{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,24]],"date-time":"2025-08-24T00:00:58Z","timestamp":1755993658199,"version":"3.44.0"},"reference-count":17,"publisher":"Georg Thieme Verlag KG","issue":"04","funder":[{"name":"The Ohio State University Clinical and Translational Science Institute","award":["UL1TR002733"],"award-info":[{"award-number":["UL1TR002733"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Appl Clin Inform"],"published-print":{"date-parts":[[2025,8]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Major depression in adolescents is recognized as a serious psychiatric illness and a risk factor for suicide. It is important for providers to screen for depression and suicidality and have clinical decision support (CDS) for evaluation, risk assessment, and initial management. Our efforts focused on leveraging the electronic health record (EHR) to ensure that high-risk adolescents received appropriate interventions before leaving the office.<\/jats:p><jats:p>This study aims to improve notification of positive adolescent depression and suicide risk screening results. Subaims include (1) designing and optimizing CDS alerts for severe depression and\/or acute lethality; and (2) increasing visibility for different EHR users to avoid the near misses.<\/jats:p><jats:p>We implemented several iterations of an interruptive alert after a positive mental health screening for patients aged 12 to 20 years seen in primary care and subspecialty rheumatology clinics between 2016 and 2023. Screening started with the Patient Health Questionnaire (PHQ) and Ask Suicide-Screening Questions (ASQ) on paper, and later via tablets.<\/jats:p><jats:p>There were 76,919 visits during the study period, of which 50,502 (66%) completed PHQ screening. Rates of PHQ screening increased throughout the study period. Of the ASQ screenings completed, alerts were fired for 2,355 nonacute positive and 411 acute positive. In most cases, all alerts fired were more than once. Providers and clinicians receiving alerts (physicians, nurse practitioners, social workers, and psychologists) acknowledged 63 to 96% of alerts and cancelled 6 to 70% of alerts. We revised the initial alert identifying lethality to include separate alerts for major depressive symptoms and suicide risk. Iterations also included an icon on the clinic schedule and incorporated guidance on appropriate actions.<\/jats:p><jats:p>By creating multiple types of alerting within different workflows, we improved notification and increased next-step visibility, leveraging decision support for patients screening positive for depression and suicidality.<\/jats:p>","DOI":"10.1055\/a-2591-4071","type":"journal-article","created":{"date-parts":[[2025,8,22]],"date-time":"2025-08-22T23:30:31Z","timestamp":1755905431000},"page":"816-824","source":"Crossref","is-referenced-by-count":0,"title":["Suicidality Screening: Ensuring Providers Do Not Miss Adolescents at High Risk through Clinical Decision Support"],"prefix":"10.1055","volume":"16","author":[{"given":"Shravani","family":"Vundavalli","sequence":"additional","affiliation":[{"name":"Division of Primary Care, Nationwide Children's Hospital, Columbus, Ohio, United States"},{"name":"Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio, United States"}]},{"given":"Aarti","family":"Chandawarkar","sequence":"additional","affiliation":[{"name":"Division of Primary Care, Nationwide Children's Hospital, Columbus, Ohio, United States"},{"name":"Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio, United States"}]},{"given":"Kristen","family":"Beck","sequence":"additional","affiliation":[{"name":"Division of Primary Care, Nationwide Children's Hospital, Columbus, Ohio, United States"}]},{"given":"Emily","family":"Decker","sequence":"additional","affiliation":[{"name":"Division of Primary Care, Nationwide Children's Hospital, Columbus, Ohio, United States"}]},{"given":"Stefanie","family":"Bester","sequence":"additional","affiliation":[{"name":"Division of Primary Care, Nationwide Children's Hospital, Columbus, Ohio, United States"}]},{"given":"Juan D.","family":"Chaparro","sequence":"additional","affiliation":[{"name":"Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio, United States"},{"name":"Division of Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio, United States"}]},{"given":"Alysha J.","family":"Taxter","sequence":"additional","affiliation":[{"name":"Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, Ohio, United States"},{"name":"Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio, United States"}]}],"member":"194","published-online":{"date-parts":[[2025,8,22]]},"reference":[{"issue":"03","key":"ref1","doi-asserted-by":"crossref","first-page":"e20174081","DOI":"10.1542\/peds.2017-4081","article-title":"Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management","volume":"141","author":"R A Zuckerbrot","year":"2018","journal-title":"Pediatrics"},{"issue":"02","key":"ref2","doi-asserted-by":"crossref","first-page":"e549","DOI":"10.1097\/pq9.0000000000000549","article-title":"Improving primary care adolescent depression screening and initial management: A quality improvement study","volume":"7","author":"K E Beck","year":"2022","journal-title":"Pediatr Qual Saf"},{"issue":"15","key":"ref3","doi-asserted-by":"crossref","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":"C M Mangione","year":"2022","journal-title":"JAMA"},{"issue":"04","key":"ref8","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1055\/s-0041-1733908","article-title":"Evaluation of electronic health record-based suicide risk prediction models on contemporary data","volume":"12","author":"R L Walker","year":"2021","journal-title":"Appl Clin Inform"},{"issue":"04","key":"ref9","doi-asserted-by":"crossref","first-page":"e0249833","DOI":"10.1371\/journal.pone.0249833","article-title":"A direct comparison of theory-driven and machine learning prediction of suicide: A meta-analysis","volume":"16","author":"K M Schafer","year":"2021","journal-title":"PLoS ONE"},{"issue":"05","key":"ref10","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1055\/a-2411-5796","article-title":"Enhancing suicide attempt risk prediction models with temporal clinical note features","volume":"15","author":"K J Krause","year":"2024","journal-title":"Appl Clin Inform"},{"issue":"12","key":"ref11","doi-asserted-by":"crossref","first-page":"2654","DOI":"10.1093\/jamia\/ocab179","article-title":"Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics","volume":"28","author":"E W Orenstein","year":"2021","journal-title":"J Am Med Inform Assoc"},{"issue":"03","key":"ref12","doi-asserted-by":"crossref","first-page":"560","DOI":"10.1055\/s-0042-1748856","article-title":"Clinical Decision Support Stewardship: Best practices and techniques to monitor and improve interruptive alerts","volume":"13","author":"J D Chaparro","year":"2022","journal-title":"Appl Clin Inform"},{"issue":"09","key":"ref14","doi-asserted-by":"crossref","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":"K Kroenke","year":"2001","journal-title":"J Gen Intern Med"},{"issue":"12","key":"ref15","doi-asserted-by":"crossref","first-page":"1170","DOI":"10.1001\/archpediatrics.2012.1276","article-title":"Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department","volume":"166","author":"L M Horowitz","year":"2012","journal-title":"Arch Pediatr Adolesc Med"},{"key":"ref16","doi-asserted-by":"crossref","first-page":"l1476","DOI":"10.1136\/bmj.l1476","article-title":"Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis","volume":"365","author":"B Levis","year":"2019","journal-title":"BMJ"},{"issue":"01","key":"ref17","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1186\/s12888-020-02885-6","article-title":"The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital","volume":"20","author":"Y Sun","year":"2020","journal-title":"BMC Psychiatry"},{"key":"ref18","volume-title":"Improving Outcomes with Clinical Decision Support: An Implementer's Guide","author":"J A Osheroff","year":"2005","edition":"2nd ed."},{"issue":"02","key":"ref19","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1055\/s-0044-1787006","article-title":"Suicide risk screening for head and neck cancer patients: An implementation study","volume":"15","author":"B Kansara","year":"2024","journal-title":"Appl Clin Inform"},{"issue":"03","key":"ref20","doi-asserted-by":"crossref","first-page":"196","DOI":"10.1016\/S1054-139X(01)00333-0","article-title":"The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients","volume":"30","author":"J G Johnson","year":"2002","journal-title":"J Adolesc Health"},{"issue":"18","key":"ref21","doi-asserted-by":"crossref","first-page":"1737","DOI":"10.1001\/jama.282.18.1737","article-title":"Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. 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