Primary care physicians are not advised to screen general patients for suicide risk at present, because evidence remains insufficient to properly assess the benefits and harms of suicide screening in this setting, according to a clinical guideline updated by the U.S. Preventive Services Task Force and published May 19 online.
Suicide was the 10th leading cause of death in the United States in 2010, and it ranks among the top 5 causes of death in adolescents and young adults. Nevertheless, currently "there is insufficient evidence to conclude that screening adolescents, adults, and older adults in primary care adequately identifies patients at risk for suicide who would not otherwise be identified on the basis of an existing mental health disorder, emotional distress, or previous suicide attempt," said Dr. Michael L. LeFevre, chair of the USPSTF and professor of family and community medicine at the University of Missouri–Columbia, and his associates (Ann. Intern. Med. 2014;160:719-26).
They emphasized that screening the general population for depression is a separate issue. Depression screening by primary physicians is recommended for all age groups.
Dr. Michael LeFevre
The USPSTF first issued a clinical guideline regarding suicide screening in 2004, when research indicated that 38% of adults – and 50%-70% of adults over age 65 – who committed suicide had visited their primary care provider within 1 month of taking their lives. Later research also showed that nearly 90% of adolescents and children who committed suicide had seen their primary care provider during the preceding year. It was reasoned that primary caregivers might be in a position to intervene and prevent some of these deaths.
At the time of the 2004 Clinical Guideline, the USPSTF concluded that there was insufficient evidence to recommend either for or against clinicians conducting routine screening to detect suicide risk in the general population. After reviewing new data from studies conducted since the last review, the USPSTF again has reached the same conclusion. (The American Academy of Family Physicians published a similar recommendation in January of this year, Dr. LeFevre and his colleagues noted.)
Since the 2004 recommendations, only four studies have assessed the accuracy of screening instruments, and all of them were considered to be only of fair quality. Only one study involved primary care patients of all ages. Two studies involved only adolescents, one involved only the elderly, and one involved depressed patients receiving outpatient mental health services.
Similarly, no studies since the 2004 recommendations have directly assessed whether screening and subsequent referral for treatment improved health outcomes. Few studies have examined treatment efficacy, particularly that of medication; those that have done so were of only fair quality, with small sample sizes, high attrition rates, and extremely low incidences of suicide. The treatments found most effective at reducing the risk of suicide attempts include psychotherapy, specifically cognitive-behavioral therapy and related approaches, Dr. LeFevre wrote. "Although most of these treatments are not customarily administered by primary care providers in the office, patients can be referred to behavioral health providers for them. The primary care provider can play a continued role in the care of these patients by monitoring them during the process, providing follow-up, and coordinating with other care providers," the investigators wrote.
Few studies have assessed the potential harms of screening the general population for suicide, and at this time the possibility cannot be ruled out that a primary caregiver’s inquiring about suicide might actually increase a patient’s distress.
In contrast to the general patient population, certain subsets of patients are at risk for suicide attempts. Primary caregivers "should consider identifying patients with [these] risk factors or those who seem to have high levels of emotional distress and referring them for further evaluation," the USPSTF said.
Risk factors for suicide include:
• Mental health disorders. These include depression, schizophrenia, posttraumatic stress disorder (PTSD), and substance use disorders. "About 87% of patients who die by suicide meet the criteria for one or more mental health disorders." In addition, "depression is probably present in 50%-79% of youths attempting suicide, although it may not always be recognized," the investigators said.
• Older age. Suicide risk begins to rise in both men and women in their 50s and 60s, compared with those in their 30s and 40s, and continues to rise with increasing age. Social isolation, unemployment, grief over a spouse’s death, physical illness or disability, and functional impairment all add to this risk.
• Ethnicity. American Indians and Alaskan natives of all ages have higher-than-average rates of death by suicide. Among adolescents, Hispanic girls are at higher risk than girls of other ethnicities.