{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T00:45:10Z","timestamp":1793148310582,"version":"4.5.0"},"reference-count":40,"publisher":"American Medical Association (AMA)","issue":"7","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Psychiatry"],"published-print":{"date-parts":[[2024,7,1]]},"abstract":"Importance<\/jats:title>Given that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected.<\/jats:p><\/jats:sec>Objective<\/jats:title>To understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023.<\/jats:p><\/jats:sec>Exposures<\/jats:title>Demographic, diagnostic, treatment, and health care utilization characteristics.<\/jats:p><\/jats:sec>Main Outcome(s) and Measure(s)<\/jats:title>Responded \u201cnot at all\u201d (score\u2009=\u20090) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide.<\/jats:p><\/jats:sec>Results<\/jats:title>The study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P<\/jats:italic>\u2009=\u2009.03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P<\/jats:italic>\u2009=\u2009.02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P<\/jats:italic>\u2009=\u2009.001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P<\/jats:italic>\u2009=\u2009.007) within 90 days.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>Study results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamapsychiatry.2024.0603","type":"journal-article","created":{"date-parts":[[2024,4,24]],"date-time":"2024-04-24T15:33:07Z","timestamp":1713972787000},"page":"717","source":"Crossref","is-referenced-by-count":15,"title":["Adolescents Who Do Not Endorse Risk via the Patient Health Questionnaire Before Self-Harm or Suicide"],"prefix":"10.1001","volume":"81","author":[{"given":"Jean P.","family":"Flores","sequence":"first","affiliation":[{"name":"Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geoffrey","family":"Kahn","sequence":"additional","affiliation":[{"name":"Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert B.","family":"Penfold","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth A.","family":"Stuart","sequence":"additional","affiliation":[{"name":"Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian K.","family":"Ahmedani","sequence":"additional","affiliation":[{"name":"Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arne","family":"Beck","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Colorado, Aurora"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer M.","family":"Boggs","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Colorado, Aurora"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen J.","family":"Coleman","sequence":"additional","affiliation":[{"name":"Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena"},{"name":"Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yihe G.","family":"Daida","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Hawaii, Honolulu"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frances L.","family":"Lynch","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Northwest, Portland, Oregon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julie E.","family":"Richards","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rebecca C.","family":"Rossom","sequence":"additional","affiliation":[{"name":"HealthPartners Institute, Minneapolis, Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory E.","family":"Simon","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Washington, Seattle"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Holly C.","family":"Wilcox","sequence":"additional","affiliation":[{"name":"Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"15","key":"yoi240014r3","doi-asserted-by":"publisher","first-page":"1534","DOI":"10.1001\/jama.2022.16946","article-title":"Screening for depression and suicide risk in children and adolescents: US Preventive Services Task Force recommendation statement.","volume":"328","author":"Mangione","year":"2022","journal-title":"JAMA"},{"issue":"9","key":"yoi240014r4","doi-asserted-by":"publisher","first-page":"606","DOI":"10.1046\/j.1525-1497.2001.016009606.x","article-title":"The PHQ-9: validity of a brief depression severity measure.","volume":"16","author":"Kroenke","year":"2001","journal-title":"J Gen Intern Med"},{"issue":"12","key":"yoi240014r6","doi-asserted-by":"publisher","first-page":"1195","DOI":"10.1176\/appi.ps.201200587","article-title":"Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?","volume":"64","author":"Simon","year":"2013","journal-title":"Psychiatr Serv"},{"issue":"3","key":"yoi240014r7","doi-asserted-by":"publisher","first-page":"313","DOI":"10.1111\/sltb.2013.43.issue-3","article-title":"Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration.","volume":"43","author":"Allen","year":"2013","journal-title":"Suicide Life Threat Behav"},{"issue":"1","key":"yoi240014r8","doi-asserted-by":"publisher","first-page":"71","DOI":"10.1097\/00004583-200401000-00016","article-title":"The Columbia Suicide Screen: validity and reliability of a screen for youth suicide and depression.","volume":"43","author":"Shaffer","year":"2004","journal-title":"J Am Acad Child Adolesc Psychiatry"},{"issue":"5","key":"yoi240014r9","doi-asserted-by":"publisher","first-page":"854","DOI":"10.1111\/sltb.v51.5","article-title":"Utility of item 9 of the patient health questionnaire in the prospective identification of adolescents at risk of suicide attempt.","volume":"51","author":"Penfold","year":"2021","journal-title":"Suicide Life Threat Behav"},{"issue":"2","key":"yoi240014r10","doi-asserted-by":"publisher","first-page":"98","DOI":"10.1192\/bjp.bp.107.040113","article-title":"Cross-national prevalence and risk factors for suicidal ideation, plans and attempts.","volume":"192","author":"Nock","year":"2008","journal-title":"Br J Psychiatry"},{"issue":"7","key":"yoi240014r11","doi-asserted-by":"publisher","first-page":"718","DOI":"10.1001\/jamapsychiatry.2022.1256","article-title":"Prevalence and correlates of suicide and nonsuicidal self-injury in children: a systematic review and meta-analysis.","volume":"79","author":"Liu","year":"2022","journal-title":"JAMA Psychiatry"},{"issue":"5","key":"yoi240014r12","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2021.11563","article-title":"Trends in suicide rates by race and ethnicity in the US.","volume":"4","author":"Ramchand","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"10","key":"yoi240014r13","doi-asserted-by":"publisher","first-page":"951","DOI":"10.1176\/appi.ajp.2018.17101167","article-title":"Predicting suicide attempts and suicide deaths following outpatient visits using electronic health records.","volume":"175","author":"Simon","year":"2018","journal-title":"Am J Psychiatry"},{"key":"yoi240014r14","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1016\/j.jad.2021.06.057","article-title":"Predicting suicide attempts and suicide deaths among adolescents following outpatient visits.","volume":"294","author":"Penfold","year":"2021","journal-title":"J Affect Disord"},{"issue":"8","key":"yoi240014r15","doi-asserted-by":"publisher","first-page":"868","DOI":"10.1038\/mp.2009.29","article-title":"Mental disorders, comorbidity, and suicidal behavior: results from the National Comorbidity Survey Replication.","volume":"15","author":"Nock","year":"2010","journal-title":"Mol Psychiatry"},{"issue":"2","key":"yoi240014r16","doi-asserted-by":"publisher","first-page":"229","DOI":"10.1002\/eat.v53.2","article-title":"Understanding suicide risk and eating disorders in college student populations: results from a national study.","volume":"53","author":"Lipson","year":"2020","journal-title":"Int J Eat Disord"},{"issue":"3","key":"yoi240014r17","doi-asserted-by":"publisher","first-page":"501","DOI":"10.1002\/eat.v56.3","article-title":"Non-suicidal self-injury, suicidal thoughts and behaviors in individuals with an eating disorder relative to healthy and psychiatric controls: a systematic review and meta-analysis.","volume":"56","author":"Sohn","year":"2023","journal-title":"Int J Eat Disord"},{"key":"yoi240014r18","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1016\/j.schres.2021.07.029","article-title":"A systematic review of suicide and suicide attempts in adolescents with psychotic disorders.","volume":"235","author":"Barbeito","year":"2021","journal-title":"Schizophr Res"},{"issue":"4","key":"yoi240014r19","doi-asserted-by":"publisher","first-page":"234","DOI":"10.1016\/j.rpsmen.2016.03.002","article-title":"Suicidal behavior characteristics and factors associated with mortality in the hospital setting.","volume":"11","author":"Sendra-Guti\u00e9rrez","year":"2018","journal-title":"Rev Psiquiatr Salud Ment (Engl Ed)"},{"issue":"4","key":"yoi240014r20","doi-asserted-by":"publisher","first-page":"757","DOI":"10.12998\/wjcc.v8.i4.757","article-title":"Prevalence and associated factors of suicide among hospitalized schizophrenic patients.","volume":"8","author":"Woottiluk","year":"2020","journal-title":"World J Clin Cases"},{"issue":"6","key":"yoi240014r21","doi-asserted-by":"publisher","first-page":"566","DOI":"10.1176\/appi.ps.20220145","article-title":"Health diagnoses and service utilization in the year before youth and young adult suicide.","volume":"74","author":"Braciszewski","year":"2023","journal-title":"Psychiatr Serv"},{"issue":"9","key":"yoi240014r22","doi-asserted-by":"publisher","first-page":"794","DOI":"10.1002\/da.22623","article-title":"Between-visit changes in suicidal ideation and risk of subsequent suicide attempt.","volume":"34","author":"Simon","year":"2017","journal-title":"Depress Anxiety"},{"issue":"11","key":"yoi240014r23","doi-asserted-by":"publisher","first-page":"1107","DOI":"10.1001\/jama.2014.501","article-title":"Focusing suicide prevention on periods of high risk.","volume":"311","author":"Olfson","year":"2014","journal-title":"JAMA"},{"issue":"2","key":"yoi240014r24","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1002\/jclp.v62:2","article-title":"Psychosocial treatments of suicidal behaviors: a practice-friendly review.","volume":"62","author":"Comtois","year":"2006","journal-title":"J Clin Psychol"},{"issue":"5","key":"yoi240014r25","doi-asserted-by":"publisher","first-page":"563","DOI":"10.1001\/jama.294.5.563","article-title":"Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial.","volume":"294","author":"Brown","year":"2005","journal-title":"JAMA"},{"key":"yoi240014r27","doi-asserted-by":"publisher","DOI":"10.1177\/26334895211011769","article-title":"An implementation evaluation of \u201czero suicide\u201d using normalization process theory to support high-quality care for patients at risk of suicide.","volume":"2","author":"Richards","year":"2021","journal-title":"Implement Res Pract"},{"key":"yoi240014r28","doi-asserted-by":"publisher","first-page":"48","DOI":"10.3389\/fped.2019.00048","article-title":"Comorbidity index as a predictor of mortality in pediatric patients with solid tumors.","volume":"7","author":"Torres-Esp\u00edndola","year":"2019","journal-title":"Front Pediatr"},{"issue":"2","key":"yoi240014r29","doi-asserted-by":"publisher","first-page":"134","DOI":"10.1111\/camh.v26.2","article-title":"Risk factors for suicide attempt in children, adolescents, and young adults hospitalized for mental health disorders.","volume":"26","author":"Ong","year":"2021","journal-title":"Child Adolesc Ment Health"},{"issue":"2","key":"yoi240014r30","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1017\/S003329170500588X","article-title":"The association between suicide and the socioeconomic characteristics of geographical areas: a systematic review.","volume":"36","author":"Rehkopf","year":"2006","journal-title":"Psychol Med"},{"issue":"1","key":"yoi240014r31","doi-asserted-by":"publisher","first-page":"124","DOI":"10.1080\/10503307.2018.1543977","article-title":"\u201cIt is never okay to talk about suicide\u201d: patients\u2019 reasons for concealing suicidal ideation in psychotherapy.","volume":"30","author":"Blanchard","year":"2020","journal-title":"Psychother Res"},{"issue":"9","key":"yoi240014r32","doi-asserted-by":"publisher","first-page":"1215","DOI":"10.1007\/s11606-013-2412-6","article-title":"Trust is the basis for effective suicide risk screening and assessment in veterans.","volume":"28","author":"Ganzini","year":"2013","journal-title":"J Gen Intern Med"},{"issue":"2","key":"yoi240014r33","doi-asserted-by":"publisher","first-page":"221","DOI":"10.4088\/JCP.15m09776","article-title":"Risk of suicide attempt and suicide death following completion of the Patient Health Questionnaire depression module in community practice.","volume":"77","author":"Simon","year":"2016","journal-title":"J Clin Psychiatry"},{"issue":"11","key":"yoi240014r34","doi-asserted-by":"publisher","first-page":"2017","DOI":"10.1007\/s00127-021-02048-2","article-title":"Investigating the impact of involuntary psychiatric hospitalization on youth and young adult trust and help-seeking in pathways to care.","volume":"56","author":"Jones","year":"2021","journal-title":"Soc Psychiatry Psychiatr Epidemiol"},{"issue":"1","key":"yoi240014r35","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1176\/appi.ps.201800342","article-title":"Understanding why patients may not report suicidal ideation at a health care visit prior to a suicide attempt: a qualitative study.","volume":"70","author":"Richards","year":"2019","journal-title":"Psychiatr Serv"},{"issue":"10","key":"yoi240014r36","doi-asserted-by":"publisher","first-page":"2075","DOI":"10.1007\/s11606-019-05136-x","article-title":"If you listen, i will talk: the experience of being asked about suicidality during routine primary care.","volume":"34","author":"Richards","year":"2019","journal-title":"J Gen Intern Med"},{"key":"yoi240014r37","doi-asserted-by":"publisher","first-page":"349","DOI":"10.1016\/j.jad.2022.01.024","article-title":"Prevalence of suicidal ideation and suicide attempt among patients with traumatic brain injury: a meta-analysis.","volume":"300","author":"Chen","year":"2022","journal-title":"J Affect Disord"},{"key":"yoi240014r38","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyg.2020.571101","article-title":"Current and retrospective childhood ratings of emotional fluctuations in adults with ADHD.","volume":"11","author":"Lundervold","year":"2020","journal-title":"Front Psychol"},{"issue":"1","key":"yoi240014r39","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1111\/jcpp.2019.60.issue-1","article-title":"What distinguishes adolescents with suicidal thoughts from those who have attempted suicide: a population-based birth cohort study.","volume":"60","author":"Mars","year":"2019","journal-title":"J Child Psychol Psychiatry"},{"issue":"5","key":"yoi240014r40","doi-asserted-by":"publisher","first-page":"77S","DOI":"10.1097\/01.ALC.0000127417.99752.87","article-title":"Adolescent substance use and suicidal behavior: a review with implications for treatment research.","volume":"28","author":"Esposito-Smythers","year":"2004","journal-title":"Alcohol Clin Exp Res"},{"key":"yoi240014r2","volume-title":"Youth Risk Behavior Survey Data Summary & Trends Report: 2011-2021","author":"CDC","year":"2023"},{"key":"yoi240014r1","unstructured":"Centers for Disease Control and Prevention. National Vital Statistics System\u2014mortality data Accessed March 25, 2023. https:\/\/www.cdc.gov\/nchs\/nvss\/deaths.htm"},{"key":"yoi240014r5","unstructured":"Collander? TG. Detecting and treating suicide ideation in all settings. Accessed September 9, 2023. https:\/\/www.jointcommission.org\/-\/media\/tjc\/documents\/resources\/webinar-replays\/webinar_slides_detecting_treating_suicide_settings_collanderpdf.pdf"},{"key":"yoi240014r26","unstructured":"Mental Health Research Network. About Mental Health Research Network. Accessed December 9, 2023. https:\/\/mhresearchnetwork.org\/"}],"container-title":["JAMA Psychiatry"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamapsychiatry\/articlepdf\/2818039\/jamapsychiatry_flores_2024_oi_240014_1719970573.54219.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,7,3]],"date-time":"2024-07-03T15:11:13Z","timestamp":1720019473000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamapsychiatry\/fullarticle\/2818039"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,7,1]]},"references-count":40,"journal-issue":{"issue":"7","published-print":{"date-parts":[[2024,7,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamapsychiatry.2024.0603","relation":{},"ISSN":["2168-622X"],"issn-type":[{"value":"2168-622X","type":"print"}],"subject":[],"published":{"date-parts":[[2024,7,1]]}}}