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Screening for Suicide Risk: Recommendation and Rationale

Summary of the Recommendation The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population. This is a grade I recommendation. (See Appendix Table 1 for a description of the USPSTF classification of recommendations.) Appendix Table 1. U.S. Preventive Services Task Force Grades and Recommendations The USPSTF found no evidence that screening for suicide risk reduces suicide attempts or mortality. There is limited evidence on the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify those at high risk (see Clinical Considerations). The USPSTF found insufficient evidence that treatment of those at high risk reduces suicide attempts or mortality. The USPSTF found no studies that directly address the harms of screening and treatment for suicide risk. As a result, the USPSTF could not determine the balance of benefits and harms of screening for suicide risk in the primary care setting. (See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.) Appendix Table 2. U.S. Preventive Services Task Force Strength of Overall Evidence Clinical Considerations The strongest risk factors for attempted suicide include mood disorders or other mental disorders, comorbid substance abuse disorders, history of deliberate self-harm, and a history of suicide attempts. Deliberate self-harm refers to intentionally initiated acts of self-harm with a nonfatal outcome (including self-poisoning and self-injury). 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. Screening instruments are commonly used in specialty clinics and mental health settings. The test characteristics of most commonly used screening instruments (Scale for Suicide Ideation [SSI], Scale for Suicide IdeationWorst [SSI-W], and the Suicidal Ideation Questionnaire [SIQ]) have not been validated to assess suicide risk in primary care settings. There has been limited testing of the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) screening instrument in a primary care setting. The brief review of the evidence that is normally included in USPSTF recommendations is available in the complete recommendation and rationale statement on the USPSTF Web site (www.preventiveservices.ahrq.gov). Recommendations of Others The Canadian Task Force on the Periodic Health Examination (now the Canadian Task Force on Preventive Health Care) found insufficient evidence to recommend for or against routine evaluation of suicide risk and recommends that physicians should remain alert to the possibility of suicide in high-risk patients, particularly if there is evidence of psychiatric disorder, depression, or substance abuse or if the patient has recently attempted suicide or has a family member who committed suicide (1). The American Academy of Pediatrics recommends asking about depression, substance abuse, suicidal thoughts, and other risk factors associated with suicide risk in routine history taking throughout adolescence (2). The American Academy of Child and Adolescent Psychiatry recommends that clinicians be aware of patients at high risk for suicide (older male adolescents or adolescents of either sex, regardless of age, who have a current mental disorder or disordered mental state [such as depression, mania or hypomania, or mixed states], especially when complicated by comorbid substance abuse, irritability, agitation, or psychosis) (3). The American Medical Association Guidelines for Adolescent Preventive Services recommend that all adolescents be asked annually about behaviors or emotions that indicate risk for suicide (4).