NUR 7641 Module 5 Adolescent Suicide Risk Case: ASQ Screening, Safety Planning and DBT Example

Four Questions in the Emergency Department: Screening, Safety Planning and Dialectical Behavior Therapy After a 16-Year-Old's Overdose

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7641: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Child and Adolescent Populations, Part B

Mentor Name

Month Day, Year

Four Questions in the Emergency Department: Screening, Safety Planning and Dialectical Behavior Therapy After a 16-Year-Old's Overdose

An Overdose After a Breakup

Brianna is an invented patient, 16 years old and in eleventh grade in Jersey City. Her mother found her drowsy on the bathroom floor late one evening and brought her to the emergency department, where Brianna admitted taking about fifteen of her mother's prescribed pills two hours earlier after her girlfriend ended their relationship by text. Poison control was consulted, blood levels were drawn and she was observed until medically cleared the next morning.

On interview she describes cutting her thighs with a razor blade about twice a week for six months to relieve feelings she cannot stand, a prior episode of swallowing pills a year ago that no one knew about, and fights with her mother about her sexuality and her grades. She has low mood most days, sleeps poorly and has stopped going to soccer. She drinks at weekend parties but uses no other drugs. She says she is glad to be alive now but is not sure she will feel that way next week.

She has never been in therapy. A gym teacher once noticed scars on her arm and was told they came from a cat, and no one followed up. Her mother, shaken by the overdose, says she had no idea how bad things had become.

The Screen

Horowitz et al. (2012) developed the Ask Suicide-Screening Questions in three pediatric emergency departments by testing 17 candidate questions against a longer questionnaire in 524 patients aged 10 to 21. Four questions worked best together: whether the patient wished they were dead in recent weeks, thought the people around them would be better off with them gone, had thoughts of killing themselves, or had ever tried. This set caught 97 percent of those at elevated risk, with specificity of 88 percent and a negative predictive value above 99 percent among medical and surgical patients. A yes to any question calls for a full assessment. Brianna answers yes to three of the four, including the past attempt.

The Full Assessment

A positive screen leads to a structured interview about the current attempt, prior attempts, ongoing ideas and plans, access to means, warning signs and protective factors. Brianna's risk factors are serious: a recent attempt with intent to die, a prior undisclosed attempt, repeated self-injury, depression, alcohol use, conflict at home over her identity and the loss of a relationship. Her protective factors include her stated relief at being alive, her closeness to an aunt, her younger brother whom she does not want to hurt and her willingness to talk. Depression is confirmed as a major depressive episode. She is judged at high but not imminent risk, and with her mother's commitment to supervision and to securing medicines, discharge with intensive follow-up is chosen over hospital admission, after discussion with the attending physician.

Building a Safety Plan

Before discharge, Brianna and the nurse practitioner write a safety plan together in her own words. Its steps run from warning signs she can recognize, such as lying awake replaying texts, to coping she can do alone, such as running or drawing, to people and places that distract her, to adults she can ask for help, including her aunt, and finally crisis lines and the emergency number. Her reason for living, her brother, is written at the top.

Stanley et al. (2018) compared this kind of safety planning intervention, with at least two follow-up phone calls after discharge, against usual care in 1,640 suicidal patients seen in emergency departments of the Veterans Health Administration. Those who received the intervention had about half the odds of suicidal behavior over six months and twice the odds of attending an outpatient mental health visit. The patients were adults, mostly men, so the result is applied to Brianna with caution, but the approach is widely recommended for young people, and the calls cover the risky days after discharge before her first outpatient visit.

Securing Lethal Means

Her mother is counseled, privately and with Brianna, about removing access to the means of a further attempt: locking or removing prescription and over-the-counter medicines, keeping only small amounts in the house and making sure no firearms are present, which she confirms. Razor blades are removed from the bathroom. These steps are explained as making the home safer during a dangerous period, not as punishment.

Treatment After Discharge

McCauley et al. (2018) randomly assigned 173 adolescents aged 12 to 18 with a prior suicide attempt and repeated self-harm to six months of dialectical behavior therapy or individual and group supportive therapy. After treatment, 90 percent of the DBT group had made no suicide attempt, against 79 percent of the comparison group, and DBT also reduced self-injury. More adolescents finished DBT than supportive therapy. The advantage narrowed by one year, though self-harm kept falling in both groups.

Brianna is referred to an adolescent DBT program with weekly individual therapy, a skills group that her mother attends and phone coaching between sessions. Its skills in distress tolerance and emotion regulation fit her use of cutting to manage overwhelming feelings. Her depression is treated alongside, and any antidepressant is started with close monitoring and small supplies. Family sessions address the conflict over her identity, since acceptance from family protects young people who identify as LGBTQ.

Follow-Up

She is called within 24 hours and again within 72 hours of discharge, and is seen within a week. The safety plan is reviewed at every visit. Her school counselor, with her consent, knows to check in daily during her first week back.

Conclusion

A four-question screen identified Brianna's risk in a busy emergency department, and a full assessment showed high but not imminent risk. Her written safety plan, the calls after discharge, her mother's counseling on locking up medicines and the DBT referral, a therapy that reduced repeat attempts and self-harm in adolescents like her, together form a plan grounded in evidence and in her own reasons to live.

References

Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., Wharff, E. A., Ginnis, K., Cannon, E., Joshi, P., & Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): A brief instrument for the pediatric emergency department. Archives of Pediatrics and Adolescent Medicine, 166(12), 1170-1176. https://doi.org/10.1001/archpediatrics.2012.1276

McCauley, E., Berk, M. S., Asarnow, J. R., Adrian, M., Cohen, J., Korslund, K., Avina, C., Hughes, J., Harned, M., Gallop, R., & Linehan, M. M. (2018). Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: A randomized clinical trial. JAMA Psychiatry, 75(8), 777-785. https://doi.org/10.1001/jamapsychiatry.2018.1109

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900. https://doi.org/10.1001/jamapsychiatry.2018.1776