Accuracy of Self-Report Questionnaires and Records-Based Risk Scores to Identify Adolescents’ Risk for Self-Harm

This study aimed to evaluate screening strategies for identifying risk for self-harm among adolescents making outpatient health care visits. Health system records were used to identify a prospective cohort of adolescents completing the Patient Health Questionnaire-9 (PHQ-9) at outpatient visits between October 1, 2015, and March 15, 2020, and a retrospective cohort of adolescents experiencing self-harm events (ascertained from health records and state mortality data) during the same period. Self-harm risk scores were computed from health records. Analyses of the prospective sample examined the sensitivity and positive predictive value (PPV) of questionnaires and risk scores, separately and in combination. Analyses of the retrospective sample examined the proportion of self-harm events that could have been detected by different screening strategies. The prospective sample (N=8,929) included 43,548 questionnaires, with 1,045 questionnaires followed by a self-harm event within 180 days. A score of ≥2 on PHQ-9 item 9 had a sensitivity of 0.37 and a PPV of 0.09 for self-harm within 180 days of a mental health specialty visit, with similar results for primary care visits. In the retrospective sample, 89% of adolescents made a mental health specialty visit or a primary care visit with a recorded psychiatric diagnosis in the 180 days before a self-harm event. Responses to PHQ-9 item 9 and risk scores computed from health records accurately identified adolescents needing additional assessment for risk for self-harm. Over 80% of adolescents experiencing self-harm could have been identified by screening during an outpatient health care visit.