Pediatrics (System-Integrated)

Adolescent suicide risk assessment

Clinical Overview and When to Suspect Adolescent Suicide Risk

— Suicide is the 2nd leading cause of death in US adolescents ages 10–24 (after unintentional injury)

— Rates have risen ~60% over the past decade, with sharpest increases in girls, sexual/gender minority youth, and Black adolescents

— For every completed suicide, ~25 attempts occur; ~20% of high schoolers report serious suicidal ideation in the past year (YRBS data)

— Firearms account for ~50% of adolescent suicide deaths; suffocation/hanging is rising rapidly

— All adolescent encounters: AAP and USPSTF support universal screening for depression in youth ≥12 (USPSTF 2022: Grade B for depression; "I" for suicide-specific screening, but AAP/Joint Commission endorse universal screening)

— Any ED visit, regardless of chief complaint (Joint Commission NPSG 15.01.01 mandates suicide risk screening in all behavioral health and ED patients)

— After any self-harm presentation, ingestion, MVC of unclear circumstances, unexplained injury

— New depression, anxiety, substance use, eating disorder, psychotic symptoms, recent trauma, bullying, family discord, school refusal, sleep disruption

— Chronic medical illness flares (epilepsy, IBD, T1DM with recurrent DKA, chronic pain)

— LGBTQ+ youth (4× attempt risk), transgender youth (especially in non-affirming families)

— Prior attempt (single strongest predictor — 30–40× risk)

— Family history of suicide; mood disorder; firearm in home

— Recent psychiatric discharge (highest risk in first 30 days)

— Foster care, juvenile justice involvement, Indigenous youth

Board pearl: A prior suicide attempt is the single strongest predictor of completed suicide in adolescents — always document it explicitly and ensure means restriction counseling is delivered at every visit thereafter, not just the index encounter.

Epidemiology and scope

When to actively assess risk

High-risk demographic clusters to recognize on stems

Presentation Patterns and Key History

— Verbalized ideation by patient or report from parent/teacher/peer

— Post-attempt ED arrival: ingestion (most common method in girls), cutting, hanging attempt, firearm injury

— "Accidental" overdose of acetaminophen, SSRIs, parent's medications — always probe intent

— Recurrent vague somatic complaints (headache, abdominal pain, fatigue)

— Sudden academic decline, school refusal, dropping out of activities

— Giving away possessions, saying goodbye, sudden calm after depression ("terminal calm")

— Increased substance use, reckless driving, unprotected sex

— Social media posts about death/hopelessness

— Home, Education/employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety (firearms, violence)

— Interview adolescent alone for at least part of visit; explicitly state confidentiality limits upfront (harm to self/others, abuse → mandatory disclosure)

— "Are you thinking about killing yourself?" — direct questioning does not increase risk (meta-analyses confirm)

— Probe: ideation frequency/intensity, plan, means/access, intent, preparatory behaviors (writing notes, stockpiling pills, researching methods), rehearsal, deterrents (reasons for living)

— Prior attempts: method, lethality, medical consequence, ambivalence/regret about survival

— Parents (with adolescent's awareness), school counselor, prior providers, EHR for prior ED visits

Step 3 management: When an adolescent endorses ideation, physically secure means before they leave the room — instruct parent to remove/lock firearms and lethal medications today, not "soon." Document the means restriction counseling verbatim; this is both a quality measure and a malpractice shield.

Direct presentations

Indirect/masked presentations (high-yield Step 3 vignette setup)

HEEADSSS framework — must cover at every adolescent visit

Specific ideation questioning (do NOT euphemize)

Collateral history is essential

Physical Exam Findings and Mental Status Assessment

— Vital signs: tachycardia/hypotension (ingestion, blood loss), bradypnea (opioid), hyperthermia (serotonin syndrome, anticholinergic, sympathomimetic)

— Full skin survey including thighs, abdomen, upper arms, breasts: linear parallel scars (non-suicidal self-injury, NSSI), fresh cuts, burns, ligature marks on neck

— Wrists/forearms: hesitation marks vs deep transverse lacerations

— Oropharynx: caustic burns (bleach, cleaner ingestion)

— Neuro: pupil size, gag, mental status (toxidromes)

— Acetaminophen: initially asymptomatic → RUQ pain, transaminitis at 24–72h

— Salicylate: tachypnea, tinnitus, mixed respiratory alkalosis/anion gap acidosis

— TCA: wide QRS, anticholinergic signs, seizures (parental antidepressant access)

— SSRI overdose alone: usually mild; serotonin syndrome with co-ingestion

— Opioid: miosis, bradypnea, depressed MS

— Benzodiazepine: somnolence, normal vitals (rarely fatal alone)

— Appearance, eye contact, psychomotor activity (retardation vs agitation)

— Speech, mood (patient's words) vs affect (your observation)

— Thought process (linear vs tangential), thought content (ideation, hopelessness, command AH)

— Cognition, insight, judgment

— Reassess safety at end of exam — ideation can shift in minutes

— Eating disorder: lanugo, parotid hypertrophy, knuckle calluses, bradycardia

— Substance use: needle marks, nasal septal erosion

— Abuse: patterned bruises, genital trauma — triggers mandatory CPS reporting

Key distinction: NSSI (cutting to regulate emotion, no intent to die) and suicide attempt are distinct but bidirectionally linked — NSSI roughly triples future suicide attempt risk, so do not dismiss "just superficial cutting" as low risk.

General exam priorities

Toxidrome recognition (post-ingestion stems)

Mental status exam components to document

Look for comorbid signs

Diagnostic Workup — Initial Screening Instruments and Labs

— PHQ-9 Modified for Adolescents (PHQ-A): depression screen, ≥10 = moderate; item 9 directly probes self-harm ideation

— ASQ (Ask Suicide-Screening Questions): NIMH-developed, 4 yes/no questions, validated in ED and medical inpatient settings ages 10–24; takes <1 min — preferred universal screen

— Columbia Suicide Severity Rating Scale (C-SSRS): stratifies ideation intensity, behavior, lethality; used after positive ASQ

— SAFE-T (Suicide Assessment Five-step Evaluation and Triage): structured risk formulation framework

— Positive ASQ → C-SSRS or full Brief Suicide Safety Assessment (BSSA) by clinician → disposition decision

— CBC, CMP, glucose

— Acetaminophen and salicylate levels at presentation and at 4 hours post-ingestion (acetaminophen — Rumack-Matthew nomogram from 4h)

— Ethanol level, urine drug screen (interpret cautiously — doesn't capture synthetics, designer drugs)

— β-hCG in all females of reproductive age (changes management, pregnancy itself is a risk factor)

— ECG: QRS >100 ms (TCA), QTc prolongation (citalopram, antipsychotics, methadone)

— ABG/VBG if altered, tachypneic, or salicylate suspected

— Lactate, ammonia, creatine kinase if seizures/agitation/rhabdo

— Head CT if altered mental status of unclear etiology, trauma, focal deficits, post-hanging

— C-spine imaging after hanging attempt (cervical injury, vascular dissection)

— CXR if aspiration suspected

Board pearl: A negative urine drug screen does not rule out ingestion — many modern agents (synthetic cannabinoids, GHB, novel opioids, gabapentinoids) are not detected. Always send a specific acetaminophen level regardless of history; occult acetaminophen co-ingestion is a classic missed-diagnosis vignette.

Validated screening tools (know these by name for the exam)

Tiered screening logic

Initial labs for any attempt/ingestion

Imaging

Diagnostic Workup — Advanced and Confirmatory Evaluation

— Performed by psychiatry, psychiatric social worker, or trained ED clinician

— Components: longitudinal ideation history, prior attempts (method, intent, medical lethality, regret), current stressors, protective factors (family, faith, future-oriented thinking), substance use, trauma history, access to lethal means

— No single tool reliably predicts suicide — synthesize acute (current ideation, plan, intent, recent attempt, agitation, insomnia, intoxication) with chronic (prior attempts, psychiatric dx, family hx, trauma, chronic pain, firearm access) factors

— Document risk level (low/moderate/high) and rationale, not just a checklist score

— Screen for major depressive disorder, bipolar disorder (mood elevation hx — antidepressant monotherapy can precipitate mania), anxiety disorders, PTSD, ADHD, eating disorders, substance use, psychosis

— Bipolar screening matters: starting SSRI in undiagnosed bipolar youth can worsen suicidality

— Thyroid: TSH (hypothyroid → depression; hyperthyroid → anxiety/agitation)

— Anemia, vitamin D, B12 (low yield but common stems)

— Mononucleosis, post-viral fatigue

— TBI/concussion sequelae

— Substance-induced mood disorder (cannabis, alcohol, stimulants, steroids)

— Medication-induced: isotretinoin (controversial but check), montelukast (FDA boxed warning for neuropsychiatric effects including suicidality), corticosteroids, levetiracetam, varenicline, hormonal contraceptives in susceptible youth

— First-episode psychosis with atypical features, focal neuro signs, or marked cognitive change → MRI brain

Step 3 management: Always reconcile the adolescent's medication list for agents with neuropsychiatric warnings — montelukast discontinuation is the classic "easy win" intervention on a vignette where a teen on chronic asthma controllers develops new ideation.

Structured psychiatric evaluation after medical clearance

Risk formulation rather than risk "prediction"

Comorbid psychiatric diagnostic workup

Medical mimics to exclude before attributing to psychiatric cause

When to image the brain

Risk Stratification and Disposition Logic

— High risk

— Moderate risk

— Low risk

— Written safety plan (Stanley-Brown model: warning signs → internal coping → social distractions → people to contact → professionals/crisis line → means restriction)

— 988 Suicide & Crisis Lifeline provided in writing and saved in phone

— Means restriction counseling with documentation: firearms removed from home or locked with ammunition stored separately; medications locked

— Follow-up appointment scheduled within 7 days (ideally 72 hours) — not just "referred"

Step 3 management: "Contracts for safety" (no-suicide contracts) do not reduce risk and are not standard of care — use a collaborative safety plan instead. This swap is a frequent distractor on board questions.

Three-tier risk stratification (synthesize, then disposition)

Current ideation with plan, intent, or recent preparatory behavior

Recent attempt (especially with high lethality, low rescue likelihood, or expressed regret about surviving)

Active psychosis with command hallucinations, severe agitation, intoxication that won't clear safely

Inability to engage in safety planning or unreliable caregiver supervision

Disposition: inpatient psychiatric admission (voluntary if possible; involuntary hold per state statute if refusing and meets criteria)

Ideation without plan/intent, or chronic ideation at baseline intensity

Recent stressor, multiple risk factors, but engaged in evaluation and willing to safety plan

Reliable caregiver, means restriction achievable, rapid outpatient follow-up available (within 24–72h)

Disposition: discharge with intensive outpatient program, partial hospitalization, or expedited psychiatry follow-up + safety plan + means restriction

Passive ideation without plan, no recent attempt, strong protective factors

Disposition: outpatient care, primary care + therapy referral, safety plan, follow-up 1–2 weeks

Mandatory components before any discharge (all 4)

Pharmacotherapy — First-Line Treatment of Underlying Disorder

— Fluoxetine and escitalopram are the only SSRIs FDA-approved for adolescent depression

— Fluoxetine: approved ages ≥8 for MDD; escitalopram: ≥12 for MDD

— Sertraline approved for pediatric OCD (≥6) but commonly used off-label for depression

— All antidepressants carry a boxed warning for increased suicidal ideation/behavior in patients <25

— Absolute risk increase ~1–2%; no increase in completed suicides

— Untreated depression carries higher risk than treatment — do not withhold SSRI in moderate-severe depression with suicidality

— TADS trial: fluoxetine + CBT > either alone > placebo for adolescent MDD; combination reduced suicidality fastest

— Start low (fluoxetine 10 mg, escitalopram 5 mg), titrate after 1–2 weeks

— Weekly contact for first 4 weeks, biweekly weeks 5–8, then monthly (FDA recommendation)

— Full response takes 4–8 weeks; warn family about transient activation, akathisia, insomnia

— Screen for bipolar features before starting — SSRI monotherapy can induce mania

— Continue effective regimen for 6–12 months after remission before considering taper

— Paroxetine: avoid in adolescents — efficacy data poor, withdrawal severe, ideation signal stronger

— Venlafaxine: stronger ideation signal in pediatric trials

— TCAs: ineffective in pediatric depression and lethal in overdose — avoid prescribing

— Benzodiazepines: avoid chronically; disinhibition can worsen impulsivity

— Treat comorbid ADHD (stimulants do not increase suicide risk and treating ADHD reduces it)

— Insomnia: melatonin, sleep hygiene; avoid hypnotics

Board pearl: Fluoxetine + CBT is the highest-yield combination for moderate-severe adolescent MDD with suicidality — recognize it as the correct answer when a stem offers it against SSRI alone, CBT alone, or no treatment.

Treating depression to reduce suicide risk

FDA boxed warning — must know cold

Initiation and monitoring

Agents to avoid or use with caution

Adjuncts

Psychotherapy and Non-Pharmacologic Interventions

— Cognitive Behavioral Therapy for suicide prevention (CBT-SP)

— Dialectical Behavior Therapy for Adolescents (DBT-A)

— Family-Based Therapy / Attachment-Based Family Therapy (ABFT)

— Interpersonal Psychotherapy for Adolescents (IPT-A)

— Safety planning intervention (Stanley-Brown): single-session, reduces 6-month suicidal behavior ~45% when paired with follow-up phone calls

— Caring contacts: brief postcards/texts after discharge reduce reattempt rates

— Firearm access in the home doubles to quadruples adolescent suicide risk; 80% of youth firearm suicides use a family member's gun

— Counsel: remove from home (relative, storage facility, police hold) > locked safe + locked ammo + trigger lock

— Restrict acetaminophen, TCAs, opioids, beta-blockers — lockbox or remove

— Document discussion explicitly

— ECT: severe MDD with active suicidality unresponsive to meds (rare in adolescents but appropriate)

— TMS: FDA-cleared for adolescent MDD ≥15 (2024)

— Ketamine/esketamine: emerging evidence, not first-line in <18

CCS pearl: Order "psychiatric social work consult" early in an ED case — they coordinate safety planning, means restriction documentation, and outpatient linkage that the score sheet rewards. Don't wait until disposition.

First-line evidence-based therapies

12–16 sessions; targets cognitive distortions, problem-solving, emotion regulation

Reduces reattempt rates ~50% in RCTs

First-line for adolescents with repeated self-harm/suicide attempts, borderline traits, emotion dysregulation

Components: individual therapy + multi-family skills group + phone coaching + therapist consultation team

Skills: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness

Strongest evidence base for reducing self-harm in adolescents

Useful when family conflict is a driver; rebuilds parent-adolescent attachment

For depression rooted in interpersonal conflict, role transitions, grief

Acute interventions

Means restriction counseling — single most impactful population intervention

Procedural/somatic options for treatment-resistant cases

Special Considerations — Comorbid Medical Illness and Hepatic/Renal Factors

— Epilepsy: 3× suicide risk; AEDs carry FDA class warning (levetiracetam, topiramate especially)

— IBD, type 1 diabetes, cystic fibrosis, sickle cell, chronic pain: 2–3× risk

— TBI/concussion: persistent post-concussive symptoms linked to ideation

— Cancer survivors: long-term increased risk; screen during survivorship visits

— Obesity, acne, alopecia: appearance-related distress and bullying

— Fluoxetine, sertraline — extensive hepatic metabolism; start at half-dose, slow titration

— Escitalopram — preferred in mild-moderate hepatic impairment (cleaner profile)

— Avoid duloxetine in significant hepatic disease

— Check baseline LFTs in adolescents with eating disorders, hepatitis exposure, heavy alcohol use

— Most SSRIs require no dose adjustment in mild-moderate CKD

— Lithium: renally cleared, narrow therapeutic index — caution with NSAIDs, dehydration, ACEi; monitor levels, TSH, creatinine q3–6 months

— Venlafaxine, desvenlafaxine: dose reduce in CKD

— Fluoxetine/paroxetine: potent CYP2D6 inhibitors — affect atomoxetine, risperidone, codeine

— Sertraline: lower interaction burden — often preferred when polypharmacy

— Serotonin syndrome risk: SSRI + tramadol, linezolid, MAOI, triptans, dextromethorphan, St. John's wort — counsel explicitly

— QTc prolongation: citalopram (max 40 mg adults, 20 mg if hepatic impairment or >60), with ondansetron, azithromycin, methadone — get baseline ECG if cardiac history

— Anorexia nervosa carries highest mortality of any psychiatric illness, largely from suicide

— Bupropion contraindicated in eating disorders (seizure risk)

— Avoid QT-prolonging agents in malnourished patients with bradycardia

Key distinction: A teen on levetiracetam with new irritability/ideation should prompt consideration of switching to lamotrigine or another agent — the AED neuropsychiatric effect is a high-yield Step 3 maneuver.

Adolescents with chronic medical illness — elevated baseline risk

Medication considerations in hepatic impairment

Renal impairment

Drug interactions to flag

Eating disorder overlap

Special Populations — Sexual/Gender Minority, Trauma-Exposed, and Marginalized Youth

— ~4× lifetime attempt risk vs heterosexual peers; transgender youth highest risk

— Drivers: family rejection, bullying, internalized stigma, conversion practices, lack of gender-affirming care

— Protective factors with strong evidence: family acceptance, school anti-bullying policies, access to gender-affirming care, chosen-name use, supportive adult

— Ask sexual orientation and gender identity (SOGI) routinely and confidentially; use chosen name/pronouns

— Connect with Trevor Project (1-866-488-7386, text START to 678-678) as supplement to 988

— ACE score correlates linearly with suicide risk (4+ ACEs = ~12× risk)

— Screen for current abuse, sexual violence, intimate partner violence in older adolescents

— Mandatory reporting of suspected child abuse — Step 3 consistently tests this trigger

— 3–4× risk; high rates of trauma, disrupted attachment, polypharmacy

— Coordinate with caseworker; ensure medication continuity during placement transitions

— Black youth ages 10–14: suicide rates rising fastest of any group

— American Indian/Alaska Native youth: highest rates by ethnicity

— Cultural competence: avoid assumptions, ask about acculturation stress, family expectations, religious framing of death

— Pregnancy in teens increases suicide risk (vs decreased in adult pregnancy)

— Screen with Edinburgh Postnatal Depression Scale postpartum

— Sertraline preferred SSRI in pregnancy/lactation

— Family/peer loss increases personal risk — postvention matters

— Schools need coordinated response after a student death to prevent contagion/cluster suicides (CDC/AFSP guidelines, safe messaging)

Board pearl: Family acceptance is the single most powerful modifiable protective factor for LGBTQ+ adolescent mental health — the correct counseling answer almost always includes engaging and educating parents toward acceptance.

LGBTQ+ adolescents

Trauma and abuse survivors

Foster care and juvenile justice-involved youth

Racial and ethnic considerations

Pregnant and postpartum adolescents

Bereaved by suicide (suicide loss survivors)

Complications and Adverse Outcomes

— Acetaminophen overdose: most common adolescent ingestion

— Salicylate: AGMA + respiratory alkalosis, tinnitus, cerebral edema — alkalinize urine, hemodialysis if level >100 mg/dL acute, altered MS, pulmonary edema, renal failure

— TCA: wide QRS → sodium bicarbonate IV; treat seizures with benzos (avoid phenytoin)

— Hanging/strangulation: cerebral anoxia, C-spine injury, carotid/vertebral dissection (CTA neck), delayed laryngeal edema, post-obstructive pulmonary edema — admit for 24h observation even if asymptomatic

— Firearm injury: ~85–90% case fatality; survivors face TBI, facial reconstruction, chronic pain

— Reattempt: ~15–20% within 1 year of index attempt; highest in first 30–90 days post-discharge

— Completed suicide following attempt: 1–2% per year for years

— PTSD from the attempt itself

— Functional decline, academic disruption, family system strain

— Antidepressant activation, akathisia, induced mania

— Polypharmacy in complex youth

— Discharge to inadequate follow-up (system failure) — leading malpractice driver

Step 3 management: The first 30 days after psychiatric discharge carry the highest reattempt risk — schedule the follow-up visit before discharge, ideally within 7 days, and consider a transitional phone call at 24–48h. "Caring contact" texts/calls are evidence-based and exam-favored.

Acute medical complications of attempts

Phases: I (0–24h, asymptomatic/nausea), II (24–72h, RUQ pain, rising AST/ALT), III (72–96h, fulminant hepatic failure, coagulopathy, encephalopathy, AKI), IV (recovery or death)

Treat per Rumack-Matthew at ≥4h post-ingestion with N-acetylcysteine; transfer to liver transplant center if King's College criteria met (pH <7.3, or PT >100s + Cr >3.4 + grade III/IV encephalopathy)

Chronic complications

Iatrogenic complications

When to Escalate — Inpatient Psychiatric Admission and Involuntary Hold

— Active suicidal ideation with plan and intent

— Recent attempt with persistent ideation, ambivalence about living, or high-lethality method

— Inability to maintain safety in current environment (means cannot be secured, caregiver unable/unwilling to supervise)

— Severe psychiatric symptoms: psychosis, severe agitation, catatonia, severe mood episode

— Failure of intensive outpatient measures

— Substance withdrawal complicating assessment

— Prefer voluntary; engage adolescent and family

— Involuntary commitment criteria (vary by state but generally): mental illness + imminent danger to self or others + refusal of voluntary care

— Most states allow minor consent thresholds for mental health treatment (often age 12–14); parents can typically admit minors but adolescent dissent must be addressed

— Document criteria explicitly; follow state statute timelines (typically 72-hour initial hold, then judicial review)

— Stable vitals, resolved intoxication, post-ingestion observation complete (acetaminophen levels trending appropriately, ECG normalized)

— Treat acute medical issues fully — psychiatric units cannot manage active medical instability

— Surgical wounds repaired; tetanus updated

— Inpatient psychiatry → residential treatment → partial hospitalization (PHP, 5d/wk, 6h/d) → intensive outpatient (IOP, 3d/wk, 3h/d) → outpatient therapy + medication management

— Child and adolescent psychiatry — primary

— Social work — disposition, insurance, family resources

— Toxicology for complex ingestions

— CPS if abuse/neglect suspected

CCS pearl: Before transferring an adolescent post-ingestion to psych, confirm the 4-hour acetaminophen level is non-toxic AND the patient is medically stable for ≥6h. Skipping the toxicology window is a common case-failure trap.

Indications for inpatient psychiatric hospitalization

Voluntary vs involuntary admission

Medical clearance before psychiatric transfer

Levels of care continuum (know the ladder)

Consultations

Key Differentials — Other Psychiatric Causes of Apparent Suicidality

— 5+ SIGECAPS symptoms ≥2 weeks; most common driver of adolescent suicidality

— Treat with SSRI + CBT

— Adolescent bipolar often presents as irritability + mood lability rather than classic euphoria

— Mixed episodes (depression + agitation/energy) carry highest suicide risk

— Family history is key; antidepressant monotherapy can induce mania — always screen

— Treatment: lithium (anti-suicide effect specifically), lamotrigine, atypical antipsychotics

— Chronic ideation, repeated NSSI, abandonment fear, identity disturbance, affective instability

— DBT-A is first-line; avoid polypharmacy

— SSRIs only if comorbid MDD; benzodiazepines worsen disinhibition

— Re-experiencing, avoidance, hyperarousal, negative cognitions; suicidality common

— Trauma-focused CBT, EMDR; SSRIs (sertraline) adjunct

— Panic disorder and OCD both elevate suicide risk; treat with SSRI + CBT/ERP

— First-episode psychosis carries acute suicide risk, especially with insight return

— Command auditory hallucinations to self-harm → inpatient

— Treat with atypical antipsychotic; clozapine has unique anti-suicide effect in schizophrenia

— Cannabis (especially high-THC, daily use in adolescents), alcohol, stimulants, opioids all increase risk

— Acute intoxication lowers threshold for impulsive attempts

— Co-occurring SUD + mood disorder ("dual diagnosis") needs integrated treatment

— Anorexia nervosa: high suicide mortality; restrictive subtype especially

— Treat the eating disorder; address comorbid mood

Key distinction: Chronic, low-intensity ideation with repeated NSSI in an adolescent with affective instability and unstable relationships should raise emerging BPD — the management pivot is DBT-A, not escalating SSRI doses.

Major depressive disorder

Bipolar disorder

Borderline personality disorder traits / emerging BPD

PTSD and acute stress disorder

Anxiety disorders, OCD

Psychotic disorders

Substance use disorders

Eating disorders

Key Differentials — Medical and Substance-Induced Causes

— Hypothyroidism: depression, fatigue, weight gain, cold intolerance — check TSH

— Hyperthyroidism: anxiety, irritability, weight loss, palpitations

— Cushing syndrome (exogenous steroids more common in teens): mood lability, depression, psychosis

— Diabetes: depression 2–3× more common; recurrent DKA can signal psychosocial distress, insulin omission as self-harm

— Epilepsy: AED-induced or interictal depression; postictal psychosis

— TBI/concussion: post-concussive depression, irritability, ideation

— Autoimmune encephalitis (anti-NMDA receptor): psychiatric prodrome, movement disorders, autonomic instability — high-yield in young women with new psychosis + neuro signs

— Wilson disease in adolescents: psychiatric + hepatic + neurologic; check ceruloplasmin

— Mononucleosis (post-viral depression)

— HIV (consider neuropsychiatric effects, also screen given risk behaviors)

— PANDAS/PANS (acute-onset OCD, tics, mood after strep)

— Montelukast (FDA boxed warning, 2020)

— Isotretinoin (controversial signal; monitor)

— Corticosteroids, interferon, anabolic steroids

— AEDs (levetiracetam classically irritable)

— Beta-blockers (propranolol — depression in susceptible patients)

— Varenicline, bupropion (rare neuropsychiatric effects)

— Hormonal contraceptives in select adolescents (mixed evidence)

— Alcohol intoxication/withdrawal

— Stimulant crash (cocaine, methamphetamine, prescription stimulant misuse)

— Cannabis use disorder (especially high-potency daily use)

— Synthetic cannabinoids, hallucinogens, novel psychoactive substances

— Inhalants

Board pearl: A teen with new-onset psychiatric symptoms plus orofacial dyskinesias, autonomic instability, or seizures should prompt evaluation for anti-NMDA receptor encephalitis — LP for anti-NMDAR antibodies, MRI, EEG. Missing this organic cause is a classic distractor.

Endocrine and metabolic

Neurologic

Infectious

Medication-induced

Substance-induced mood

Secondary Prevention and Long-Term Care Plan

— Safety plan (Stanley-Brown), copy to patient and family

— 988 and crisis text line (text HOME to 741741) saved in phone

— Means restriction confirmed — firearm removal documented, medication lockbox in place

— Follow-up appointment scheduled within 7 days (ideally 72 hours) with mental health

— Caring contact plan — phone call or text within 24–48h

— Continue SSRI for 6–12 months after remission of first episode; longer for recurrent

— Monitor weight, BP, sexual side effects, sleep, akathisia

— Reassess suicidality at every visit using PHQ-9 item 9 or C-SSRS

— Avoid sudden discontinuation — taper over weeks

— CBT, DBT-A, or family therapy ongoing; assess engagement and progress

— Address school accommodations: 504 plan, IEP if applicable, gradual reentry after hospitalization

— Substance use treatment integrated

— Sleep hygiene, screen time, social media boundaries

— Physical activity (evidence for mood benefit)

— Bullying intervention; school engagement

— Educate family on warning signs, when to contact crisis services

— Address parental mental health (parental depression increases adolescent risk)

— Family therapy if conflict is a driver

— Universal depression and suicide screening at well-child visits ≥12 (AAP Bright Futures)

— Recheck means restriction at each visit — firearms get reintroduced

— Vaccinations, contraception, STI screening as standard adolescent preventive care continue

— Plan transition by age 17–18; warm handoff to adult psychiatry/PCP

— Discuss HIPAA shift at 18 — adolescent now controls disclosure to parents

Step 3 management: At every follow-up, the answer to "what's the most important question to ask?" is reassess current ideation and verify means restriction is still in place — both, every visit, documented.

Post-discharge bundle (must be in every discharge plan)

Ongoing pharmacotherapy

Therapy continuity

Address modifiable risk factors longitudinally

Family-level interventions

Annual reassessment

Transition to adult care

Follow-Up, Monitoring Parameters, and Rehabilitation

— Within 7 days of psychiatric discharge or ED visit for ideation (ideally 72h)

— Phone/text caring contact within 24–48h

— First month: weekly mental health visits

— Months 2–3: biweekly

— Months 4–12: monthly to every 6 weeks

— Annual screening thereafter at minimum

— Weekly visits or contact × 4 weeks after start

— Biweekly weeks 5–8

— At week 12

— Then as clinically indicated, minimum quarterly

— Reassess ideation, side effects, response, adherence at each contact

— PHQ-A or PHQ-9 every visit (treat-to-target: PHQ-9 <5 = remission)

— C-SSRS at any concerning change

— GAD-7 if anxiety comorbid

— Functional measures: school attendance, grades, peer engagement, sleep

— School reentry plan after hospitalization: meeting with counselor, gradual academic load, accommodations

— Address peer relationships, bullying, social media exposure

— Engage in protective activities: sports, arts, faith community, volunteering

— Sleep regularization (often the most impactful behavioral lever)

— Warning signs of relapse: withdrawal, sleep change, giving away possessions, sudden calm, talking about being a burden

— Communication strategies: validate emotions, avoid problem-solving immediately

— Limit access to means continuously — not just acutely

— Safe messaging if media coverage of suicide occurs (avoid sensationalizing, focus on resources)

— HEDIS measure: follow-up after ED visit for mental illness within 7 and 30 days

— Document follow-up clearly for quality reporting

Board pearl: PHQ-9 score reduction of ≥50% from baseline at 6–8 weeks indicates adequate SSRI response; if not met, consider dose increase, switch, or adding/intensifying therapy — measurement-based care is the exam-correct framework.

Follow-up cadence after acute event

Monitoring on SSRI (FDA-recommended schedule)

Objective monitoring tools to repeat

Rehabilitation and reintegration

Family education topics at follow-up

Health system measures (value-based care touchpoint)

Ethical, Legal, and Patient Safety Considerations

— State the limits at the start of every adolescent interview: harm to self, harm to others, and abuse must be disclosed

— Most states permit minors to consent to mental health treatment at age 12–16 (varies); know your jurisdiction

— Suicidality breaches confidentiality — inform the adolescent you must tell parents to keep them safe; involve them in how the conversation happens when possible

— SSRI initiation: explicitly counsel on boxed warning for increased ideation in <25, the activation period, and monitoring plan — document

— Involuntary admission: explain rationale, rights to legal review, expected duration

— Adolescents with mature minor status may consent to outpatient mental health care without parental involvement in many states, but emergency safety overrides this

— Suspected child abuse or neglect → CPS report; failure is criminally actionable

— Threat against an identified third party may trigger Tarasoff duty to warn (varies by state)

— Firearm in home with at-risk adolescent: counseling is mandated standard of care; some states have extreme risk protection orders (ERPOs/"red flag laws") that can be invoked

— Record: risk factors, protective factors, ideation/plan/intent/means/preparatory behaviors, risk level with rationale, interventions offered, means restriction counseling specifics, follow-up appointment date and provider, safety plan completion

— Document why disposition chosen (admit vs discharge) — defensibility hinges on reasoning shown

— Highest reattempt risk is first 30 days post-discharge

— Mitigation: warm handoff (direct provider-to-provider communication), follow-up scheduled before discharge, caring contact within 48h, medication reconciliation, accessible after-hours contact (988)

— After a youth suicide death in a community/school: coordinated response per AFSP/SAMHSA guidelines; identify exposed peers; provide screening; follow safe messaging

— Implicit bias screening: Black, Indigenous, and LGBTQ+ youth are under-recognized and under-referred — universal screening reduces disparity

Step 3 management: When confidentiality and safety conflict, safety wins — but the exam-favored approach is to tell the adolescent first that you're going to involve parents, frame it as care not punishment, and engage them in the disclosure conversation.

Confidentiality and its limits

Informed consent edge cases

Mandatory reporting

Documentation as patient safety

Transition-of-care risk (high-yield Step 3 patient safety item)

Postvention and contagion

Equity and bias

High-Yield Associations and Rapid-Fire Clinical Facts

— Suicide: #2 cause of death ages 10–24

— 988: Suicide & Crisis Lifeline (call or text)

— Crisis Text Line: text HOME to 741741

— Trevor Project (LGBTQ+): 1-866-488-7386; text START to 678-678

— Prior attempt → ~30–40× increased completion risk

— Firearm in home → 2–4× increased adolescent suicide risk

— First 30 days post-psychiatric discharge = highest reattempt window

— Follow-up within 7 days of psych discharge (HEDIS)

— Acetaminophen toxicity nomogram starts at 4 hours post-ingestion

— Fluoxetine (≥8 for MDD) and escitalopram (≥12 for MDD): only FDA-approved SSRIs for adolescent depression

— Paroxetine: avoid in adolescents

— TCAs: avoid (lethal in OD, ineffective in pediatric MDD)

— Lithium: anti-suicide effect in bipolar

— Clozapine: anti-suicide effect in schizophrenia

— N-acetylcysteine: acetaminophen antidote

— Sodium bicarbonate: TCA cardiotoxicity

— Naloxone: opioid OD; prescribe to teens at risk and families

— HEEADSSS: adolescent psychosocial interview

— ASQ → C-SSRS → BSSA: screening to assessment ladder

— SAFE-T: 5-step assessment and triage

— Stanley-Brown safety plan: 6 steps

— TADS: fluoxetine + CBT best for adolescent MDD

— Bright Futures (AAP): annual depression/suicide screening ≥12

— Joint Commission NPSG 15.01.01: universal suicide screening

— USPSTF 2022: Grade B depression screening 12–18; "I" for suicide-specific (but AAP endorses)

— "Giving away possessions" / "saying goodbye" / "sudden calm"

— "Recent psychiatric discharge"

— "Firearm in the home"

— "Parents away for the weekend"

— "Acetaminophen bottle empty"

Board pearl: 988 replaced the old 1-800 lifeline number in July 2022 — know this; expect it on every adolescent mental health stem.

Numbers to memorize

Drugs to memorize

Frameworks

Red flag stem cues

Board Question Stem Patterns

— "16-year-old girl found by mother after taking 'a handful of Tylenol' 6 hours ago" → check acetaminophen level (treat per Rumack-Matthew with NAC), β-hCG, comprehensive tox, ECG, psychiatric evaluation after medical clearance

— "Adolescent newly diagnosed with MDD, mother concerned that antidepressants 'cause suicide'" → counsel on boxed warning + that untreated depression is more dangerous + weekly monitoring × 4 weeks; recommend fluoxetine + CBT

— "Teen reports passive ideation but no plan, denies intent, engaged, parents present, firearms in home" → safety plan + means restriction (remove firearm) + outpatient follow-up within 7 days; do not automatically admit

— "Transgender adolescent with family rejection presents with depression" → most impactful intervention is family acceptance education and gender-affirming care + connect to Trevor Project

— "Started fluoxetine 3 weeks ago, now euphoric, decreased sleep, grandiose, racing thoughts" → SSRI-induced mania; stop SSRI, evaluate for bipolar disorder, start mood stabilizer

— "Asthmatic teen on montelukast develops new ideation" → discontinue montelukast (FDA boxed warning)

— "Teen survived hanging attempt, vitals stable" → admit for 24h observation (post-obstructive pulmonary edema, vascular dissection), CTA neck if indicated, psych eval

— "Discharged from psych 2 weeks ago, now ED with second attempt" → readmit; recognize 30-day high-risk window and inadequate transition

— "16yo discloses suicidal plan, asks you not to tell parents" → explain limits of confidentiality, involve parents, frame collaboratively — safety overrides confidentiality

— "Parent asks how to keep teen safe at home" → remove firearms from home (not just lock); lock medications; provide 988

Board pearl: When a question offers "no-suicide contract" as an option, it is always wrong — pick the collaborative safety plan + means restriction + 7-day follow-up combination instead.

Pattern 1: ED ingestion

Pattern 2: SSRI counseling

Pattern 3: Disposition decision

Pattern 4: LGBTQ+ youth

Pattern 5: Bipolar unmasked

Pattern 6: Medication-induced

Pattern 7: Post-hanging

Pattern 8: Recent discharge reattempt

Pattern 9: Confidentiality conflict

Pattern 10: Means restriction

One-Line Recap

Adolescent suicide risk assessment is a universal, structured, longitudinal process — every adolescent encounter screens with a validated tool (ASQ/PHQ-A), every positive screen is risk-stratified with C-SSRS and a clinical formulation, and every disposition includes a collaborative safety plan, documented means restriction (especially firearms), 988 access, and follow-up within 7 days, while first-line treatment of underlying depression is fluoxetine or escitalopram combined with CBT or DBT-A — with the highest reattempt risk falling in the first 30 days after discharge.

— Screen universally: ASQ in ED/inpatient, PHQ-A in primary care; ask directly about ideation (does not increase risk); use HEEADSSS at every adolescent visit; state confidentiality limits upfront and breach them only for safety

— Stratify and disposition: high risk (plan/intent/recent attempt/unsecurable means) → inpatient; moderate → IOP/PHP with rapid follow-up; low → outpatient + safety plan; no-suicide contracts do not work — use Stanley-Brown collaborative safety planning

— Treat the underlying disorder: fluoxetine or escitalopram + CBT for MDD (TADS); DBT-A for repeated self-harm/emerging BPD; screen for bipolar before SSRI; counsel boxed warning but treat — untreated depression is more dangerous; weekly contact × 4 weeks

— Prevent the next event: remove firearms from home (not just lock), lockbox medications, 988 saved in phone, follow-up scheduled within 7 days before discharge, caring contact at 48h, reassess means restriction at every visit, address family acceptance for LGBTQ+ youth, recognize and treat medication-induced (montelukast, levetiracetam) and medical (thyroid, anti-NMDA encephalitis) mimics

Board pearl: If you remember only one Step 3 maneuver: means restriction — especially firearm removal — is the single most impactful, board-favored, life-saving intervention you can document at the index visit and every visit thereafter.

Highest-yield recaps