Putting Prevention into Practice

An Evidence-Based Approach

Screening for Suicide Risk



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Am Fam Physician. 2004 Dec 1;70(11):2193-2194.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available at http://www.ahrq.gov/clinic/uspstf/uspssuic.htm.

Case Study

SJ is a 17-year-old boy brought in by his mother for a pre-college physical. His mother pulls you aside and shares a story from the local newspaper about a college freshman who committed suicide after the first week of school. She is anxious because of SJ’s history of “cutting himself” after her divorce years ago. At the time, he was seen by a psychiatrist for this behavior. Since then, he has been doing better, but she is still concerned.

Case Study Questions

  1. Which one of the following statements accurately describes the U.S. Preventive Services Task Force (USPSTF) findings on general population screening for suicide risk?

    • A. There is good evidence that screening by primary care physicians for suicide risk reduces suicide attempts.

    • B. There is good evidence that screening tools accurately identify suicide risk in the primary care setting.

    • C. There is good evidence that treatment of persons at high risk reduces suicide attempts.

    • D. There is good evidence for substantial harms of screening and treatment for suicide risk.

    • E. The USPSTF could not determine the balance of benefits and harms of screening for suicide risk in the primary care setting.

  2. You elicit a further medical, social, and psychiatric history from SJ. Which of the following are risk factors for attempted suicide?

    • A. Alcohol abuse.

    • B. Cutting oneself.

    • C. Adolescent age.

    • D. Major depression.

Answers

1. The correct answer is E. The USPSTF concludes that the evidence is insufficient to recommend for or against routine general population screening by primary care physicians to detect suicide risk. The USPSTF found no evidence that screening reduces suicide attempts or mortality rates. Evidence also is insufficient to determine which treatments, if any, are effective in decreasing suicide attempts in patients who screen positive for suicide risk in the primary care setting. For example, patients with a history of deliberate self-harm who participated in problem-solving therapy showed improvements in intermediate outcomes such as suicidal ideation. However, no intervention in patients with a history of deliberate self-harm has generated reproducible, statistically significant effects on the outcomes of suicide attempts and completion. The USPSTF found no studies that directly addressed the harms of screening and treatment for suicide risk.

Suicide risk screening instruments are used commonly in specialty clinics and mental health settings. However, there is only limited evidence that they are accurate in primary care populations. Furthermore, test characteristics of the most commonly used screening instruments (i.e., Scale for Suicide Ideation, Scale for Suicide Ideation–Worst, and the Suicidal Ideation Questionnaire) have not been validated in primary care settings. One good-quality study evaluated the Symptom-Driven Diagnostic System for Primary Care, a tool for identifying patients with psychiatric illnesses in primary care. One of its items, “feeling suicidal,” was predictive of plans to attempt suicide. However, this item has not been tested independent of the longer instrument.

SJ’s mother provides information that elevates your concern for suicide risk. What is not clear is whether physicians should seek this type of information as part of routine health maintenance, what tools they should use, or what steps will reduce suicide if they identify risk.

2. The correct answers are A, B, C, and D. SJ presents with multiple risk factors for suicide. Adolescents and elderly persons are particularly at risk. The strongest risk factors for attempted suicide include mood disorders or other mental disorders, comorbid substance abuse disorders, history of deliberate self-harm, and history of suicide attempts. SJ’s history of cutting himself is an example of deliberate self-harm. This term refers to intentionally initiated acts of self-harm, including self-poisoning and self-injury, with a nonfatal outcome, regardless of whether suicide was intended. Additional risk factors for attempted suicide in youth are aggressive or disruptive behavior and a history of physical or sexual abuse.

Suicide risk is assessed along a continuum ranging from suicidal ideation alone (relatively less severe) to suicidal ideation with a plan (more severe). Suicidal ideation with a specific plan of action is associated with a significant risk for attempted suicide.

Suicide was the 11th leading cause of death in the United States in 2000. Two thirds of suicidal deaths occur on the first attempt. Although men complete suicide more often than women, women attempt suicide more often than men. Between 3 and 5 percent of persons who have had an episode of deliberate self-harm die by suicide within five to 10 years. More than 90 percent of persons who complete suicide have a psychiatric illness at the time of death, usually depression, alcohol abuse, or both.

JANELLE GUIRGUIS-BLAKE, M.D.

Program director, U.S. Preventive Services Task Force

Center for Primary Care, Prevention, and Clinical Partnerships

Agency for Healthcare Research and Quality

Rockville, Maryland;

CRAIG M. HALES, M.D., M.P.H.

Resident, preventive medicine

Baltimore, Maryland

Johns Hopkins Bloomberg School of Public Health

Baltimore, Maryland

SOURCES

Gaynes BN, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for suicide risk in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:822–35.

Gaynes BN, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for suicide risk. Systematic evidence review no. 32. Prepared by the Research Triangle Institute–University of North Carolina Evidence-based Practice Center under contract no. 290-97-0011. Rockville, Md.: Agency for Healthcare Research and Quality, 2004. Accessed online October 8, 2004, at: http://www.ahrq.gov/clinic/serfiles.htm.

U.S. Preventive Services Task Force. Screening for suicide risk: recommendations and rationale.. Ann Intern Med. 2004;140:820–1.

The case study and answers to the following questions on screening for suicide risk are based on the recommendations of the U.S. Preventive Services Task Force (USPSTF), part of the Put Prevention into Practice program of the Agency for Healthcare Research and Quality (AHRQ). This recommendation was released in 2003. More detailed information on this subject is available in the USPSTF Recommendations and Rationale, the summary of the evidence, and the systematic evidence review on the USPSTF Web site (http://www. ahrq.gov/clinic/uspstfix.htm). The summary of the evidence and recommendation statement are available in print by subscription through the AHRQ Publications Clearinghouse (800-358-9295, e-mail, ahrqpubs@ahrq.gov).

This case study is part of AFP’s CME. See “Clinical Quiz” on page 2067.



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