Suicide Risk: Screening -- Adolescents, Adults, and Older Adults


General

Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Specific Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care.

Frequency of Service

No information available.

Risk Factor Information

No information available.


Clinical

Patient Population Under Consideration

This recommendation applies to adolescents, adults, and older adults in the general U.S. population who do have an identified psychiatric disorder.

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

In 2010, suicide accounted for more than 1.4 million years of potential life lost before age 85 years, or 4.3% of total years of potential life lost in the United States. Past studies estimated that 38% of adults (50% to 70% of older adults) visited their primary care provider within 1 month of dying by suicide. Nearly 90% of suicidal youths were seen in primary care during the previous 12 months.

Given that most persons who die by suicide have a psychiatric disorder and many have been seen recently in primary care, primary care clinicians should be aware of psychiatric problems in their patients and should consider asking these patients about suicidal ideation and referring them for psychotherapy, pharmacotherapy, or case management. The USPSTF recommends that primary care clinicians screen adolescents and adults for depression when appropriate systems are in place to ensure adequate diagnosis, treatment, and follow-up. Primary care clinicians should also focus on patients during periods of high suicide risk, such as immediately after discharge from a psychiatric hospital or after an emergency department visit for deliberate self-harm. Recent evidence suggests that interventions during these high-risk periods are effective in reducing suicide deaths.

Potential Harms

Evidence on the potential harms of screening for suicide risk is insufficient.

Costs

The monetary cost of screening for suicide risk is minimal. Additional time would be needed in the primary care visit to accommodate screening.

Current Practice

In a study of U.S. primary care providers, suicide was discussed in 11% of encounters with patients who had (unbeknown to their providers) screened positive for suicidal ideation. Similarly, 36% of U.S. primary care physicians explored suicide in encounters with standardized patients presenting with major depression or adjustment disorder or those who sought antidepressants. Less than one quarter of surveyed primary care pediatricians or family practice physicians in Maryland reported that they frequently or always screened adolescents for suicide risk factors.

Risk Factors for Suicide

Although evidence to determine whether the general asymptomatic population should be screened for suicide risk is inadequate, providers should consider identifying patients with risk factors or those who seem to have high levels of emotional distress and referring them for further evaluation.

Suicide risk varies by age, sex, and race or ethnicity. In men, the greatest increases in suicide rate were in those aged 50 to 54 years (49.4% [from 20.6 to 30.7 deaths per 100,000]) and those aged 55 to 59 years (47.8% [from 20.3 to 30.0 deaths per 100,000]). In women, the suicide rate increased with age, and the largest percentage increase was in those aged 60 to 64 years (59.7% [from 4.4 to 7.0 deaths per 100,000]).

American Indians and Alaskan natives aged 14 to 65 years and non-Hispanic white persons older than 18 years have higher-than-average rates of suicide death, and the risk among non-Hispanic white persons continues to increase after age 75 years. The highest rates are seen in American Indians and Alaskan natives aged 19 to 24 years and non-Hispanic white persons older than 75 years. Among adolescents, Hispanic females are at especially high risk for attempting suicide.

The greatest increases in suicide rate from 1999 to 2010 by racial or ethnic population in men and women overall were among American Indians and Alaskan natives (65.2%) and white persons (40.4%). Among American Indians and Alaskan natives, the suicide rate in women increased by 81.4% (from 5.7 to 10.3 deaths per 100,000) and the rate in men increased by 59.5% (from 17.0 to 27.2 deaths per 100,000). Among white persons, the rate in women increased by 41.9% (from 7.4 to 10.5 deaths per 100,000) and the rate in men increased by 39.6% (from 24.5 to 34.2 deaths per 100,000).

Increased risk is also associated with the presence of a mental health disorder, such as depression, schizophrenia, posttraumatic stress disorder, and substance use disorders. About 87% of patients who die by suicide meet the criteria for 1 or more mental health disorders. A lifetime history of depression more than doubles the odds of a suicide attempt in U.S. adults, and depression is probably present in 50% to 79% of youths attempting suicide, although it may not always be recognized.

Other important risk factors for suicide attempt include serious adverse childhood events; family history of suicide; prejudice or discrimination associated with being lesbian, gay, bisexual, or transgender; access to lethal means; and possibly a history of being bullied, sleep disturbances, and such chronic medical conditions as epilepsy and chronic pain. In males, socioeconomic factors, such as low income, occupation, and unemployment, are also related to suicide risk.

In older adults, additional risk factors, such as social isolation, spousal bereavement, neurosis, affective disorders, physical illness, and functional impairment, increase the risk for suicide. Risk factors of special importance to military veterans include traumatic brain injury, separation from service within the past 12 months, posttraumatic stress disorder, and other mental health conditions.

Individual risk factors have limited ability to predict suicide in an individual at a particular time. A large proportion of Americans have 1 of these risk factors; however, only a small proportion will attempt suicide, and even fewer will die by it.

Screening Tests

The reviewed studies used various screening tools. One example is the Suicide Risk Screen, a 20-item screening instrument embedded in a broader self-report questionnaire administered in high schools to youths at risk for dropping out of school. Another tool consists of 3 suicide-related items (“thoughts of death,” “wishing you were dead,” and “feeling suicidal” within the past month) targeting primary care patients aged 18 to 70 years with scheduled appointments.

Sensitivity and specificity of screening tools generally ranged from 52% to 100% and from 60% to 98%, respectively. The instruments showed a wide range in accuracy, but data were limited and no instruments were examined in more than 1 study.

Treatment

Most effective treatments to reduce risk for suicide attempt include psychotherapy. The most commonly studied psychotherapy intervention was cognitive behavioral therapy and related approaches, including dialectical behavior therapy, problem-solving therapy, and developmental group therapy. Other approaches included psychodynamic or interpersonal therapy. 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.

Other Approaches to Prevention

In addition to approaching the problem of suicide from an individual level in primary care, approaches are being implemented at community, regional, and national levels. In the health care system, laws requiring coverage parity between mental and physical health disorders will give more persons the ability to access care for psychiatric problems associated with suicide, such as depression. Efforts to coordinate care among programs that address mental health, substance use, and physical health can also increase access to care. Activities that have been shown to be correlated with lower suicide rates in other countries include detoxification of domestic gas in the United Kingdom and discontinuation of the use of highly toxic pesticides in Sri Lanka. These actions were associated with 19-33% and 50% reductions in suicide, respectively, providing evidence that engineering controls can be effective. Such activities as installing barriers at frequent suicide jump spots may also be effective.

On an individual level, patients with a history of suicide attempt or suicidal ideation should not have easy access to means that may be used in suicide attempts, such as firearms or other weapons, household chemicals or poisons, or materials that can be used for hanging or suffocation.

Useful Resources

The USPSTF recommends that physicians screen adolescents and adults for depression when appropriate systems are in place to ensure adequate diagnosis, treatment, and follow-up (available at www.uspreventiveservicestaskforce.org).

The Community Preventive Services Task Force has related recommendations on collaborative care approaches to managing depression, mental health parity policy, and home-based depression care for older adults (available at www.thecommunityguide.org/mentalhealth/index.html).

In 2012, the U.S. Surgeon General and the National Action Alliance for Suicide Prevention released the National Strategy for Suicide Prevention, which includes goals and objectives for action (available at www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf).

The Suicide Prevention Resource Center, supported by the Substance Abuse and Mental Health Services Administration, offers various resources on suicide prevention (available at www.sprc.org). 


Other Considerations

Research Needs and Gaps

More research on the epidemiology and natural history of suicide risk is needed. Persons who attempt suicide and survive and those who die by suicide are overlapping populations. Some individuals die on their first attempt and may never be seen in primary care, whereas others may repeat nonfatal attempts and never die or die after multiple attempts. More research to understand these subgroups and to determine who accesses primary care is needed.

Several key areas need further research to improve the evidence base for screening for suicide risk in primary care. For screening to be effective, more information on the performance characteristics of screening tests, particularly in average-risk adolescents,n is needed. More information is needed to determine whether more individuals with screen-detected suicidal ideation could be helped before they act. Studies examining the benefits and potential harms of targeted versus general screening would also be helpful. The possibility of incorporating technology into large-scale screening studies should also be explored.

Treatment studies in populations with screen-detected suicide risk in all age groups are needed. Targeting persons at high risk, such as American Indians and Hispanic persons, may help determine whether tailored therapies are more effective in these populations. It is critical that more investigations on the benefits and risks of interventions targeting average- and high-risk adolescents be conducted. Trials including interventions aimed at parents have shown some promise and should be further explored.

It would also be valuable to replicate trials in adults that focus primarily on the process of care (including quality of care and patient adherence) rather than the specific content of treatment sessions because trials on the latter have shown moderate-sized but statistically nonsignificant effects.

Investigating ways to link clinical and community resources might also lead to other possible methods to help patients at risk for suicide.

Rationale

Importance
Suicide was the 10th leading overall cause of death in the United States in 2010 and 1 of the 5 leading causes of death for children, adolescents, and adults aged 10 to 54 years. Rates of suicide attempts and deaths vary by sex, age, and race or ethnicity. Psychiatric disorders and previous suicide attempts increase suicide risk.

Detection
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 based on an existing mental health disorder, emotional distress, or previous suicide attempt.

Benefits of Detection and Early Intervention or Treatment
Evidence on the benefits of screening adolescents, adults, and older adults for suicide risk in primary care is inadequate.  

Evidence is inadequate on whether interventions reduce suicide risk in patients identified through primary care screening or similar methods; most evidence for treatment effectiveness is in high-risk populations who were not discovered through screening, such as persons who presented to an emergency department because of a suicide attempt.

Harms of Detection and Early Intervention or Treatment
Evidence on the possible harms of screening adolescents, adults, and older adults for suicide risk is inadequate.

USPSTF Assessment
The USPSTF concludes that the evidence on screening for suicide risk in primary care is insufficient and that the balance of benefits and harms cannot be determined.


Others

Several groups have made recommendations or commented on screening patients for suicide risk. The American Academy of Child and Adolescent Psychiatry recommends that clinicians be aware of patients at high risk for suicide. The American Academy of Pediatrics recommends that pediatricians ask questions about mood disorders, sexual orientation, suicidal thoughts, and other risk factors associated with suicide during routine health care visits. The American Medical Association states that all adolescents should be asked annually about behaviors or emotions that indicate recurrent or severe depression or risk for suicide and that physicians should screen for depression or suicidal risk in those with risk factors, such as family dysfunction, declining school grades, and history of abuse. The American College of Obstetricians and Gynecologists recommends that all adolescents be screened annually for emotions and behaviors that indicate recurrent or severe depression and thoughts of killing or harming themselves. In addition, suicide risk and depressive symptoms are included as part of the College's annual well-woman visit evaluation and counseling recommendations for females aged 13 to 65 years or older. The American Academy of Family Physicians concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. The recommendation of the Canadian Task Force on Preventive Health Care also mirrors the 2004 USPSTF recommendation in that it found poor evidence to include or exclude routine evaluation of suicide risk during a periodic health examination.


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