and support. The current article presents a case study exploring the chronicity of suicidality, mental health workforce challenges, and the critical role of primary care in youth suicide prevention. Primary care is a critical yet underutilized setting to enhance youth suicide prevention efforts. Evidence-based practices for how primary care providers can screen, assess, intervene, and follow up with youth experiencing suicidality and their families are presented. Recommended solutions to address the suicide prevention gaps in primary care, including workforce education and training, care integration, and expansion of care delivery models, are offered. Youth suicide prevention is the responsibility of all care providers and requires a coordinated approach across a child’s entire system of care.

Case Study

Alex is a 14-year-old adolescent in high school who presents to the primary care office with their parent due to recent mood changes. Alex has a history of anxiety and depressive symptoms for three years. Alex was seen in the emergency department last year for acute suicidal ideation and was referred for outpatient mental health services. Alex has been making progress in treatment, but recently their mental health provider left the practice. Alex has not been able to find another provider and is currently on a waiting list. Alex’s parents have seen an overall improvement in Alex’s symptoms and have not been very concerned with finding a new mental health provider given Alex’s improvement. They are comfortable following up with Alex’s primary care provider (PCP) as needed. During a recent visit, the PCP conducted a universal suicide risk screening. Alex screened positive for suicidal ideation over the past few weeks but no current ideation at screening with a non-specific plan and no intent to carry the plan. Alex further disclosed to the PCP that these feelings really have never gone away since they stopped seeing their mental health provider six months ago, but they have been hiding it from their parents. Alex did not want to worry or burden their parents but recently has not been able to hide how they have been feeling. If you were Alex’s PCP, what would you do next? The case presented is to provide an example of how a youth might present in primary care endorsing suicidality. The purpose of this commentary is to briefly discuss the chronicity of suicidal thoughts and behavior and highlight the critical role of primary care (e.g., pediatricians, advanced practice registered nurses, and registered nurses) and community-based services, including schools, in addressing youth suicide prevention with evidence-based strategies.

Overview

Suicide is a pressing public health problem and leading cause of death among youth in the United States (Garnett & Curtin, 2023). The rates of youth suicide and suicidality (i.e., suicidal thoughts and behaviors) have increased over the past two decades, growing significantly among racial and ethnic minority youth (Centers for Disease Control and Prevention[CDC], 2024; Lindsey et al., 2019; Stone et al., 2023). Recent CDC data indicates an increase in suicide deaths among youth since 2018, with the most significant and disproportionate growth in suicide deaths at 36.6% among Black youth (Stone et al., 2023). The trends in suicide deaths and suicidality have continued to worsen despite best efforts to mitigate risk and prevent suicide.

In 2023, 20% of high-school-aged adolescents seriously considered attempting suicide, 16% reported making a suicide plan, and 9% made a suicide attempt (CDC, 2024). Racial, ethnic, and sexual/gender minority youth are disproportionately at an increased risk for suicidality and death by suicide (Bridge et al., 2018; Gaylor et al., 2023). The COVID-19 pandemic further exacerbated an already prevalent youth mental health crisis and has been associated with increasing mental health concerns and suicidal behavior in youth (Office of the Surgeon General, 2021). Multiple national healthcare and professional organizations, including the federal government, have sounded the alarm calling for increased efforts across community, healthcare, and social service settings to address the need for comprehensive youth suicide prevention.

Chronicity of Suicidality

The experience of suicidality may not always be a singular event, and an individual can have chronic or persistent suicidal thoughts and behaviors that occur over an extended period of time. It can range in frequency, duration, and intensity, becoming part of a person’s daily life. Youth who experience chronic suicidality often have underlying mental health concerns, such mood and anxiety disorders, which contribute to their ongoing challenge with suicidality. In addition, youth with chronic suicidality are more likely to experience it for months after onset and face compounding psychosocial challenges, such as trauma, life stress, self-esteem issues, feelings of hopelessness, emotional dysregulation, limited social support, interpersonal conflicts with family and peers, or a history of child maltreatment (Blasco et al., 2019; Wolff et al., 2018). Studies have found that youth who report suicidality during adolescence are more likely to have chronic suicidality for years after onset as they transition into young adulthood (Benjet et al., 2018; Sivertsen et al., 2023). Due to the potential chronicity of suicidality, ongoing mental health care and support are crucial for these individuals and their families. Addressing the needs of youth experiencing chronic suicidality requires a collaborative effort among mental health professionals, primary care providers, schools, and families offering a holistic and effective system of care and support.

Critical Role of Primary Care in Youth Suicide Prevention

Today, more than 75% of counties in the U.S. are experiencing a significant shortage of mental health professionals, affecting 163 million Americans (Health Resources Services Administration [HRSA], 2024a). Rural areas and areas with a higher proportion of racial and ethnic minority groups experience even greater challenges in accessing mental health services. HRSA projects a continued significant shortage of mental health professionals by 2037, exacerbating access to care issues and mental health disparities (HRSA, 2024b).

Primary care settings are often the consistent point of healthcare contact for many youth at risk for suicide. Primary care, as used here, is defined as a routine access point where individuals can seek care. These spaces include medical offices, school-based health centers, urgent care centers, retail clinics, and telehealth platforms (Stene-Larsen & Reneflot, 2019). Consistently, individuals who die by suicide are more likely to have engaged in a primary care visit a month before their death (Sisler et al., 2020; Spottswood et al., 2022). However, evidence-based suicide risk screening, assessment, and treatment are not universally available in primary care settings. The American Academy of Pediatrics (AAP) recommends universal suicide risk screening for youth aged 12 and older and when clinically indicated for youth ages 8 to 11 (AAP, 2023). However, primary care providers (PCPs) report having little time, inadequate knowledge and training on suicide risk, and limited access to mental health resources and services to refer at-risk youth as barriers to implementing suicide prevention activities (Davis et al., 2023; Diamond et al., 2012; Plax et al., 2024).

When screening does occur, evidence-based interventions and/or follow-up are not always provided, and often, youth and their families are referred to emergency care. Depression screening has been used as a proxy for assessing suicide risk in primary care, which is problematic because it does not have adequate sensitivity for detecting suicide risk (Horowitz et al., 2021). The need for evidence-based youth suicide prevention in primary care has reached an unprecedented level. Youth, families, and providers are supportive of integrating suicide risk screening in primary care; however, PCPs need additional support to effectively integrate suicide prevention activities into current practice (Horowitz et al., 2022; Plax et al., 2024). The mental health workforce shortages and other structural and social barriers (e.g., racism, insurance, stigma) to accessing mental health care across the service continuum demonstrate the critical need to improve suicide prevention in primary care settings.

What can Primary Care Providers do?

Primary care providers play an essential role in suicide prevention across screening, assessment, intervention, and follow-up (see Figure 1). Foundational to these efforts are primary care settings that are prepared to respond and act when presented with a child endorsing suicidality. All PCPs should have fundamental competency in suicide risk assessment and intervention and knowledge of local services and available resources.

Figure 1. Primary Care of Suicidality in Youth.

Given the dynamic and evolving nature of adolescent development, routine screening is critical. Suicide and suicidal behavior are influenced by various risk factors, including family history, early life adversity, substance use, feelings of hopelessness, lack of social connectedness, depressed mood, and stressful life events (Turecki & Brent, 2016), which also manifest differently during adolescence (Stewart et al., 2017). These risk factors are further exacerbated by social and environmental factors, such as social isolation, racism, discrimination, sensationalized media reporting, access to lethal means, and inadequate access to mental health care (Turecki & Brent, 2016). Adolescent suicidal behavior is often precipitated by changes or conflict within their immediate environment (e.g., home and school) or interpersonal relationships, such as with peers and family members (Diamond et al.. 2022; Hawton et al., 2012).

All youth should also have a comprehensive psychosocial evaluation with each visit. A static educational, social, or relational context cannot be assumed. Two widely accepted general screening instruments are HEEADSSS and SSHADESS (See Table 1; Doukrou & Segal, 2018; Ginsburg & McClain, 2020). Each tool screens for health behaviors, social and environmental context that convey a potential increased risk to physical, mental, and behavioral health and for suicidality. The SSHADESSS screens for strength/protective behaviors as well, using open-ended questions like “tell me about your social media use”. Most importantly, both tools specifically ask about suicide. These general screeners can be completed during check-in or prior to the visit with findings reviewed during the appointment. Using a social-ecological approach, PCPs can identify risk and protective factors across a child’s social ecology influencing suicidality and intervene using appropriate evidence-based interventions.

Table 1.

Evidence-Based Suicide Prevention Activities for Use in Primary Care

	Activities	Resources
General Screening	• Assess for risk and protective factors of suicide risk using evidenced-based psychosocial and developmental screening tool	• HEEADSSS Adolescent Psychosocial (Doukrou & Segal, 2018)  ∘ Home, Education and Employment, Activities, Drugs, Sexuality, Suicidality, Safety • SSHADESS Psychosocial Assessment (Ginsburg & McClain, 2020)  ∘ Strengths, School, Home, Activities, Drugs and substance use, Emotions, Eating, Depression, Sexuality, Safety, Social Media
Suicide Risk Screening and Safety Assessment	• Use reliable and valid screening tool, including but not limited to the C-SSRS and ASQ. • Utilize an evidence-based suicide safety assessment including but not limited to the full C-SSRS, ASQ Brief Suicide Safety Assessment, or the SAFE-T Protocol.	• Ask Suicide-Screening Questions (ASQ) Toolkit (National Institute of Mental Health, n.d.) • Columbia-Suicide Severity Rating Scale (C-SSRS (The Columbia Lighthouse Project, n.d.) • SAFE-T Suicide Assessment Five Step Evaluation and Triage (Substance Abuse and Mental Health Services Administration, 2024) • AAP (2023) Screening for Suicide Risk in Clinical Practice
Interventions & Follow-up	• Suicide safety planning • Lethal means restriction and counseling • Psychoeducation for youth and family • Problem-solving and coping skills development • Referral to mental health services • Offer community resources (e.g., local crisis lines, support groups, etc.) • Caring contacts via phone, text, email, etc. after visit • Collaborate with caregivers and school staff (e.g., school nurses, social workers, counselors) to promote safety and well-being in school and community settings	• Safety Planning Intervention (Stanley & Brown, 2012; n.d.) • Suicide Prevention Resource Center (SPRC; n.d.) • 988 Suicide and Crisis Line (988 Lifeline, n.d.) • Blueprint for Youth Suicide Prevention (American Academy of Pediatrics, n.d.)

Note: This is not a comprehensive list of tools and resources. This table is intended to serve as a starting point for providers to explore and tailor to their primary care setting.

Specific valid and reliable suicide risk screenings include the Ask Suicide-Screening Questions (ASQ), Columbia-Suicide Severity Rating Scale (C-SSRS), Suicide Ideation Questionnaire-Junior (SIQ-Jr), and Suicide Behaviors Questionnaire-Revised (SBQ-R). These instruments can be used for universal screening as well as for benchmarking as the patient undergoes treatment. While these are valid screening and assessment tools, it is important for providers to select the tool that best fits their context, practice, and population.

If concerns are identified or a patient screens positive for suicidality, then a more specific suicide risk and safety assessment should be undertaken (See Table 1). At a minimum, providers need to assess safety, frequency, intent, plan, active or passive nature of these thoughts, and access to lethal means. Based on the safety assessment, appropriate interventions beyond referral to outpatient or emergency care should be initiated (See Table 1). This is a critical step that is too often omitted. All patients and families should be provided information on crisis support lines, referral resources specific to age and co-morbidity, safety plans, and lethal means restriction plans should all be a practiced component of clinical policies and procedures (Sisler et al., 2020). Patient facing staff along with the primary care team should all be well-versed in referral resources. All referrals should include a warm handoff when able and a definitive date for follow-up included prior to the end of the visit with emergency contingency plans. Interventions can include long-term psychotherapy, medication, or a combination of inpatient/outpatient care and group therapy. Many of these interventions are the purview of specialty providers; however, the primary care team will need to incorporate the treatment plan into the broader plan of care, monitor the long-term impact, and potentially advocate with the school system for appropriate supports and accommodations.

Youth who experience chronic suicidality may go through an acute, active period of suicidality, followed by a passive, intermittent periods where suicidal thoughts are present, but they do not have a suicide plan or intent. Follow-up and coordination across the child’s system of care is essential and provides both support and accountability for patients, family members, school staff, and care providers. With school particularly, coordination and collaboration are key to best support the child with necessary accommodations, especially if the child is transitioning back to school after hospitalization (Vanderburg et al., 2023).

Throughout screening, assessment, intervention, and follow up, PCPs need to also assess the needs of the patient’s support system, such as parents. Parents play a central role in suicide prevention efforts and are essential partners with the care team in enacting care plans and preventing future suicidality (Ewell Foster et al., 2022). However, parents’ needs are often not considered yet they hold primary responsibility for ensuring their child’s safety at home and in the community, including navigating child mental health services and supporting their child’s mental health. A child’s experience of suicidality can have significant physical, emotional, and psychosocial effects on parents and the entire family system (Smith et al., 2023; Weissinger et al., 2023). PCPs must meaningfully engage parents in suicide prevention care, ensuring they have the support and skills necessary to care for themselves, while also caring for their children and family.

Call to Action

Implementing evidence-based suicide prevention strategies in primary care that are brief, require minimal effort, and are supported by evidence hold tremendous potential for preventing youth suicide and suicidality. In fact, primary care may be the only setting where these interventions or supports may be available for many youths at risk for suicide. One of the most significant hurdles to successfully implementing effective strategies for youth suicide prevention is access to timely mental health services. The projected deficit of mental health providers by 2037 is alarming and remains a critical area for increased investment to support individuals interested in pursuing a career as a mental health professional (HRSA, 2024b). Recommended solutions to address care gaps for youth suicide prevention in primary care are:

1. Bolstering the capacity of the primary care workforce to respond to an evolving national mental health crisis. PCPs often have very limited training in suicide, suicide prevention, and mental health more broadly, which is a barrier to addressing growing mental health concerns among youth (Diamond et al., 2012). A recent scoping review of suicide prevention training programs in pediatric primary care found that when implemented training improves provider knowledge and confidence (Parkhurst et al., 2025). Health profession education programs must meaningfully integrate suicide prevention and mental health content with developmental considerations into their core curricula more prominently with continual reinforcement through residency training, professional development, and continuing education.

2. Purposeful integration of mental health and primary care services. Such service integration will allow for more timely access and appropriate support, follow-up, and referrals for suicide prevention and mental health services. Psychiatric mental health nurse practitioners (PMHNPs) play a vital role in these integrated models, particularly in screening, diagnosing, and managing mental health conditions within primary care settings. Their ability to collaborate with primary care providers ensures continuity of care and helps bridge service gaps (Kumar et al., 2020). Creating programs that support both primary care and mental health specialty practice will also be critical in alleviating the projected workforce shortages. The removal of practice barriers (i.e., institutional and regulatory) and implementation of full practice authority for APRNs are key strategies to support integration efforts (Birch et al., 2021; Delaney et al., 2018). In addition, the use of telehealth goes a long way to optimize the reach of integrated primary care and mental health services and should be reimbursed accordingly. The acceptance of limited-service provisions via telehealth should not reflect a limit on reimbursement. Reimbursement for mental health services must be at parity with physical health services and support the continued use of telehealth services to improve access.

3. Expanding care delivery models to facilitate coordinated primary and mental health care. Given the shortage of mental health professionals, there is ripe opportunity to expand care models to integrate additional providers to support the delivery of suicide prevention and mental health services in primary care settings. Psychiatric-Mental Health registered nurses (PMH-RNs) and community health workers (CHWs) with appropriate training or specialty expertise can implement suicide risk screening and assessment, interventions, and follow-up once a suicidal youth is identified. By capitalizing on the expertise and skills of PMH-RNs and CHWs, primary care teams can ensure that evidenced-based mental health interventions and care plans initiated in primary care are maintained and individuals are connected to appropriate services and resources (Delaney et al., 2018).

Implementing evidenced-based suicide prevention strategies in primary care can ensure youth, like Alex, can receive timely support to maintain safety, promote recovery, and access mental health services. Collectively, we must change the narrative on suicidality as a singular event to one that can have an ongoing chronic impact from youth to adulthood. Accepting the nature of suicidality as potentially recurring and the need for ongoing treatment and support allows for continued engagement and coordination of treatment across the care continuum and lifespan (Haroz et al., 2023). Given the current and projected mental health workforce shortages, we can no longer place this responsibility solely on mental health providers when the demand for care is at alarming levels. Youth suicide prevention is a responsibility for all health professionals regardless of specialty or practice setting.