Screening for suicide
Posted on May 28, 2014 by Aaron Sacheli
Should primary care physicians screen for suicide risk?
A new recommendation from the U.S. Preventive Services Task Force (USPSTF) has been released regarding suicide risk screening at the primary care level. The USPSTF has concluded that there is still insufficient evidence to assess the balance and benefits of suicide screening.
The evidence-based experts
The USPSTF serves as an independent, volunteer panel of national experts in prevention and evidence-based medicine. Through their analysis of peer-reviewed evidence, their goal is to assign recommendations directed to primary care physicians on whether a preventative service is suited for a patient’s need. In essence, they help set guidelines to assist U.S. primary care doctors in delivering focused and effective clinical care.
In this recommendation, they wanted to address the issue of suicide risk when encountered at the primary care level. Clearly, a national issue worth the attention:
“Suicide was the 10th leading overall cause of death in the United States in 2010 and 1 of the 5 leading causes of death for children, adolescents, and adults aged 10 to 54 years.”
Their objective – should primary care physicians routinely screen for suicide risk in adolescents, adults and older adults, in an attempt to identify those at risk of suicide, who may not otherwise be identified?
A balance of benefits and harms
An opportunity for benefit
Suicide is potentially preventable. The task force cites statistics that within 1 month prior to suicide, 38% of adults had visited their primary care provider. Among adolescents who committed suicide, 90% had seen their primary care doctor within the past year.
How do we screen?
Screening tools have been developed, including self-report questionnaires, and focused questions to be used during a clinical encounter.
“Sensitivity and specificity of screening tools generally ranged from 52% to 100% and from 60% to 98%, respectively.”
What’s the harm?
Currently, the USPSTF states the harms for suicide screening are insufficiently known. It is known, however, that the estimated monetary cost of the screening is minimal. Potential harms that have been studied include a potential increase in ideation or suicide attempts after screening, and distress from participating in the screening questionnaire. Though, both of these are largely in the adolescent population.
The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. This is consistent with the USPSTF previous 2004 recommendation on the same topic.
This evidence was given an “I statement.”
The USPSTF grades its recommendations from A “recommended with substantial net benefit” to D “recommends against”, and an “I statement” that concludes there is insufficient evidence to balance benefit against harms of the screening practice.
What does this change?
Without a conclusive statement for or against suicide screening, it is unlikely that current clinical practice will change at this moment. What is acknowledged though, is that clinical decisions involve more than guidelines and evidence alone, and that recommendations directed toward physicians in clinical practice should not serve as the sole factor for suicide risk screening.
The clinical future
With two consistent “I statements” from the USPSTF on this topic over the last 10 years, we are likely to see more research focused on obtaining evidence on suicide risk in primary care. As stated in their recommendation:
“For screening to be effective, more information on the performance characteristics of screening tests, particularly in average-risk adolescents, is needed. More information is needed to determine whether more individuals with screen-detected suicidal ideation could be helped before they act.”
Links & References:
Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care: U.S. Preventive Services Task Force Recommendation Statement. Michael L. LeFevre, MD, MSPH, on behalf of the U.S. Preventive Services Task Force. Ann Intern Med. 2014;160(10):719-726. doi:10.7326/M14-0589
You can read more about the U.S. Preventive Services Task Force and their recommendations
Featured image: Depression – artist’s interpretation, Wellcome Image Library. B0003566 Adrian Cousins