Objective: To review systematically the literature regarding whether screening for suicide risk in primary care results in decreased morbidity, mortality, or both.
Design and Data Sources: We searched MEDLINE from 1966 to June 30, 2002 using the Medical Subject Headings “suicide” and “suicide, attempted” and combined these terms with predefined strategies to identify screening and treatment studies relevant to our inclusion criteria. We supplemented this information by searching the Cochrane Collaboration Library; using the same search terms in PsycINFO; and hand searching the bibliographies of systematic reviews, relevant original articles, and the 1996 US Preventive Services Task Force review on suicide risk.
Study Selection: We developed an analytic framework consisting of 8 key questions. For screening studies, we included only those studies whose test characteristics were assessed in a primary care setting. For treatment studies, we included randomized controlled trials (RCTs) and cohort studies from primary care or specialty care settings for which suicide completions, suicide attempts, or suicidal ideation were reported.
Data Extraction: Two authors reviewed abstracts and articles independently and excluded those that they agreed clearly did not meet inclusion criteria. The reviewers then examined the full articles of the remaining studies and determined final eligibility by consensus. For the included studies, a primary reviewer abstracted relevant information using standardized abstraction forms, and a secondary reviewer checked the clarity of the information in the evidence tables. Outcomes were categorized as either main (involving suicide attempts or completions) or intermediate (involving suicidal ideation, decreased morbidity, or increased quality of life). We graded the quality of all included articles according to USPSTF criteria.
Data Synthesis: No studies exist addressing the overarching question of whether screening for suicide risk in primary care patients reduces morbidity and mortality; the remainder of the review focused on the linkage questions. We identified 1 screening study involving patients ages 18 to 70 years that provided limited evidence for the accuracy of a suicide screen in the primary care setting. The evidence is fair and mixed that interventions to treat those at risk of suicide reduce the number of suicide attempts or completions. The evidence suggests mild to moderate improvement for interventions addressing intermediate outcomes such as suicidal ideation, decreased depressive severity, decreased hopelessness, or improved level of functioning for those at risk for suicide. We identified no information directly addressing the harms and costs of either screening or treatment.
Conclusions: Because of the complexity of studying the risk of suicide and the paucity of well-designed research studies, there is limited evidence to guide the primary care clinician's assessment and management of suicide risk.