The validity of three suicide risk screening tools among Native American youth in a reservation-based ED

Suicide is a leading cause of death among adolescents, with disproportionately high rates among American Indian/Alaska Native (AI/AN) youth. Early identification is critical for youth suicide prevention, and the Emergency Department is an important and viable setting for targeting suicide risk. The Emergency Department Study for Teens at Risk for Suicide (ED-STARS) was a prospective, multi-site cohort study conducted across 13 EDs in the Pediatric Emergency Care Applied Research Network, and one Indian Health Service site. The present study examined the comparative validity of the Ask Suicide Screening Questions (ASQ), Patient Health Questionnaire (PHQ-2) and Comprehensive Assessment of Suicide Screening in Youth (CASSY) in AI youth from the White Mountain Apache site of the ED-STARS parent study. A total of 174 AI adolescents from the Whiteriver IHS hospital site were included in the analytic sample. The CASSY performed well in this sample with an overall AUC of 0.86 [95% CI, 0.79-0.93], and, importantly, did not miss identifying anyone at risk who went on to have a subsequent suicide event. The ASQ and PHQ-2 did not perform as well as the CASSY in terms of AUCs (0.82 and 0.72 respectively). Both the ASQ and PHQ-2 missed a substantial number of individuals with a subsequent suicide event. Given the relatively widespread implementation of suicide screening in hospitals, this data has substantial clinical and public health significance. AI/AN youth experience disproportionately high suicide risk, yet screening tools lack validation in these populations.