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Screening for Suicide Risk in Primary Care

A Systematic Evidence Review for the U.S. Preventive Services Task Force

Evidence Syntheses, No. 103

Investigators: , PhD, , MD, MPH, , MPH, , MPA, and , MD, MPH.

Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 13-05188-EF-1

Structured Abstract

Background:

In the United States, the annual burden of suicide is substantial, accounting for almost 37,000 deaths and an estimated 1.4 million years of potential life lost in recent years.

Purpose:

To systematically review evidence for the accuracy of suicide risk screening instruments, the efficacy and safety of screening for suicide risk, and the efficacy and safety of treatments to prevent suicide.

Methods:

We searched MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and the Cumulative Index for Nursing Allied Health to identify literature that was published between January 2002 and July 17, 2012. We also examined the references from the previous review and additional relevant reviews, searched Web sites of government agencies, professional organizations, and other organizations for grey literature, and monitored health news Web sites and journal tables of contents to identify potentially eligible trials. Two investigators independently reviewed identified abstracts and full-text articles against a set of a priori inclusion and quality criteria. One investigator abstracted data into an evidence table and a second investigator checked these data. We conducted random effects meta-analyses to estimate the effect size of suicide prevention interventions on suicide attempts, suicidal ideation, depression, and global functioning. We grouped trials into 11 intervention types among three categories (psychotherapy, medication, and enhanced usual care).

Results:

We included 86 articles representing 56 unique studies. Very limited data showed no clear positive or negative immediate (1 to 14 days) effects of suicide risk screening. Limited data suggest that there are screening instruments with acceptable performance characteristics for adults and possibly older adults; however, positive predictive value was below 40 percent in all cases where sensitivity was 80 percent or higher. No effects of treatment were seen on suicide deaths, though reporting was sparse and trials were underpowered for this rare outcome. Psychotherapy reduced the risk of suicide attempts by 32 percent compared with usual care in adults, but did not show a benefit in adolescents, and four of 11 adolescent trials reporting on suicide attempts showed statistically nonsignificant increases in the risk of suicide attempt by 22 percent or more. Depression was improved in both adults (standardized mean difference [SMD], −0.37 [95% CI, −0.55 to −0.19]) and adolescents (SMD, −0.36 [95% CI, −0.63 to −0.08]), but there was little or no consistent effect on suicidal ideation. Other outcomes were sparsely reported. The single trial of lithium in adults was limited by high attrition. Practice-based interventions in primary care settings targeting older adults showed some benefits; however, a variety of other approaches to enhance usual care showed no consistent benefit.

Conclusions:

Suicide screening is of high national importance. It is very difficult, however, to predict who will die from suicide, and there are many inherent difficulties in establishing the effectiveness of treatment to reduce suicide and suicide attempts. Limited evidence suggests that primary care-feasible screening instruments may be able to identify adults at increased risk of suicide, and psychotherapy targeting suicide prevention can be an effective treatment in adults. Evidence was more limited in older adults and adolescents; additional research is urgently needed.

Contents

Acknowledgments: The authors gratefully acknowledge the following individuals for their contributions to this project: Charlotte Mullican, M.P.H., at AHRQ; David Grossman, M.D., M.P.H., Glenn Flores, M.D., Al Siu, M.D., M.S.P.H., Linda Baumann, Ph.D., R.N., and Bernadette Melnyk, Ph.D., R.N., C.P.N.P./N.P.P., of the U.S. Preventive Services Task Force; and Daphne Plaut, M.L.S., Kevin Lutz, M.F.A., Tracy Beil, M.S., and Heather Baird at the Kaiser Permanente Center for Health Research.

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. HHS-290-2007-10057-I, Prepared by: Kaiser Permanente Research Affiliates Evidence-based Practice Center, Kaiser Permanente Center for Health Research2

Suggested citation:

O’Connor E, Gaynes B, Burda BU, Williams C, Whitlock EP. Screening for Suicide Risk in Primary Care: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 103. AHRQ Publication No. 13-05188-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2013.

This report is based on research conducted by the Kaiser Permanente Research Affiliates Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHS-290-2007-10057-I). The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

1

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

2

3800 N. Interstate Avenue, Portland, OR 97227

Bookshelf ID: NBK137737PMID: 23678511

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