Elizabeth O'Connor, PhD; Bradley N. Gaynes, MD, MPH; Brittany U. Burda, MPH; Clara Soh, MPA; Evelyn P. Whitlock, MD, MPH
Note: Ms. Soh accepted a position at the Pharmaceutical Research and Manufacturers of
America during the finalization of the full report and drafting and final submission of this
manuscript; she contributed most of her intellectual content to this review while she was employed
with the Oregon Evidence-based Practice Center at Kaiser Permanente Center for Health Research.
Disclaimer: The views and opinions expressed in this article are those of the authors
and do not necessarily reflect the views of the Pharmaceutical Research and Manufacturers of America.
The findings and conclusions in this document are those of the authors, who are responsible for its
content, and do not necessarily represent the views of AHRQ. No statement in this report should be
construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank the AHRQ staff; the USPSTF; J. Michael Bostwick, MD;
David A. Brent, MD; Gregory Simon, MD, MPH, who provided expert review of the report; Kevin Lutz, MFA;
Daphne Plaut, MLS; and Heather Baird at the Kaiser Permanente Center for Health Research.
Grant Support: By the Oregon Evidence-based Practice Center under contract to AHRQ,
Rockville, Maryland (contract HHS-290-2007-10057-I).
Potential Conflicts of Interest: Dr. O'Connor: Grant (money to
institution): AHRQ; Support for travel to meetings for the study or other purposes
(money to institution): AHRQ; Payment for writing or reviewing the manuscript (money
to institution): AHRQ; Provision of writing assistance, medicines, equipment, or
administrative support (money to institution): AHRQ. Dr. Gaynes: Grant (money to
institution): AHRQ. Ms. Burda: Grant (money to institution): AHRQ;
Consultancy: Oregon Health & Science University; Employment:
Howard Hughes Medical Institute, Vollum Institute (Oregon Health & Science University);
Other: Pennsylvania State University, Howard Hughes Medical Institute. Ms. Soh:
Grant (money to institution): AHRQ; Support for travel to meetings for the
study or other purposes (money to institution): AHRQ; Provision of writing
assistance, medicines, equipment, or administrative support (money to institution): AHRQ. Dr.
Whitlock: Grant (money to institution): AHRQ; Support for travel to meetings
for the study or other purposes (money to institution): AHRQ; Payment for writing or
reviewing the manuscript (money to institution): AHRQ; Provision of writing
assistance, medicines, equipment, or administrative support (money to institution): AHRQ.
Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2880.
Corresponding Author: Elizabeth O'Connor, PhD, Center for Health Research, Kaiser
Permanente NW, 3800 North Interstate Avenue, Portland, OR 97227; e-mail, email@example.com.
Current Author Addresses: Dr. O'Connor, Ms. Burda, and Dr. Whitlock: Center for Health
Research, Kaiser Permanente NW, 3800 North Interstate Avenue, Portland, OR 97227.
Dr. Gaynes: Department of Psychiatry, CB #7160, University of North Carolina School of Medicine,
Chapel Hill, NC 27599.
Ms. Soh: Pharmaceutical Research and Manufacturers of America, 950 F Street NW, Suite 300, Washington,
Author Contributions: Conception and design: E. O'Connor, B.N. Gaynes, C. Soh, E.P.
Analysis and interpretation of the data: E. O'Connor, B.N. Gaynes, C. Soh.
Drafting of the article: E. O'Connor, B.U. Burda, C. Soh.
Critical revision of the article for important intellectual content: B.N. Gaynes, B.U. Burda, C. Soh,
Final approval of the article: B.N. Gaynes, B.U. Burda, C. Soh, E.P. Whitlock.
Provision of study materials or patients: B.N. Gaynes.
Statistical expertise: E. O'Connor.
Obtaining of funding: E.P. Whitlock.
Administrative, technical, or logistic support: B.U. Burda.
Collection and assembly of data: E. O'Connor, B.N. Gaynes, B.U. Burda, C. Soh.
In 2009, suicide accounted for 36 897 deaths in the United States.
To review the accuracy of screening instruments and the efficacy and safety of screening for and
treatment of suicide risk in populations and settings relevant to primary care.
Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002
to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening
trials (July to December 2012).
Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in
primary care or similar populations and trials of suicide prevention interventions in primary or
mental health care settings.
One investigator abstracted data; a second checked the abstraction. Two investigators rated study
Evidence was insufficient to determine the benefits of screening in primary care populations; very
limited evidence identified no serious harms. Minimal evidence suggested that screening tools can
identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies
of older adults. Minimal evidence limited to high-risk populations suggested poor performance of
screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide
attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect
effects on deaths.
Treatment evidence was derived from high-risk rather than screening-detected populations. Evidence
relevant to adolescents, older adults, and racial or ethnic minorities was limited.
Primary care–feasible screening tools might help to identify some adults at increased risk for
suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce
suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are
not yet proven.
Agency for Healthcare Research and Quality.
Analytic framework for suicide risk relevant to primary care.
KQ = key question (see Appendix Table 1). * All studies must
report at least 1 suicide-specific outcome measure.
Appendix Table 1. Key Questions
Summary of evidence search and selection.
* Surveillance search of MEDLINE only from July 2012 through December 2012 for trials related to
screening are not included. No additional trials were identified.
Appendix Table 2. Test Performance Characteristics of Suicide Screening Instruments (Key Question
Appendix Table 3. Study Population and Intervention Characteristics of Included Studies (Key
Questions 4 and 5)
Appendix Table 4. Outcomes Reported in Included Trials for Benefits and Harms of Treatment (Key
Questions 4 and 5)
Suicide attempts in psychotherapy trials.
Weights are from random-effects analysis. CB = cognitive behavioral; D = dialectical; DG =
developmental group; DSH = deliberate self-harm; ODT = other therapy, direct; OTND = other
therapy, nondirect; P = psychodynamic; PS = problem solving; SA = suicide attempt.
Suicidal ideation in psychotherapy trials.
Weights are from random-effects analysis. CB = cognitive behavioral; D = dialectical; DG =
developmental group; OTND = other therapy, nondirect; P = psychodynamic; PS = problem solving;
SMD = standard mean difference.
Depression in psychotherapy trials.
Suicide attempts in enhanced usual care studies.
Weights are from random-effects analysis. DSH = deliberate self-harm; PROSPECT = Prevention of
Suicide in Primary Care Elderly: Collaborative Trial; SA = suicide attempt.
Table. Summary of Evidence
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Richard G. Malish, Robert L. Czech, David W. Cole
USA MEDDAC Fort Stewart, GA and the 3rd Infantry Division
June 5, 2013
Conflict of Interest:
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the U.S. Army Medical Activity Fort Stewart, Georgia, the 3rd Infantry Division, the United States Army, or the United States Department of Defense. 1. O’Connor E, Gaynes BN, Burda BU, Soh C, Whitlock EP. Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Task Force. Ann Intern Med. 2013; 158: 741-754.2. Screening for Suicide Risk: Recommendation and Rationale. Ann Intern Med. 2004: 140: 820-821.3. Zoroya G. Army, Navy suicides at record high. 18 November 2012. USA Today.
Evidence to Support Screening for Suicide Remains Insufficient
We would like to congratulate O’Conner et al. for their comprehensive review of the literature regarding the evidence in support of screening to prevent suicide. However, we do not believe the evidence presented in the manuscript supports the conclusion that, “primary care-feasible screening tools could probably identify adult patients at increased risk for suicide.”
1 We suspect that this conclusion may be flavored by unsupported optimism. We instead feel the 2004 United States Preventive Task Force (USPTF) statement is more technically sound. Specifically, “the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population.”
2 In their article, O’Conner et al. recognize the growing epidemic of suicides in the general population. Because of its characteristics as a contained and easily studied population, the United States Army has recognized this phenomenon for several years. It would not be unfair to characterize our efforts to prevent suicide as a collective “obsession.” To this end, the Army has adopted many initiatives of which aggressive screening is one of two prominent pillars. Because of these efforts, U.S. military service members are likely (anecdotally) the population most screened for suicide in the world. Not only are Soldiers screened at every primary care visit, they are also screened annually as part of a periodic health assessment. Furthermore, non-medical military leaders complete periodic questionnaire-based interviews with Soldiers to identify their risk for suicide, substance abuse, sexual abuse, and other personal and societal dangers. These interviews vary by unit but occur no less than yearly. Finally, deploying Soldiers are screened for depression and suicidal ideation at 4-5 deployment-related touch-points.In spite of these screening efforts (which have escalated rapidly over the past five years), Army suicide rates have continued to increase.
3 Without evidence to the contrary, we must acknowledge the possibility that screening is as likely to be neutral or harmful as it is to be beneficial based on this observation. Repetitive screening may conceivably introduce suicide as a potential course of action for relief of psychic pain and emotional distress through suggestion. Anecdotal observations could as easily support a negative-leaning statement against screening as they do a slightly positive supporting one. In supporting screening for suicide, we believe O’Conner et al. may have fallen prey to the common misconception that detecting suicidal ideation in populations equates to preventing completed suicides. In fact, to our knowledge, no study designed to detect suicidal ideation has resulted in a reduction in suicide. This makes ideation endpoints invalid as predictors of suicide and inappropriate surrogates. While the authors correctly identify this pitfall in their text, the studies used to support the faintly positive recommendation in favor of screening, in fact, rely upon screening to detect suicidal behavior. None of the supporting studies was designed to demonstrate an effect on completed suicide. O’Conner et al. are conscientious in their efforts to qualify their assertion in favor of screening. But even the suggestion that “limited evidence” exists is misleading.It is important that scientific verbiage is technically precise because military and political leaders rely upon it to support multi-million dollar programs. Even the suggestion by experts that unproven methodologies “might help” may result in their adoption by government officials desperate to curb this alarming trend. This may divert resources from pivotal research or other pillars of suicide prevention (such as building resiliency or creating policy).
We should instead be quite frank and deliberate. Recognizing that many of the authors are likely the same for both works, nothing new is presented in the 2013 O’Conner et al. manuscript that repudiates the 2004 statement, “the USPTF found no evidence that screening for suicide reduces suicide attempts or mortality.”2
Elizabeth A. O'Connor, PhD, Evelyn P. Whitlock, MD, MPH, Bradley N. Gaynes, MD
July 2, 2013
We thank Dr. Malish and his colleagues for their comments. First, we would like to clarify that our review is a statement of the evidence related to suicide screening that the U.S. Preventive Services Task Force (USPSTF) used to develop their recommendation for suicide screening in primary care in the United States (1). Our task was to accurately characterize the body of evidence through application of rigorous systematic review methods. The USPSTF then used this review to interpret the strength and clinical significance of the evidence as it is related to primary care. The USPSTF’s draft recommendation has been published separately, and is consistent with the 2004 USPSTF recommendation that the evidence is insufficient to recommend for or against screening for suicide in primary care (2).
We agree that there was very little direct evidence that screening for suicide risk is either beneficial or harmful (3). Therefore, we examined the evidence for (a) whether there were screening instruments that adequately identify patients at increased risk of suicide, and (b) whether treatment was effective in patient populations similar to those who would be identified through screening. When we said that “primary care-feasible screening tools could probably identify adult patients at increased risk for suicide” we were referring only to the ability of the screening instruments to identify people who are suicidal, not to whether screening would reduce the rate of suicide.
Dr. Malish and colleagues point out that despite very high rates of screening in military populations, suicide in active military and veteran populations is still very high and has even increased, suggesting that screening has not been effective in preventing suicide and might even be counterproductive in this population. As outlined in our paper and review, we did not include such ecological data in our evidence review because this type of data cannot establish a causal connection between screening and suicide rate, especially given war-related events and potential social/cultural shifts that may have occurred in the same time period.
In summary, we agree that evidence on the effectiveness of screening programs is lacking and cannot assume that increased identification of suicidal persons will reduce the suicide rate. The experience of the military provides valuable insights that could have important implications for other high-risk populations and we appreciate the extensive efforts undertaken on behalf of service members and veterans to prevent suicide. We do not yet know how to prevent suicide at a population level, and we hope researchers or institutions, including the armed services, will help to identify measures that are effective in preventing suicide in the near future.
Elizabeth A. O’Connor, PhD
Evelyn P. Whitlock, MD MPH
Bradley N. Gaynes, MD
(1) U.S.Preventive Services Task Force. U.S. Preventive Services Task Force Procedure Manual. Rockville, MD: Agency for Healthcare Quality and Research; 2008. [PMID: None]
(2) U.S.Preventive Services Task Force. Screening for suicide risk in adolescents, adults and older adults: U.S. Preventive Services Task Force Recommendation Statement [DRAFT]. USPSTF Website [cited 2013 July 1]; Available from: URL:http://www.uspreventiveservicestaskforce.org/uspstf13/suicide/suicidedraftrec.htm [PMID: None]
(3) O'Connor E, Gaynes BN, Burda BU, Soh C, Whitlock EP. Screening for and treatment of suicide risk relevant to primary care: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158:741-754. [PMID: 23609101]
O'Connor E, Gaynes BN, Burda BU, Soh C, Whitlock EP. Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for
the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158:741-754. doi: 10.7326/0003-4819-158-10-201305210-00642
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Published: Ann Intern Med. 2013;158(10):741-754.
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