How to Assess Suicide Risk in Youth With PTSD
How should clinicians assess suicide risk in children and adolescents hospitalized with posttraumatic stress disorder?
Hospitalized youth with posttraumatic stress disorder can present with substantial suicide risk, but risk is not uniform across patients. This study identifies a subgroup with sexual abuse history that carries more psychiatric comorbidity and higher unadjusted suicidality, while showing that major depressive disorder, substance use disorder, and female sex are the more important independent risk markers to prioritize during assessment.
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Ask about sexual abuse history early
Determine whether the child or adolescent with posttraumatic stress disorder has a history of sexual abuse as part of the initial inpatient psychiatric evaluation. In this cohort, patients with posttraumatic stress disorder and sexual abuse history had higher rates of suicidal ideation or attempt than those with posttraumatic stress disorder alone, 35.4% versus 29.8%, with 29% higher unadjusted odds.
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Screen specifically for major depressive disorder
Assess for comorbid major depressive disorder rather than attributing suicidal risk to posttraumatic stress disorder or sexual abuse history alone. Major depressive disorder was more common in the posttraumatic stress disorder plus sexual abuse group, 23.0% versus 14.4%, and it was one of the strongest independent predictors of suicidal ideation or attempt in multivariate analysis with an odds ratio of 1.66.
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Evaluate for substance use disorder
Screen for substance use disorder during the same suicide risk assessment because it marked additional risk in this inpatient population. Substance use disorder was more prevalent in patients with posttraumatic stress disorder and sexual abuse history, 19.6% versus 10.8%, and suicidal ideation or attempt incidence was 18% higher in patients with substance use disorder than in those without it.
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Use female sex as an added risk marker
Factor female sex into risk stratification when deciding which youth with posttraumatic stress disorder need closer suicide monitoring. Female sex independently predicted suicidal ideation or attempt with an odds ratio of 1.50, and the posttraumatic stress disorder plus sexual abuse group was predominantly female at 80.9%.
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Broaden the psychiatric assessment beyond core PTSD symptoms
Look for additional anxiety disorders and other psychiatric comorbidity when sexual abuse history is present, because the higher-risk group had a broader comorbid burden. Anxiety disorders other than posttraumatic stress disorder were also more common in the posttraumatic stress disorder plus sexual abuse group, while psychotic disorders, adjustment disorders, and behavioral disorders did not differ significantly between groups.
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Interpret sexual abuse history in the context of comorbidity
Do not treat sexual abuse history by itself as an independent predictor of suicidal ideation or attempt once other major risk factors have been assessed. Although the unadjusted association was significant at the threshold level, sexual abuse history was not independently associated with suicidal ideation or attempt after adjustment, with an odds ratio of 1.16 and P value of .29.
Clinical Considerations
- The data represent inpatient hospitalizations rather than unique patients, so some individuals may have been counted more than once.
- The observational design is vulnerable to confounding bias and cannot establish causation.
- The dataset lacked information on medication history, age at abuse, frequency of abuse, family composition, socioeconomic support, and other childhood adversities that could affect suicidality.
- The findings come from a nationwide inpatient sample of children and adolescents aged 6 to 17 years with a primary diagnosis of posttraumatic stress disorder, so applicability outside this hospitalized population is limited.
Bottom Line
In hospitalized youth with posttraumatic stress disorder, ask about sexual abuse history but focus suicide risk assessment most strongly on comorbid major depressive disorder, substance use disorder, and female sex.
