Our study suggests that, within an integrated care system, youth with SI had similar patterns of healthcare utilization to youth without SI but with comparable depression. While most of the youth were receiving medical ambulatory care visits, few received mental health care, despite the fact that patients in GH have access to mental health services without a referral with only small co-pays.
Our results are similar to a study examining self-reported mental health services among adolescents with SI, which found a 28% utilization rate for psychological counseling.17
Our overall mental health utilization rate was similarly low (26%). Within the GH system, no differences emerged in rates of general healthcare or mental health services on the basis of SI. However, youth with SI were more likely than those without SI to seek care outside the organization’s mental health system.
Some researchers have argued that “to cast ideation in a pathology or deviance framework is to miss the normative aspects of this behavior during the adolescent stage of development.”18
While it may not be unusual to experience some morbid ideation at some point during adolescence, the current results highlight that the presence of SI in teens is indicative of clinically significant functional impairment as well as greater psychiatric co-morbidity. Functional impairment levels were in the “definitely impaired” range for the majority of youth in both groups of youth at baseline, and six-month follow up levels of impairment were still high for youth with SI, with 57% meeting the definite impairment threshold. Although previous research has established persistent differences in functional impairment for youth who have made a suicide attempt,19
our study shows that impairment is also problematic among youth with SI. Together with other studies suggesting that 29% of individuals with SI go on to make a suicide attempt,20
these data present a compelling case for the importance of identifying SI in youth. Other literature indicates that visits to primary care are associated with detection and receipt of treatment for anxious and depressed youth.21
In terms of co-morbid symptoms, in contrast to other literature, our study suggests an increased prevalence of psychiatric co-morbidities among youth with SI, including higher levels of externalizing problems and substance use. It is possible that co-morbid problems tend to cluster more proximally in time to SI, thus creating higher current prevalence (as found in the current study), but not necessarily lifetime prevalence (as found in a previous study).4
It is also possible that co-morbidities contribute in some cases to the etiology of SI.
Limitations of the study include that we did not collect data on when the SI started and considerable variability in terms of severity is likely. As a result of our study design, there was a somewhat different timeframe between administrative measures of health care utilization (12 months) and self-reported symptom and healthcare data (6 months). Another limitation is that these data were collected from an insured sample of youth in Washington State, and may not be generalizable to other populations. It is also possible that some mental health treatment occurred in the context of medical care, which was not characterized as such. Finally, data were collected using phone interviews.
Our results suggest that the clinical detection of SI and depression is low. Correspondingly, mental health service utilization of youth with SI appears to be low, even in a health care system that includes the potential for mental health services. Yet, the presence of SI is associated with significant functional impairment and co-morbidity. These results emphasize the importance of clinicians to recognize youth with SI and pursue additional evaluation to detect and treat comorbidity, underlying depression, and functional impairment. In a prior study, we found that screening for core depressive symptoms alone can miss detection of SI.6
Thus, we suggest that efforts to screen for depression in primary care should include specific questions regarding SI. A positive response to SI might then be a trigger to screen for additional disorders.