Insufficient Evidence to Support Universal Suicide Screening

Deborah Brauser

April 24, 2013

There is little evidence to support universal screening for suicide risk in adults and adolescents in the primary care setting, a new review shows.

A systematic review of 56 studies showed that although screening tools are available to help clinicians identify at-risk adults, there is no evidence that using these tools actually prevents suicide. In addition, investigators found that there are still no proven primary care–relevant screening tools to identify at-risk adolescents and no effective interventions.

On the basis of these findings, the US Preventive Services Task Force released a draft recommendation announcing that it can neither support nor oppose screening for suicide risk.

"We all would like to find ways to prevent the suffering of those who commit or attempt suicide, as well as the families and communities they may leave behind," said Task Force member David Grossman, MD, in a press release.

"Unfortunately, at this time we don't know if asking everyone who visits their doctor or nurse about their risk factors for suicide leads to fewer suicides."

Instead, the Task Force suggests that healthcare professionals consider current scientific research, expert opinions, their own knowledge and experience, and their patients' health histories, values, and preferences.

However, Dr. Grossman pointed out that the new draft recommendations do not address the needs of people who show symptoms of depression or other psychiatric illness.

"For these individuals, having clinicians ask about suicidal thoughts should be part of managing their disease," he said, adding that the Task Force continues to recommend that all patients be screened for depression.

The review was published online April 23 in the Annals of Internal Medicine.

Limited Evidence

According to the investigators, almost 37,000 people died by suicide in the United States in 2009. Previous research has shown that 38% of adults who completed suicide visited their primary care physician during the month prior and that 90% of adolescent suicide completers visited in the year prior.

In 2004, the Task Force released recommendations based on an earlier review study of routine screenings by primary care physicians.

"That review found limited evidence that screening tests can reliably detect suicide risk in primary care populations," write the researchers. "Few trials showed benefit of treatment, and many were underpowered for these rare outcomes."

In the current analysis, investigators led by Elizabeth O'Connor, PhD, from the Center for Health Research at Kaiser Permanente Northwest in Portland, Oregon, reviewed 56 English-language studies that were published between January 2002 and July 2012.

Results showed that "primary care–feasible screening tools might help to identify some adults at increased risk for suicide," report the investigators. In fact, 1 study of 1000 adults showed that 3 suicide-related items on a nurse-administered interview had sensitivity rates of 83% to 100% and specificity rates of 81% to 98%.

In a study of 626 patients older than 65 years, the sensitivity and specificity rates dropped to 80% for suicidal ideation, with just a 33% positive predictive value.

Evidence was insufficient as to the benefits of suicide screening in either adult group.

Similarly, for adolescents, the evidence suggests that screening tools have limited ability to detect suicide risk. The researchers also note that these tools "had relatively poor applicability to general primary care patients."

Treatment with psychotherapy reduced the likelihood of suicide attempts or deliberate self-harm by 32% in adults who had made such attempts before. However, it did not show greater improvement in suicidal ideation than usual care in the overall adult group. Psychotherapy did not appear to benefit adolescents.

In 1 trial of 167 adult patients with depression who had recently attempted suicide, those who were randomly assigned to receive treatment with lithium did not differ significantly in further suicide attempts or suicidal ideation from those who received placebo.

The evidence base was too small to show benefits of medication treatment in reducing suicidality in adolescents.

"Suicidal youth need treatment, but caution, close monitoring, and care coordination are also warranted," write the investigators.

Overall, "suicide risk can be difficult to accurately assess because some person may attempt to conceal suicidal thoughts (creating false-negative results on screening) and some may express [these] thoughts without serious intention to kill themselves (creating false-positive results on screening)," note the investigators.

They add that more research is drastically needed.

No Definitive Recommendation

The Task Force notes that the systematic review makes it clear that there is currently not enough evidence available to make a definitive recommendation about suicide screening in the primary care setting.

They add that most of the studies in the review included individuals with recognized mental disorders or those who had previously attempted suicide instead of individuals in general populations.

"For people not already known to be at increased risk, there are not good ways for primary care professionals to identify those who are likely to try to take their own lives," the Task Force notes.

Instead, a healthcare professional should consider a number of things when providing guidance, including their own experiences and the patient's history. In addition, "providers should consider identifying patients with risk factors or who appear to be experiencing high levels of emotional distress and referring them for further evaluation."

Dr. Grossman said that the Task Force is now calling upon the research community to prioritize studies to develop tools that better identify people who are without symptoms and to create more effective treatment programs for these people when they are identified.

"We know that many people who attempt suicide have visited a health care professional within a month before their attempt. This means that we have a real opportunity to help if we find better tools," he concluded.

The draft recommendation statement is posted on the Task Force's Web site and will be available for public comment until May 20.

The study review was funded by the Agency for Healthcare Research and Quality. The study authors have reported several potential conflicts, which are fully listed in the original article.

Ann Intern Med. Published online April 23, 2013. Abstract

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