Evidence for or against the value of screening for suicide risk in primary care settings must be considered within a complex practice and epidemiological context. Suicide is a rare outcome, even among high-risk groups; this fact alone creates methodological challenges. RCTs, the gold standard for showing efficacy in evidence reviews, ethically cannot include a true placebo arm; consequently, all interventions are being compared with treatment arms that in fact may or may not be effective. Finally, patterns of suicide behaviors are very complex. Although a prior suicide attempt is a strong risk factor for completed suicide, sociodemographic characteristics and behaviors clearly differ across groups of those who attempt suicide, practice repetitive deliberate self-harm, and successfully complete suicide. To focus exclusively on completed suicide reveals dramatic differences in rates and methods across the life span, between males and females, and between different race and ethnicity groups. Current research, in large part, does not address this complexity.
Within this context, we have reviewed literature published since 1966 with the goal of better defining the clinician's role in screening for suicide risk in primary care settings. Despite the public health import of suicide and the Surgeon General's call to action, evidence to guide the primary care clinician's assessment and management of suicide risk is extremely limited. No studies address the overarching question of whether screening for suicide risk in primary care patients improves outcome. Consequently, we must approach this issue by analyzing studies examining the intervening linkage questions.
Very little is known about use of screening instruments for suicide risk in primary care populations. One prospective study identified reasonable test characteristics for persons reporting that they were "feeling suicidal" compared with responses indicating the presence of a plan. This study has not been replicated, nor has the specific question identified ("feeling suicidal") been tested independently of the longer instrument.
Regarding whether interventions for those at risk reduce suicide attempts or completions, the poor generalizability of the studies makes the overall strength of evidence fair, at best, while the results are mixed.25 Although some trends suggest incremental benefit from several interventions, no consistent statistically significant effects have emerged for interventions for which more than 1 study has been done. Of the interventions for which only 1 study has been done, promising interventions included DBT for borderline personality disorder49 and interpersonal psychotherapy for deliberate self-harm.60 These interventions, however, require further confirmation.
We should emphasize that our review did not include all of the available clinical trial literature involving suicide attempts or completions. Some literature has examined the effectiveness of medications, such as lithium, in the prevention of suicide among psychiatric patients with major mood disorders, as reflected in a recent meta-analysis by Tondo et al.72 We excluded these studies because they did not meet our inclusion criteria of controlled trials with adequate comparison groups.
Several studies showed improvement for intermediate outcomes, primarily for persons at high risk for deliberate self-harm. Specifically, meta-analyses of RCTs using problem-solving therapy have shown benefit, as indicated by improved mood, decreased hopelessness, and improvement in problems.26 In addition, 1 RCT involving interpersonal psychotherapy60 and 1 RCT involving DBT34 documented decreased suicidal ideation; finally, 1 cohort study of cognitive-behavioral therapy showed decreased suicidal ideation.65
Our review highlights several important issues involving research on assessing and managing suicide risk. First, the challenge of studying interventions for a rare event is underscored by the fact that, even in a population with a relatively high risk for deliberate self-harm, documenting incremental benefit relative to standard care has been difficult. This difficulty is attributable at least in part to the fact that most studies are underpowered to detect significant differences, thereby increasing the risk for falsely concluding that an effective intervention does not produce a statistically significant benefit, whereas studies that have larger sample sizes typically provide the least intense (and, arguably, likely less efficacious) interventions.35 Future research must consider the feasibility of large, multi-site studies that have sufficient power to identify the benefit of interventions for a substantial health problem that is a relatively rare event.
Second, the generalizability of the available evidence to a primary care population with unidentified suicide risk is poor. The great majority of research has been conducted in psychiatric populations with an already identified risk for suicide rather than among unidentified patients in primary care, who as a group are at lower risk. The existing literature includes only 1 screening study conducted in a primary care setting.10 Only 1 intervention study involved patients recruited from primary care practices,34 and all the intervention studies involved patients identified as being at high risk for harming themselves (and, consequently, are likely to be in treatment with a mental health professional). Only 1 study conducted the intervention in a primary care setting.35 High priorities for future research include examining the test characteristics of instruments used to determine suicide risk in primary care settings, recruiting patients for intervention studies from primary care settings, and testing interventions in primary care settings.
Third, the available studies focused on those with relatively moderate risk for suicide and, for ethical and clinical reasons, excluded patients at the highest risk. Most identified high-risk patients are likely admitted to a psychiatric unit for safety, which may or may not in itself be an effective intervention. Subsequent research should consider how to stratify at-risk primary care patients and target interventions to risk severity.
Fourth, the lack of evidence for incremental benefit from a particular intervention compared with standard care is not equivalent to saying that nothing works. Standard care in many instances may be a successful intervention; it may be "good enough." However, the components of standard care are poorly described in the existing literature and probably vary across studies, making the comparison to the experimental intervention difficult to evaluate. Subsequent research could address this shortcoming by more carefully monitoring and defining standard care.
Fifth, making meaningful conclusions specific to any particular age group is difficult. Available studies were not stratified by age; as a result, drawing conclusions specific to young adults or elderly adults is a challenge. In addition, despite the concern about increased risk for suicide in the elderly, there is a dearth of information to guide evidence-based assessment and management strategies in primary care. Results from the PROSPECT trial will begin to fill this void.36 Subsequent research should involve populations with more clearly defined age groups and analyses stratified by age to allow more meaningful interpretation for specific high-risk age groups.
Sixth, dramatic differences in suicide behaviors among men and women and among different racial and ethnic groups have drawn little attention. A better understanding of these variations may have direct implications for screening and treatment strategies, and they warrant further research.
Seventh, our review is relevant only to those individuals who access clinical care, which means that a large portion of the population may be ignored. Community-based research can presumably address this question.
Finally, we did not find studies meeting our inclusion criteria that addressed whether more adequate treatment of depressed patients or substance-abusing patients will decrease the risk for suicide. We think such a clinically guided approach is key for the primary care physician to balance effectively the public health import of suicide with the real challenge of improving the outcome of a rare event. Approximately 90 percent of patients who completed suicide have a diagnosable psychiatric illness, with the great preponderance having depression or substance abuse. A more feasible means of decreasing suicide may be to focus on the high-risk groups, such as depressed primary care patients for whom routine screening is already recommended,73 and to focus efforts to decrease risk toward improving the adequate management of depression.74 Improving depression management may both improve depressive outcomes and decrease suicide risk. This strategy is reasonable and practical from a clinical perspective and testable from a research perspective. It is also necessary. Assessing suicidal ideation is the standard of care in the evaluation for depression, and routine depression screening will likely identify more patients with suicidal ideation, for which primary care clinicians will need evidence-based management strategies. Retrospective analyses have suggested that educating general practitioners on better identification and treatment of depression may be an effective method of suicide prevention.75 Subsequent prospective clinical trials focusing on primary care are needed to develop this evidence base.
This study was performed by the RTI-University of North Carolina at Chapel Hill (RTI-UNC) Evidence-based Practice Center under contract to the AHRQ, Contract No 290-97-0011, Task Order No. 3, Rockville MD.
We acknowledge the continuing support of David Atkins, M.D., M.P.H., who is the Chief Medical Officer for AHRQ's Center for Practice and Technology Assessment; and Jean Slutsky, P.A., M.S.P.H., AHRQ Task Order Officer for the USPSTF project. We appreciate the considerable support and contributions of members of the RTI International staff: Sonya Sutton, B.S.P.H. and Loraine Monroe. In addition, we thank the staff from the University of North Carolina at Chapel Hill and the Cecil G. Sheps Center for Health Services Research: Carol Krasnov for administrative assistance and coordination and Timothy S. Carey, M.D., M.P.H., Director of the Sheps Center and Co-director of the RTI International-University of North Carolina Evidence-based Practice Center.
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[a] Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC
[b] Department of Obstetrics and Gynecology, School of Medicine, Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
[c] Departments of Pediatrics and Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
[d] Tri-County Family Medicine, Cohocton, NY
[e] Department of Pediatrics, University of Rochester, Rochester, NY
[f] Department of Health Policy and Administration, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, and RTI International, Research Triangle Park, NC
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Source: Gaynes BN, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for suicide risk in adults. A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:822-35.
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Gaynes BN, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for Suicide Risk in Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force. May 2004. Originally in Ann Intern Med 2004;140:822-35. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/suicide/suicidesum.htm
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