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Clinical Guidelines |

Screening for Suicide Risk: Recommendation and Rationale FREE

U.S. Preventive Services Task Force*
[+] Article and Author Information

From the U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, Rockville, Maryland.


Ann Intern Med. 2004;140(10):820-821. doi:10.7326/0003-4819-140-10-200405180-00022
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This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendations on screening for suicide risk and the supporting scientific evidence and updates the 1996 recommendations on this topic. The complete information on which this statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the systematic evidence review on this topic, which is available through the USPSTF Web site (www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse (www.guideline.gov). The complete recommendation statement and the summary of the evidence are also available from the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov).

*For a list of the members of the U.S. Preventive Services Task Force, see the Appendix.

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population. This is a grade I recommendation . (See Appendix Table 1 for a description of the USPSTF classification of recommendations.)

Table Jump PlaceholderAppendix Table 1.  U.S. Preventive Services Task Force Grades and Recommendations

The USPSTF found no evidence that screening for suicide risk reduces suicide attempts or mortality. There is limited evidence on the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify those at high risk(see Clinical Considerations). The USPSTF found insufficient evidence that treatment of those at high risk reduces suicide attempts or mortality. The USPSTF found no studies that directly address the harms of screening and treatment for suicide risk. As a result, the USPSTF could not determine the balance of benefits and harms of screening for suicide risk in the primary care setting.(See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.)

Table Jump PlaceholderAppendix Table 2.  U.S. Preventive Services Task Force Strength of Overall Evidence

The strongest risk factors for attempted suicide include mood disorders or other mental disorders, comorbid substance abuse disorders, history of deliberate self-harm, and a history of suicide attempts. Deliberate self-harm refers to intentionally initiated acts of self-harm with a nonfatal outcome (including self-poisoning and self-injury). Suicide risk is assessed along a continuum ranging from suicidal ideation alone (relatively less severe) to suicidal ideation with a plan (more severe). Suicidal ideation with a specific plan of action is associated with a significant risk for attempted suicide.

Screening instruments are commonly used in specialty clinics and mental health settings. The test characteristics of most commonly used screening instruments (Scale for Suicide Ideation [SSI], Scale for Suicide Ideation—Worst [SSI-W], and the Suicidal Ideation Questionnaire [SIQ]) have not been validated to assess suicide risk in primary care settings. There has been limited testing of the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) screening instrument in a primary care setting.

The brief review of the evidence that is normally included in USPSTF recommendations is available in the complete recommendation and rationale statement on the USPSTF Web site (http://www.preventiveservices.ahrq.gov).

The Canadian Task Force on the Periodic Health Examination (now the Canadian Task Force on Preventive Health Care) found insufficient evidence to recommend for or against routine evaluation of suicide risk and recommends that physicians should remain alert to the possibility of suicide in high-risk patients, particularly if there is evidence of psychiatric disorder, depression, or substance abuse or if the patient has recently attempted suicide or has a family member who committed suicide (1). The American Academy of Pediatrics recommends asking about depression, substance abuse, suicidal thoughts, and other risk factors associated with suicide risk in routine history taking throughout adolescence (2). The American Academy of Child and Adolescent Psychiatry recommends that clinicians be aware of patients at high risk for suicide (older male adolescents or adolescents of either sex, regardless of age, who have a current mental disorder or disordered mental state [such as depression, mania or hypomania, or mixed states], especially when complicated by comorbid substance abuse, irritability, agitation, or psychosis) (3). The American Medical Association Guidelines for Adolescent Preventive Services recommend that all adolescents be asked annually about behaviors or emotions that indicate risk for suicide (4).

Appendix

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, MD, MPH, Chair(University of Washington, Seattle, Washington); Janet D. Allan, PhD, RN, CS, Vice-Chair(University of Maryland Baltimore, Baltimore, Maryland); Paul Frame, MD (Tri-County Family Medicine, Cohocton, and University of Rochester, Rochester, New York); Charles J. Homer, MD, MPH (National Initiative for Children's Healthcare Quality, Boston, Massachusetts); Mark S. Johnson, MD, MPH (University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey); Jonathan D. Klein, MD, MPH (University of Rochester School of Medicine, Rochester, New York); Tracy A. Lieu, MD, MPH (Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts); C. Tracy Orleans, PhD (The Robert Wood Johnson Foundation, Princeton, New Jersey); Jeffrey F. Peipert, MD, MPH (Women and Infants' Hospital, Providence, Rhode Island); Nola J. Pender, PhD, RN (University of Michigan, Ann Arbor, Michigan); Albert L. Siu, MD, MSPH (Mount Sinai Medical Center, New York, New York); Steven M. Teutsch, MD, MPH (Merck & Co., Inc., West Point, Pennsylvania); Carolyn Westhoff, MD, MSc (Columbia University, New York, New York); and Steven H. Woolf, MD, MPH (Virginia Commonwealth University, Fairfax, Virginia).

This list includes members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.

McNamee JE, Offord DR.  Prevention of suicide. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada; 1994:456-67. Accessed athttp://www.ctfphc.org/Full_Text/Ch40full.htmon 18 April 2003.
 
.  Suicide and suicide attempts in adolescents. Committee on Adolescents. American Academy of Pediatrics. (4 Pt 1). Pediatrics. 2000; 105:871-4.
PubMed
 
American Academy of Child Adolescent Psychiatry..  Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2001; 40:7 Suppl24S-51S.
PubMed
 
American Medical Association.  Guidelines for Adolescent Preventive Services (GAPS): Recommendation 20. In: Guidelines for Adolescent Preventive Services (GAPS) Recommendations Monograph. 1997. Accessed athttp://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdfon 18 April 2003.
 

Figures

Tables

Table Jump PlaceholderAppendix Table 1.  U.S. Preventive Services Task Force Grades and Recommendations
Table Jump PlaceholderAppendix Table 2.  U.S. Preventive Services Task Force Strength of Overall Evidence

References

McNamee JE, Offord DR.  Prevention of suicide. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada; 1994:456-67. Accessed athttp://www.ctfphc.org/Full_Text/Ch40full.htmon 18 April 2003.
 
.  Suicide and suicide attempts in adolescents. Committee on Adolescents. American Academy of Pediatrics. (4 Pt 1). Pediatrics. 2000; 105:871-4.
PubMed
 
American Academy of Child Adolescent Psychiatry..  Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2001; 40:7 Suppl24S-51S.
PubMed
 
American Medical Association.  Guidelines for Adolescent Preventive Services (GAPS): Recommendation 20. In: Guidelines for Adolescent Preventive Services (GAPS) Recommendations Monograph. 1997. Accessed athttp://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdfon 18 April 2003.
 

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Summary for Patients

Screening To Identify Primary Care Patients Who Are at Risk for Suicide: Recommendations from the U.S. Preventive Services Task Force

The summary below is from the full reports titled “Screening for Suicide Risk: Recommendation and Rationale” and “Screening for Suicide Risk in Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force.” They are in the 18 May 2004 issue of Annals of Internal Medicine (volume 140, pages 820-821 and pages 822-835). The first report was written by the U.S. Preventive Services Task Force; the second report was written by B.N. Gaynes, S.L. West, C.A. Ford, P. Frame, J. Klein, and K.N. Lohr.

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