Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk

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Research has shown that youth with major depressive disorder (MDD) are at a high risk for suicide attempts and completion - among the most significant and devastating sequelae of the disease (Fontanella et al., 2020). Suicide risk is a critical consideration in children and adolescents with MDD, and an important aspect of care that should be assessed at each visit and subsequently managed to minimize that risk. Additionally, the importance of the assessments is underscored by research (Fontanella et al., 2020; Luoma, Martin, & Pearson, 2002) that indicates that many individuals who die by suicide do make contact with primary care providers and mental health services beforehand. More specifically, approximately 15% of suicide victims aged 35 years or younger had seen a mental health professional within 1 month of suicide while approximately 23% had seen a primary care provider within 1 month of suicide (Luoma, Martin, & Pearson, 2002). A recent analysis of depression severity and suicidal ideation symptom trajectories (Witt et al., 2021) found that suicidal ideation among children and young adults (15-25 years) might not improve with depression symptom severity. This evidence suggests the potential utility of continued suicide risk screening even after improvements in depression symptoms. Better assessment and identification of suicide risk in the health care setting should lead to improved connection to treatment and reduction in suicide attempts and deaths by suicide.

The evaluation must include assessment for the presence of harm to self or others (MS) (American Academy of Child and Adolescent Psychiatry, 2007).

Suicidal behavior exists along a continuum from passive thoughts of death to a clearly developed plan and intent to carry out that plan. Because depression is closely associated with suicidal thoughts and behavior, it is imperative to evaluate these symptoms at the initial and subsequent assessments. For this purpose, low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale can be used. Also, it is crucial to evaluate the risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity) and protective factors (e.g., religious belief, concern not to hurt family) that might influence the desire to attempt suicide. The risk for suicidal behavior increases if there is a history of suicide attempts, comorbid psychiatric disorders (e.g., disruptive disorders, substance abuse), impulsivity and aggression, availability of lethal agents (e.g., firearms), exposure to negative events (e.g., physical or sexual abuse, violence), and a family history of suicidal behavior (American Academy of Child and Adolescent Psychiatry, 2007).

A careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder (Category I). Such an assessment includes specific inquiry about suicidal thoughts, intent, plans, means, and behaviors; identification of specific psychiatric symptoms (e.g., psychosis, severe anxiety, substance use) or general medical conditions that may increase the likelihood of acting on suicidal ideas; assessment of past and, particularly, recent suicidal behavior; delineation of current stressors and potential protective factors (e.g., positive reasons for living, strong social support); and identification of any family history of suicide or mental illness (Category I) (American Psychiatric Association, 2010, reaffirmed 2015).

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'American Academy of Child and Adolescent Psychiatry. (2007). Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46(11), 1503-1526. doi:10.1097/chi.0b013e318145ae1c'

Reference Type: CITATION

Reference Text: 'American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder. 3rd edition. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf
(This guideline was reaffirmed in 2015.)'

Reference Type: CITATION

Reference Text: 'Fontanella, C. A., Warner, L. A., Steelesmith, D., Bridge, J. A., Sweeney, H. A., Campo, J. V. (2020). Clinical profiles and health services patterns of Medicaid-enrolled youths who died by suicide. Journal of the American Medical Association Pediatrics, 174(5), 470-477. doi:10.1001/jamapediatrics.2020.0002'

Reference Type: CITATION

Reference Text: 'Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916. doi:10.1176/appi.ajp.159.6.909'

Reference Type: CITATION

Reference Text: 'Witt, K., Madsen, T., Berk, M., Dean, O., Chanen, A., McGorry, P.D., Cotton, S., Davey, C.G., Hetrick, S. (2021). Trajectories of change in depression symptoms and suicidal ideation over the course of evidence-based treatment for depression: Secondary analysis of a randomized controlled trial of cognitive behavioral therapy plus fluoxetine in young people. Australian and New Zealand Journal of Psychiatry, 55(5), 506-516. doi:10.1177/0004867421998763'

Numerator Definition: The specific type and magnitude of the suicide risk assessment is intended to be at the discretion of the individual clinician and should be specific to the needs of the patient. At a minimum, suicide risk assessment should evaluate:
1. Risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity) and protective factors (e.g., religious belief, concern not to hurt family) that may influence the desire to attempt suicide.
2. Current severity of suicidality.
3. Most severe point of suicidality in episode and lifetime.
 
Low burden tools to track suicidal ideation and behavior such as the Columbia-Suicidal Severity Rating Scale can also be used. Because no validated assessment tool or instrument fully meets the aforementioned requirements for the suicide risk assessment, individual tools or instruments have not been explicitly included in coding.

This eCQM is an episode-based measure. An episode is defined as each eligible encounter for major depressive disorder (MDD) during the measurement period. A suicide risk assessment should be performed at every visit for MDD during the measurement period.

In recognition of the growing use of integrated and team-based care, the diagnosis of depression and the assessment for suicide risk need not be performed by the same provider or clinician. 

Suicide risk assessments completed via telehealth services can also meet numerator performance. 

Use of a standardized tool(s) or instrument(s) to assess suicide risk will meet numerator performance, so long as the minimum criteria noted above is evaluated. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below, as no individual suicide risk assessment tool or instrument would satisfy the requirements alone.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder

Equals Initial Population

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Patient visits with an assessment for suicide risk

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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