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Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force FREE

Elizabeth O'Connor, PhD; Bradley N. Gaynes, MD, MPH; Brittany U. Burda, MPH; Clara Soh, MPA; and Evelyn P. Whitlock, MD, MPH
[+] Article and Author Information

This article was published at www.annals.org on 23 April 2013.


From Kaiser Permanente Northwest, Portland, Oregon; University of North Carolina School of Medicine, Chapel Hill, North Carolina; and Pharmaceutical Research and Manufacturers of America, Washington, DC.

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, elizabeth.oconnor@kpchr.org.

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, DC 20004.

Author Contributions: Conception and design: E. O'Connor, B.N. Gaynes, C. Soh, E.P. Whitlock.

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, E.P. Whitlock.

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.


Ann Intern Med. 2013;158(10):741-754. doi:10.7326/0003-4819-158-10-201305210-00642
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Background: In 2009, suicide accounted for 36 897 deaths in the United States.

Purpose: 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.

Data Sources: 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).

Study Selection: 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.

Data Extraction: One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality.

Data Synthesis: 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.

Limitation: 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.

Conclusion: 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.

Primary Funding Source: Agency for Healthcare Research and Quality.


Suicide was the 10th leading cause of death in the United States in 2009, accounting for 36 897 deaths with an age-adjusted rate of 11.8 per 100 000 persons (12). It accounted for more than 1.4 million years of potential life lost before age 85 years (3). Suicide attempts and death rates vary substantially by sex; age; race; and other risk factors, such as psychiatric disorders (47), prior suicide attempts (811), a history of nonsuicidal self-harm (7), and a serious adverse childhood experience (1215). Individual risk factors have a limited ability to predict suicide in a person at a particular time, but risk for a suicide attempt and death increases with multiple risk factors (covering psychosocial, biomedical, and developmental realms) and high levels of distress (1617).

Thirty-eight percent of U.S. adults who completed suicide visited their primary care providers in the prior month; this rate was even higher (50% to 70%) in older adults (18). Nearly 90% of suicidal youth had primary care visits during the previous 12 months, compared with 70% to 80% of nonsuicidal youth (1920). Screening tools that are accurate and feasible for use in primary care could represent an important opportunity to identify persons at increased risk for suicide so that it can be prevented through appropriate treatment.

In 2004, the U.S. Preventive Services Task Force (USPSTF) concluded that evidence was insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population (I statement). That review found limited evidence that screening tests can reliably detect suicide risk in primary care populations (21). A large body of evidence (33 randomized, controlled trials and 2 cohort studies) examined the effects of treatment on suicide attempts and suicide deaths in adolescents or adults.

Few trials showed benefit of treatment, and many were underpowered for these rare outcomes. Evidence also showed that nonpharmacologic treatment could reduce depressive symptoms and suicidal ideation in high-risk older adolescents and adults. Evidence was lacking on harms of screening and treatment.

We developed an analytic framework (Appendix Figure 1) with 6 key questions to guide our work (Appendix Table 1). Our full report describes the methods in detail (22).

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Appendix Figure 1.

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.

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Table Jump PlaceholderAppendix Table 1. Key Questions 
Data Sources

We considered all studies from the previous review for inclusion. We searched MEDLINE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials for studies published between January 2002 and 17 July 2012 to bridge and update from the previous review. We hand-searched bibliographies of relevant reviews and searched Web sites of government agencies and professional organizations to identify relevant research published outside of peer-reviewed journals. We also conducted a surveillance search of MEDLINE through December 2012 to identify additional screening trials.

Study Selection

Two investigators independently reviewed the abstracts and articles against specified inclusion and exclusion criteria. We resolved disagreements through consultation with the larger project team. We included English-language studies in general primary care or specialty mental health populations (or similar populations) of any age. We also included studies limited to patients with depression, substance misuse, posttraumatic stress disorder, or borderline personality disorder. We excluded studies limited to patients with other mental health conditions.

For questions related to harms and benefits of screening or treatment, we included randomized and nonrandomized clinical trials. To address effects of treatment, we included trials of behavior-based or pharmacologic treatment with a primary aim of reducing suicide deaths, suicide attempts or self-harm, or suicidal ideation. We included studies of screening instrument accuracy that reported sensitivity, specificity, or related statistics of brief screening instruments to detect current increased suicide risk (usually suicidal ideation) relative to a reference standard. The reference standard had to be a more in-depth assessment of suicide risk by a trained mental health professional or a trained interviewer using a standardized instrument to determine whether suicide risk was increased. We would have included suicide attempts in the immediate period after screening (for example, 1 month) as a gold standard if we had found any studies that did this. We also would have included comparative cohort studies addressing harms of pharmacologic treatment in suicidal populations if we had found any.

Data Extraction and Quality Assessment

One investigator abstracted data from all included studies into a standard evidence table, and a second investigator checked the data for accuracy. Two investigators independently assessed the methodological quality of each study by using predefined design-specific quality criteria based on methods developed by the USPSTF (23). We supplemented these criteria with the Quality Assessment of Diagnostic Accuracy Studies tool (24) to evaluate the quality of diagnostic accuracy (screening) studies, resulting in a rating of good, fair, or poor. We resolved disagreements in quality assessment through discussion and, if necessary, consultation with a third reviewer. We excluded poor-quality trials.

Data Synthesis and Analysis

For all key questions, we created results tables with important study characteristics. We critically examined these tables to identify the range of results and potential associations with effect size. We examined trials limited to adolescents or limited to older adults separately from other adult trials.

For key questions 4 and 5 only, we conducted random-effects meta-analyses to estimate the effect size of suicide prevention interventions on suicide attempts or self-harm, suicidal ideation, and depression. We used Stata, version 11.2 (StataCorp, College Station, Texas), for all statistical analyses. Risk ratios were analyzed for suicide attempts. All trials reported at least 1 suicide attempt or self-harm episode in each intervention group, so no correction for empty cells was needed. We analyzed standardized mean differences (SMDs) in change from baseline for the continuous outcomes (suicidal ideation and depression). We calculated SDs of change from baseline by using a standard formula (25).

We assessed the presence of statistical heterogeneity among the studies by using standard chi-square tests and the I2 statistic (26). We applied the Cochrane Collaboration (27) rules of thumb for interpreting I2 (probably unimportant, <40%; moderate, 30% to 60%; and substantial, 50% to 90%) and Cohen (28) rules of thumb for interpreting effect sizes (small, 0.2 to 0.5; medium, 0.5 to 0.8; and large, ≥0.8).

Role of the Funding Source

This research was funded by the Agency for Healthcare Research and Quality (AHRQ). The AHRQ staff provided oversight for the project and assisted in external review of the companion draft evidence synthesis but had no role in study selection, quality assessment, synthesis, or development of conclusions. The investigators are solely responsible for the content of the manuscript and the decision to submit for publication.

We included 56 studies that reported results in 86 publications, from 3925 abstracts and 303 full-text articles (Appendix Figure 2). We included 7 trials that addressed screening (key questions 1, 2, and 3): 1 examined short-term benefits of screening (29), 4 examined performance characteristics of screening instruments (3033), and 3 examined adverse effects of screening (29, 3435). We included 49 trials that addressed the benefits of treatment (key questions 4 and 5)—36 were conducted in adults or mixed adolescent and adult populations (3671), and 13 were done in adolescents (7284). A subset of 12 of these trials also reported on adverse events or a (statistically nonsignificant) paradoxical increase in suicide attempts, which is discussed under key question 6 (36, 4041, 49, 51, 5557, 66, 73, 7677).

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Appendix Figure 2.

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.

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Benefits of Screening (Key Question 1)

We identified 1 short-term, fair-quality trial (n = 443) that addressed key question 1. This trial found no clear short-term (that is, within 2 weeks) benefit of screening (29). It was published after the 2004 USPSTF review on this topic and thus was not included in the previous review.

Screening Instrument Accuracy (Key Question 2)

Appendix Table 2 shows data from the 4 studies that reported the accuracy of screening instruments for identifying persons at increased risk for suicide (3033). Two of these trials were conducted in adult or older adult primary care populations (3233). One study (the only diagnostic accuracy study also included in the 2004 review) examined the clinical utility of 3 suicide-related items in primary care patients aged 18 years or older with prescheduled appointments for any reason (n = 1001) (32).

Table Jump PlaceholderAppendix Table 2. Test Performance Characteristics of Suicide Screening Instruments (Key Question 2) 

Items had sensitivities of 83% to 100% and specificities of 81% to 98% relative to a nurse-administered structured interview on the same day. The positive predictive values were low, ranging from 6% to 30%. Accuracy was lower in the study of the Geriatric Depression Scale—Suicidal Ideation subscale in general primary care patients aged 65 years or older (n = 626) (33). The optimal cutoff yielded a sensitivity and specificity of 80% for suicidal ideation during the previous 2 weeks, and the positive predictive value was fairly low (33%).

Two trials reported instrument accuracy in adolescent samples (combined n = 799). Although these studies used different instruments and approaches to assemble their samples, both represented high-risk groups that had 22% to 27% prevalence of suicidal ideation or behavior. In these studies, sensitivity ranged from 52% to 87% and specificity ranged from 60% to 85%. These results are generalizable only to high-risk populations.

Harms of Screening (Key Question 3)

Three trials reported on potential adverse effects of screening (all published since the previous review). None identified serious adverse effects of screening (29, 3435).

Health (Key Question 4) and Intermediate (Key Question 5) Benefits of Treatment

Appendix Table 3 (36112) lists brief population and intervention characteristics of all included trials, and Appendix Table 4 (36112) lists all outcomes reported by each trial. The previous review included only 11 of these 49 trials; almost all of the new trials were published in 2003 or later, well after the end of the search window of the 2004 review. We organized treatment trials into 3 broad intervention groups: psychotherapy, enhanced usual care, and medication.

Table Jump PlaceholderAppendix Table 3. Study Population and Intervention Characteristics of Included Studies (Key Questions 4 and 5) 
Table Jump PlaceholderAppendix Table 4. Outcomes Reported in Included Trials for Benefits and Harms of Treatment (Key Questions 4 and 5) 
Psychotherapy

Thirty-one trials investigated a specific psychotherapeutic treatment approach, generally compared with usual care. Nineteen were conducted in adults (3738, 41, 44, 47, 5052, 5456, 5860, 6265, 67), and 12 were conducted in adolescents (7281, 8384). Most psychotherapy trials were done in high-risk populations, usually identified because these persons had a recent suicide attempt or selected mental health disorders (for example, borderline personality disorder) and a history of suicide attempts. The only study that identified patients through population-based screening was conducted in Sri Lanka.

In adults, evidence was insufficient to evaluate the effect on suicide deaths, because only 6 of the 19 psychotherapy trials reported suicide deaths. Psychotherapy recipients had a 32% reduction in the likelihood of a suicide attempt or deliberate self-harm compared with usual care recipients (relative risk, 0.68 [95% CI, 0.56 to 0.83]; 11 trials; n = 1583; I2 = 16.1%) (Figure 1). However, a single estimate of absolute benefit would be misleading, given the highly variable rate of suicide attempts or self-harm (15% to 71% of control group participants had a suicide attempt or self-harm episode at follow-up). When the trials with the most extreme suicide attempt rates were excluded (38, 50, 5455), absolute differences ranged from a low of 46% in the control group and 39% in the intervention group (65) to a high of 47% in the control group and 23% in the intervention group (59).

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Figure 1.

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.

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Psychotherapy did not show greater improvement than usual care for suicidal ideation (SMD, −0.10 [CI, −0.27 to 0.06]; 8 trials; n = 964; I2 = 26.3%) (Figure 2), and most trials reported reduced suicidal ideation in both intervention and control groups. Psychotherapy had a small beneficial effect on depression relative to usual care (SMD, −0.37 [CI, −0.55 to −0.19]; 12 trials; n = 1653; I2 = 60.5%) (Figure 3). Other outcomes were sparsely reported and had mixed results.

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Figure 2.

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.

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Figure 3.

Depression 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.

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In adolescents, we could not determine the effects of suicide prevention treatment on deaths because only 1 death occurred in the 3 trials reporting this outcome. Psychotherapy did not reduce suicide attempts in adolescents at 6 to 18 months (relative risk, 0.99 [CI, 0.75 to 1.31]; 9 trials; n = 1331; I2 = 49.1%) (Figure 1). The CI of the pooled effect was wide, ranging from a 25% reduction in risk to a 31% increase in risk for suicide attempts.

The absolute proportion of participants with a suicide attempt or self-harm episode varied greatly across trials, as did the difference between groups. For example, in the 3 trials reporting suicide attempts or self-harm in 20% to 23% of control group participants, the proportion of youth in the intervention groups with suicide attempts or self-harm ranged from 11.4% to 36.1% (72, 78, 84). Given the wide range of results, we cannot rule out the possibility of harm (or benefit) on the basis of existing evidence.

Psychotherapy had no beneficial effect on suicidal ideation beyond usual care (SMD, −0.22 [CI, −0.46 to 0.02]; 6 trials; n = 629; I2 = 41.2%) (Figure 2); both the psychotherapy and usual care groups generally showed substantial improvement. Psychotherapy had a small beneficial effect on depression (SMD, −0.36 [CI, −0.63 to −0.08]; 6 trials; n = 631; I2 = 53.6) (Figure 3). Although statistical heterogeneity was high, all effects suggested that psychotherapy benefited persons with depression (but most effects were not statistically significant). Other health outcomes were sparsely reported and rarely showed beneficial effects for the interventions.

Among psychotherapy studies, we found no clear predictors of effect size other than target age (adults vs. adolescents), where trials in adults more consistently showed larger beneficial effects than those in adolescents. Among adolescent trials, limited data suggested that interventions targeting parents and youth, either separately or together, seemed to be more beneficial than those targeting only adolescents.

Enhanced Usual Care

We defined trials of “enhanced usual care” as those that attempted to improve the quality or format of recommended treatment (in primary or specialty care) or patient adherence to usual care while providing little to no direct therapeutic counseling or specific prescription for psychotherapy. Treatments varied widely, from mail-only to case management interventions, but most involved considerably less contact with patients than psychotherapy. One enhanced usual care trial was limited to adolescents and young adults (aged 15 to 24 years) (82), 2 were limited to older adult primary care patients (42, 71), and the remaining trials included wide age ranges covering primarily adults.

Most trials targeted participants who had an emergency department visit or inpatient stay related to a suicide attempt or self-harm. However, 3 trials were conducted in primary care settings, including both trials in older adults. PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) addressed only depressed older adults (aged 60 to 94 years) and was the sole trial that used primary care–based screening for depression in the United States to identify eligible participants (42). The other trial of older adults was a large cluster randomized trial (patients were randomly assigned at the level of provider) that included all patients older than 60 years on the panels of participating providers; this trial thus was not limited to patients who screened positive for suicidal ideation or had known risk factors for suicide, but was representative of a general Australian primary care population (71).

The third trial with high applicability to primary care was a nonrandomized, population-based intervention trial that compared intervention and control regions of the county in Hungary with the highest suicide rates. This trial reported suicide rates per 100 000 persons as its outcome, rather than following an identified sample (70). It involved a 5-year provider-education intervention that also offered free consultation and a depression clinic for referral.

Although 7 of the 17 enhanced usual care trials reported deaths, only 1 fair-quality trial reported significant group differences. This fairly large trial (n = 843) sent participants 24 letters over 5 years expressing concern and encouraging treatment and reported a 49% reduction in suicide deaths at 2-year follow-up (1.8% in the intervention group vs. 3.5% in the control group; 1-tailed P = 0.043) (61). The large population-based trial in primary care practices seemed sufficiently powered to examine suicide deaths and found no reduction in suicide (70). Aside from this population-based trial, very few deaths occurred across the remaining trials, and deaths were frequently not reported so we could not conclude that suicide deaths decreased.

Thirteen of the 17 adult trials of enhanced usual care reported on suicide attempts, and all but 1 (53) found no difference in suicide attempts between 4 and 24 months (relative risk, 0.91 [CI, 0.80 to 1.02]; 13 trials; n = 6592; I2 = 0.0%) (Figure 4). These results are consistent with a small to moderate (20% at most) decrease in suicide attempts or no effect, compared with suicide attempt rates in the control groups ranging from 1% to 30% at 4 to 24 months.

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Figure 4.

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.

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Other health and intermediate outcomes were sparsely reported. The trials in older primary care patients reduced suicide attempts by 20% to 23% (42, 71), but the results were significant only in the larger trial (71).

Medication

We included 1 fair-quality, placebo-controlled trial of lithium to prevent suicide in patients with depression-spectrum disorders and a recent suicide attempt (167 randomly assigned patients) (57). Retention in this trial was low (only 31% of participants remained at the final 13-month follow-up). Although all 3 suicide deaths in the study occurred in placebo recipients, the groups did not differ in cumulative survival without a suicide attempt (hazard ratio, 0.517; P = 0.21, adjusted for age, sex, and prior suicide attempts) or suicidal ideation.

Harms of Treatment (Key Question 6)

Although no harms were identified in any of the adult trials, 4 of the 12 trials reporting suicide attempts in adolescents reported statistically nonsignificant increases in suicide attempts of 22% to 113% (73, 7677, 82). The possibility of harm cannot be ruled out in treatment of currently or recently suicidal adolescents.

The trial of lithium treatment reported that 13% of the lithium recipients withdrew from the study because of adverse effects, compared with 2% of placebo recipients. However, the statistical significance of this difference was not reported (57). Overall withdrawal rates for any reason were similar between groups. Specific adverse effects were not reported.

Suicide risk can be difficult to accurately assess because some persons may attempt to conceal suicidal thoughts (creating false-negative results on screening) and some may express suicidal thoughts without serious intention to kill themselves (creating false-positive results on screening) (113). Even in high-risk populations, suicide is comparatively rare. Furthermore, the known risk factors associated with suicide are relatively common and individually not very strong predictors of suicide, even in persons at high risk. This combination of factors makes accurately predicting who will die by suicide on the basis of known risk factors very difficult. Nonetheless, suicide prevention is of high national importance, so it is critical to know whether primary care–based screening is likely to help reduce suicide in the United States by identifying patients in need of treatment and referring them to appropriate care. The Table summarizes the evidence from this review for all key questions.

Summary of Findings
Screening

Although screening instruments have been developed for quick risk assessment, few studies have reported diagnostic accuracy characteristics of sensitivity, specificity, or related statistics relative to an interview with a clinician or other trained questioner. Minimal evidence (2 studies) suggested that screening tools can identify adults and older adults in primary care who are at increased risk for suicide, although these tools produce many false-positive results. Data on the accuracy of screening were even more limited in adolescents. Neither instrument performed well in adolescents, and the screening populations in which they were tested had relatively poor applicability to general primary care patients.

An important limitation of these data is the unknown accuracy of a full clinical interview in predicting suicide-related events, which are relatively rare and inherently difficult to predict (17). Instrument accuracy aside, we identified minimal data that examined whether suicide risk screening increased or decreased the likelihood of suicidality or other distress. Our results are consistent with those of an earlier review of suicide screening in adolescents, which concluded that data were very limited and future research was essential to determine whether and how screening can reduce suicide in young persons (114).

Treatment in Adults

Although the included studies involved too few deaths to determine whether a particular treatment reduced the risk for suicide deaths, they provided useful evidence about attempts. Combined assessment of all psychotherapy studies found that psychotherapy targeting suicide prevention reduced the risk for attempts by an estimated average of 32%. Psychotherapy also showed small beneficial effects on depression, although other beneficial outcomes were sparsely reported or showed no consistent group differences. Interventions that primarily focused on enhancing usual care had little effect on suicide deaths, suicide attempts, or related outcomes.

The participants in the included adult treatment trials who reported suicide attempts were at high risk for suicide, usually based on a history of multiple attempts, which resulted in a very high incidence of suicide attempts (for example, 11% to 68% in the control groups of the psychotherapy trial). This finding contrasts with the screening accuracy studies that were done in general primary care patients, where attempt rates are substantially lower (probably <1% over 1 year) (115). Thus, the indirect evidence linking screening accuracy with benefits of treatment is not good.

There are several possible explanations for why psychotherapy seemed to be effective in adults, whereas practice-based approaches or other enhanced usual care interventions were not. First, the care provided in enhanced usual care trials was generally less time-intensive than that provided in the psychotherapy trials, which may be associated with smaller effects. In addition, the enhanced usual care trials may have included slightly lower-risk samples than the psychotherapy trials, as evidenced by a smaller proportion of control group participants who attempted suicide at follow-up (0.5% to 28% of control participants).

Alternatively, usual care may have been more effective in these studies, which would also attenuate the effect (but which we could not examine with available evidence). Assuming that these interventions are less likely, on average, to be effective, some of the enhanced usual care interventions may nevertheless be useful components of a larger system-wide approach that includes psychotherapy.

We found minimal data on medication's effectiveness in preventing suicidal behavior. These data were limited to a single, short-term, fair- to poor-quality lithium trial that had high attrition. Lithium is commonly used for treating bipolar disorder and has been shown to reduce the risk for suicide in observational studies (116117) and in controlled trials of patients with unipolar and bipolar depression who were not necessarily suicidal, compared with placebo or other agents (pooled Peto odds ratio of randomized trials, 0.26 [CI, 0.09 to 0.77]) (118). We found no studies on lithium use in patients identified through screening for suicidality. Lithium is associated with important adverse effects that were not described in the 1 trial included in this review (119121).

Our findings were generally consistent with other recent reviews of treatment to prevent suicide or self-harm (122125). Each of these recent reviews generally included similar bodies of research but grouped the trials differently. Nonetheless, they all found insufficient evidence for an effect on suicide deaths because of the small number of events. They also generally found small to moderate (usually nonsignificant) reductions in suicide attempts or self-harm, and all were limited by the included trials' sparse reporting of other outcomes. The most comprehensive of these reviews, published by the National Institute for Health and Clinical Excellence, concluded that psychological and psychosocial interventions may be effective compared with usual care. However, variations in populations, treatment methods, and comparison groups created uncertainty.

Treatment in Adolescents

Psychotherapy did not reduce the risk for suicide attempts in adolescents in contrast to adults. Data did not allow us to rule out the possibility that the risk for suicide attempts was paradoxically increased. Psychotherapy showed small beneficial effects on depression for adolescents, as it did for adults. Other outcomes either showed no consistent beneficial effects or were sparsely reported.

The research on iatrogenic suicidality related to antidepressants suggests that adolescents react differently from adults to pharmacologic treatment (126). Research also suggests that risk factors and methods of committing suicide differ between younger versus older teenagers (127). Thus, different age groups seem to have different treatment needs and risks. The evidence base in adolescents is still small, and few approaches have been replicated. Replication is important, as shown by the trials of developmental behavior therapy in this review; beneficial results in a first trial (80) were not replicated in 2 subsequent good-quality trials (75, 77). Overall, our findings were consistent with the National Institute for Health and Clinical Excellence review, in which only 1 trial showed a beneficial effect in adolescents (125).

Psychotherapy trials primarily involved high-risk youth, most with a recent suicide attempt or acute suicidal ideation. These samples are consistent with those in the screening studies but may have low applicability to youth identified through primary care screening. Suicidal youth need treatment, but caution, close monitoring, and care coordination are also warranted (128). These trials suggest that active parental involvement in treatment may be important. Further research is urgently needed.

Limitations

One important limitation is that most of the treatment literature was in high-risk populations, so the generalizability of these results to screening-detected populations is unknown. In addition, there was very little evidence on the effectiveness of treatment in older adults and racial or ethnic minorities. Differences in suicide rates among ethnic groups suggest that cultures vary, both in motivation for and meaning of suicide; thus, culturally tailored risk-based screening and interventions may be important (129).

The lack of power and reports of suicide death is another important limitation. Suicide attempts and self-harm are not good surrogates for suicide death. As a result, we cannot assume that the reduced attempts seen with psychotherapy interventions will decrease the number of deaths (130). Because suicide death is relatively rare and predicting such deaths is difficult, very large collaborative trials are probably required for sufficient power to see an effect on suicide deaths (131). For example, if all participants in all psychotherapy trials that reported suicide deaths were treated as a single study that found a 57% reduction (0.62% in the intervention group vs. 1.44% in the control group), 4 times the number of actual participants would be needed to achieve statistical significance.

Power would probably be even more dramatically limited in studies of screening-detected patients. Assuming an annual suicide rate of 100 per 100 000 persons (twice as high as that of older white men, who have the highest rates of any age, sex, or racial subgroup) and the ability of a treatment to reduce suicide by 40%, more than 83 000 persons per group would be required to generate a statistically significant result. Thus, building a coherent chain of evidence from broad population-based screening through treatment to reduce suicide deaths will be difficult, because treatment studies will necessarily be limited to very high-risk groups in order to have sufficient power to detect a treatment effect.

Conclusion

Suicide prevention is a topic of high national importance in which primary care providers may have a role. Although evidence was limited, primary care–feasible screening tools could probably identify adult patients at increased risk for suicide who may need treatment. A larger body of evidence showed that psychotherapy can reduce the risk for suicide attempts in high-risk populations.

Unfortunately, whether similar benefits would be found in screening-detected patients is unknown. There was little evidence on the accuracy of screening in adolescents, and what little data are available showed that treatment did not demonstrate a positive effect. Results in adolescents also did not rule out the possibility of harm (that is, increased suicide attempts) with some forms of psychotherapy. More research on how to effectively identify and treat adolescents at increased risk for suicide is urgently needed. There is also a need for research on the effect of psychotherapy to prevent suicide attempts in primary care patients who screen positive for suicide risk, as well as whether treatments actually lead to lower suicide death rates, even in high-risk populations.

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Figures

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Appendix Figure 1.

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.

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Appendix Figure 2.

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.

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Figure 1.

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.

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Figure 2.

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.

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Figure 3.

Depression 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.

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Figure 4.

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.

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Tables

Table Jump PlaceholderAppendix Table 1. Key Questions 
Table Jump PlaceholderAppendix Table 2. Test Performance Characteristics of Suicide Screening Instruments (Key Question 2) 
Table Jump PlaceholderAppendix Table 3. Study Population and Intervention Characteristics of Included Studies (Key Questions 4 and 5) 
Table Jump PlaceholderAppendix Table 4. Outcomes Reported in Included Trials for Benefits and Harms of Treatment (Key Questions 4 and 5) 

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Evidence to Support Screening for Suicide Remains Insufficient
Posted on June 5, 2013
Richard G. Malish, Robert L. Czech, David W. Cole
USA MEDDAC Fort Stewart, GA and the 3rd Infantry Division
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.

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

Author's Reply
Posted on July 2, 2013
Elizabeth A. O'Connor, PhD, Evelyn P. Whitlock, MD, MPH, Bradley N. Gaynes, MD
Kaiser Permanente
Conflict of Interest: None Declared

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

Reference List

 

(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]

 

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