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Gaynes BN, West SL, Ford C, et al. Screening for Suicide Risk [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004 May. (Systematic Evidence Reviews, No. 32.)

1Introduction

Morbidity and Mortality

Suicide is a major public health problem in the United States. In 1999, suicide was the eleventh leading cause of death in the United States, accounting for approximately 30,000 deaths with an age-adjusted rate of 10.7 per 100,000 persons.1 Suicide accounts for 1.3% of total deaths, more than double those due to HIV/AIDS.2 It is the seventh leading cause of years of potential life lost, with a total similar to years lost from perinatal deaths and greater than years lost from diabetes, liver disease, and HIV.1 Annually, approximately 500,000 individuals require emergency room treatment in US medical centers as the result of attempted suicide.3 The public health significance of this problem is underscored by The Surgeon General's Call to Action to Prevent Suicide,3 which proposed completion of a National Strategy to Prevent Suicide.4

The risk of completed suicide is highest for individuals 65 years and older; white men over 85 years have an especially high rate (59/100,000).4 It is also a major factor in adolescent mortality; suicide was the third leading cause of death among persons 15 to 24 years of age (10.3/100,000), following unintentional injuries and homicide.1

Risk factors for all age groups are similar, although particular clinical risk factors are notable for younger populations. The strongest risk factors for attempted suicide in adults are mood disorders and comorbid substance use disorders. The strongest risk factors for attempted suicide in youth include mood disorders and comorbid substance use disorders, but they also involve aggressive or disruptive behaviors and history of physical and sexual abuse.2 In general, hopelessness and a history of previous suicide attempts are strong prospective risk factors for a suicide attempt.5

Suicide completion is closely related to psychiatric illness as well. More than 90% of those with completed suicide have a diagnosable psychiatric illness at the time of death, usually depression, alcohol abuse, or both.6 The US Preventive Services Task Force considered the evidence for screening for depression in a separate review.7 Of note, the standard of care in evaluating an individual with depressive illness includes assessing suicide risk.8

Although the risk factors have been identified and the public health significance of suicide and attempted suicide are clear, the clinical management of suicide risk is complicated. Suicide is a rare event. It has a low prevalence in the general population (0.01%)9 and, despite a 10-fold increase in adults with depression, most depressed patients (99.9%) do not commit suicide.10

As a result, many clinical trials on the management of suicide risk have focused on patients at high risk for suicide, such as those with a history of deliberate self-harm (DSH). DSH, which is understood as intentionally initiated acts of self-harm with nonfatal outcome (including self-poisoning and self-injury), encompasses terms such as attempted suicide and parasuicide.11 DSH is not synonymous with attempted suicide—attempted suicide, understood as a self-initiated act with the intent of ending one's own life, is but a single example of DSH. Still, DSH is a recurrent behavior with important long-term risks. Between 15% and 23% of patients who are seen for DSH will be seen for treatment of a subsequent episode within 1 year,12, 13 with a high risk of repeat DSH in the weeks following an episode.14 Of those with an episode of DSH, 3% to 5% die by suicide within 5 to 10 years.15 Identification of DSH is quite relevant to primary care practice: two-thirds of patients who deliberately harm themselves visit their general practitioner within 12 weeks of the episode.16 Patients with borderline personality disorder are at increased risk of DSH, with groups form psychiatric and primary care settings having similar self-harm profiles.17, 18

Suicidal Ideation

From a clinical perspective, suicide may be a final common pathway with a variety of antecedent causes and an unclear mechanism of disease. Suicidal ideation is generally understood as having thoughts of wanting to end one's own life. Traditionally, clinicians view severity of suicide risk along a continuum, ranging from suicidal ideation alone (relatively less severe) to suicidal ideation with plan (highest severity), the latter of which is a significant risk factor for suicide attempts.19

Suicidal ideation itself, whether over a lifetime, the prior year, or the past month, is remarkably common. In 2001, in a nationally representative sample of US high school students, 23.6% of female and 14.2% of male students reported that they had seriously considered attempting suicide in the previous 12 months; 17.7% of female and 11.8% of male students reported that they had made a specific plan to attempt suicide in the past year.20 In the US general population, 16.3% of young adults (ages 17 to 39 years) describe having suicidal ideation at some point in their life according to results from a national probability survey of individuals.21 Within this group, the prevalence of lifetime suicidal ideation increases to 25% for those with 1 general medical condition, and to 35% for those with 2 or more medical conditions.

In primary care settings, 2.6% of patients receiving general medical care within the past 6 months report having experienced suicidal ideation within the prior year.22 Approximately one-third of those with suicidal ideation meet criteria for major depression, indicating that a substantial proportion present with conditions other than depressive illness. Indeed, major depression (odds ratio [OR] = 10.3), panic disorder (OR = 5.2), an alcohol use disorder (OR = 2.0), and a phobic disorder (OR = 1.6) all were significantly associated with suicidal ideation within the past year.22 Similar 1-month prevalence rates of 2% to 3% of primary care patients expressing suicidal ideation have also been reported.23, 24

Suicide Attempts and Suicide Completions

Suicide attempts, understood as self-initiated acts with the intention of ending one's own life, are less frequent than suicidal ideation, although no annual national data on attempted suicides are available. Of US high school students, 10.9% of the females and 5.7% of the males reported having attempted suicide at least once in the previous 12 months. Of those students, 2.6% reported an attempt that resulted in injury, poisoning, or overdose requiring treatment by a physician or nurse.20 In a national probability survey of US young adults (ages 17 to 39 years), 5.5% of respondents reported a lifetime suicide attempt.21 The relationship between suicide attempts and completions is complicated. First attempts are especially fatal; two-thirds of suicides occur on the first attempt,25 although this varies by age, discussed in detail below. A previous suicide attempt is a strong predictor of completed suicide even when controlling for the predictive effects of mood disorders.5 Still, suicide attempts are substantially more common than completed suicides by a factor between 10 and 20.6 Consequently, data generated from suicide attempters may not generalize to suicide completers.2

Rates of suicide attempts and completions differ by sex. In 1999 suicide was the eighth leading cause of death in men and the 19th leading cause of death in women. In general, men have a higher reported rate of suicide completion than do women; the latter have a higher rate of attempted suicide.26 Men tend to use means that carry greater lethality (such as firearms), whereas women use less lethal means (self laceration and medications);25 nevertheless, suicide by firearms is the most common method used by both male and females who complete suicide.2 In the adolescent age group, girls attempt suicide much more frequently than boys, but male adolescents are 2 to 3 times more likely than adolescent females to complete suicide. In this age group, overdose is the most common method of attempt, whereas firearms, jumping, and hanging are more common methods in completed suicides.19

Rates of suicide attempts and completions also differ by age. The ratio of suicide attempts to suicide completions is substantially higher among youth compared to adults.27 In 1999, 5.9% of deaths among adolescents 10 to 14 years of age (rate = 1.2/100,000), 11.7% of deaths among adolescents 15 to 19 years of age (rate = 8.2/100,000), and 13.5% of deaths among young adults 20 to 24 years of age (rate = 12.7/100,000) were due to suicide.27 The male suicide rate tends to peak in the young adult age groups, then fall and remain relatively constant until after age 65, when rates begin to climb dramatically. Indeed, the prevalence of suicidal ideation appears slightly higher in older primary care28, 29 and general population samples.30 Thus, groups near the beginning and end of the life span seem to be most at risk.31

Finally, suicide behaviors vary widely by race and ethnicity. Nearly three-fourths (72%) of all completed suicides are by white males,2 who have a 2-fold higher risk for suicide compared with black men (19.1/100,000 vs. 10.4/100,000).1 However, other race and ethnicity groups are at particularly high risk, such as Native American males in general31 and Native American youth (both male and female) in particular.32

Role of Primary Care Physicians

Primary care physicians have a key role in the identification and management of this problem. Nearly one-half (47%) of primary care physicians surveyed in Maryland reported that 1 or more of their adolescent patients had attempted suicide in the past year, and 5% reported ever having had an adolescent complete suicide.33 Approximately one-half to two-thirds of individuals who commit suicide visit physicians less than 1 month before taking their lives; 10% to 40% visit in the week before.34–37 Of particular relevance to the role of geriatric physicians, older adults have higher rates of contact with primary care providers within one month of suicide than younger adults.36

Case reports illustrating potential missed opportunities for primary health care professionals to identify patients at risk of suicide shortly before suicide completion are particularly poignant.9, 38

Previous Recommendations

In the 1996 edition of the Guide to Clinical Preventive Services, the US Preventive Services Task Force (USPSTF) reported that there was “insufficient evidence to recommend for or against routine screening by primary care clinicians to detect suicide risk in asymptomatic patients.”39 In addition, the Task Force recommended training primary care clinicians in recognizing and treating affective disorders in order to prevent suicide.

This review from the RTI International - University of North Carolina Evidence-based Practice Center examines evidence about primary care identification and treatment of suicide risk that has been produced since the last edition of the Guide. When possible, we highlight issues that are of particular importance to adolescents.

Cover of Screening for Suicide Risk
Screening for Suicide Risk [Internet].
Systematic Evidence Reviews, No. 32.
Gaynes BN, West SL, Ford C, et al.

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