Adolescent suicide has been on the rise for over a decade, and it surged beginning with the COVID-19 pandemic.
The youth mental health crisis has increased the demand for pediatric inpatient psychiatry units (IPUs), exacerbating already critical bed shortages.
In response, Patricia Ibeziako, MD, associate chief quality officer for behavioral health at Boston Children’s Hospital, led a two-year study of symptoms and self-reported outcomes from more than 200 adolescents, ages 12-17, who were admitted to the IPU.
The hospital found one of the highest rates of suicide attempts ever reported in adolescents, with more than 75% of teens reporting at least one suicide attempt in their lifetime.
Nearly 70% of IPU patients reported having suicidal thoughts two weeks before admission, and 93% were diagnosed with a depressive disorder.
“The most severe patients are in our inpatient psych units,” Ibeziako said. “We needed to explore evidence-based protocols to enhance suicide assessment and treatment.”
Using evidence-based practices
Boston Children’s followed the Zero Suicide Framework, a national model that takes a comprehensive, systemwide approach to suicide prevention.
Study findings showed the framework helped anchor treatment to a suicide-focused lens and improved depression symptoms and emotional regulation:
- Suicidal thoughts decreased by 54% by the time of discharge.
- There was a large reduction of depressive symptoms, with significant improvement in all self-reported symptoms, including mood, sleep, energy, and interest.
- Self-reported measures of anxiety, emotional regulation, family relationships, and overall life satisfaction improved significantly.
Along with implementing the Zero Suicide Framework, in 2023, the hospital joined the nationwide Preventing Youth Suicide Collaborative, an initiative supported by the Children’s Hospital Association, the Cardinal Health Foundation, and the Zero Suicide Institute. Ibeziako said that using similar tools and a standardized approach to care allowed the 39 participating children’s hospitals to learn together and accelerate progress.
“The Preventing Youth Suicide Collaborative and Zero Suicide Framework have standardized a suicide-focused approach to care,” she said. “As we implement the framework, patients are receiving care that is safe, effective, and evidence-based.”
A suicide-focused approach to treatment
When the hospital started its suicide prevention efforts in 2019, it was driven by The Joint Commission's National Patient Safety goals.
Ibeziako developed a suicide prevention pathway and engaged clinical program directors to adopt the new protocol. She learned that these efforts were aligned with the first two elements of the Zero Suicide Framework.
“I realized how much of this work was literally the Zero Suicide Framework, including identifying suicide risk through screening and assessment and engaging patients and families through safety planning,” Ibeziako said. “We wanted to move through the next elements of enhancing our treatment.”
Identify: Use standardized risk assessment tools to determine the course of treatment and next steps.
Boston Children’s implemented the Columbia Suicide Severity Rating Scale and the Suicide Assessment Five-Step Evaluation and Triage protocol for suicide screenings and risk assessments. IPU staff used these tools upon admission, and reassessments were conducted twice a week until discharge.
Engage: Clinicians talk with patients about their suicide risk and develop a collaborative safety plan, including available treatments.
Every clinician was trained on Stanley Brown Safety Planning Intervention that consists of coping strategies and resources for decreasing the risk of suicidal behavior. Teams also administered an IPU safety scale to inform safety and coping plans.
Additionally, Boston Children’s focused on teens’ own voices by using patient-reported outcomes that asked patients how they were feeling and functioning. This helped care teams understand what was working and what needed more attention.
Treat: Apply evidence-based techniques to treat suicidal thoughts and behaviors.
Care teams used proven interventions, including cognitive behavioral therapy (CBT) and dialectical behavioral therapy, to target depressive disorders and suicidal thoughts.
“There’s this concept of suicide-focused care, where you’re not just talking about general CBT, but you’re anchoring it with suicide assessments and specific interventions,” Ibeziako said. “If you follow the framework of identify and engage throughout the admission, you’re monitoring and addressing the suicide risk, and that influences the clinician’s treatment.”
IPU patients were also seen daily by psychiatrists and social workers and had access to group therapy and school tutoring.
Changing the culture of pediatric mental health care
At the heart of the Zero Suicide Framework is the organizational culture change that is committed to reducing suicides.
The hospital CEO already had elevated mental health as a key part of the organization’s mission. And behavioral health clinicians on the IPUs understood the importance of implementing the model because they care for the most severe patients. Since efforts began, over 600 behavioral health clinicians at the hospital have been trained on the protocol, and it is used on all clinical programs in psychiatry and primary care.
Staff members across disciplines and departments have also reached out to Ibeziako to receive training in suicide-specific practices.
“We want to provide comprehensive care and bolster mental health efforts across the institution,” she said.
The systemwide transformation is reflected in the data: All acute service units, including two IPUs, an acute residential program, inpatient medical floors, and the emergency department, have achieved greater than 90% compliance with the suicide screening and intervention protocol.
Supporting patients after inpatient care
Patients are at the highest risk of suicide after a psychiatric hospitalization, prioritizing the need for continued interventions and support following discharge.
The hospital is now focusing on the transition phase of the Zero Suicide Framework and long-term outcomes post-discharge.
“When patients discharge, what is our follow-up, so they stay well and don’t come back?” Ibeziako said. “If we do our transition element right, that should improve long-term outcomes.”
Boston Children’s has proved that pediatric IPUs are essential and effective in improving the emotional well-being and quality of life for adolescents facing severe mental health crises. Since the hospital implemented this standardized approach to care to make suicide prevention a central focus, Ibeziako said others can too.
“Children’s hospitals can learn from each other and not do the work alone,” Ibeziako said. “If everybody is trained in suicide care, we can all use a standardized, universal approach and families will receive high-quality care wherever they live.”
