1. Based on the paucity of research evidence on the topic, the USPSTF released a statement noting that there is not enough evidence to make recommendations regarding screening or treatment of suicide risk in adolescents, adults or older adults in the primary care setting
Evidence Rating Level: 3 (Average)
Study Rundown: Suicide represents the tenth leading cause of death in the United States, accounting for 37,000 deaths and the loss of over 1.4 million years of potential-life. Psychiatric conditions are associated with increased risk of suicide; depression alone more than doubles the chances that a person will attempt suicide. Rates of suicide were steady in the 1990s but have been increasing over the past decade, particularly in American Indian, Alaskan natives and non-Hispanic whites. Risk factors associated with suicide were found to be numerous and vary based on the age and gender of the individual. It was noted that although many people will have one risk factor, few will attempt suicide and even fewer will die from suicide.
In 2004, USPSTF found that there was insufficient evidence to make a recommendation on screening for suicide risk in physician offices. Based on the findings of this review, the USPSTF stated that there was insufficient data to make any recommendations for or against screening for suicide in the primary care setting. The report notes that despite the paucity of evidence, many major primary care physician associations recommend that physicians either be aware of and/or screen for suicidal risk. Also, the Canadian Task Force on Preventative Health Care found that the current evidence regarding suicide risk screening was poor.
In-Depth [systematic review]: The USPSTF reviewed the limited amount of research available on the potential risk reduction and accuracy of screening for suicide risk. Only four fair quality studies that evaluate the accuracy of screening tools were found and all four used different screening tools. Of the studies, one examined the primary care setting with patients aged 18 to 70, two were in high-risk adolescents in mental health and school settings, and the last one was in a primary care setting with patients over 65 years old. The sensitivity of tools varied from 52% to 100% and the specificity from 60% to 98%. The limited number of studies and inconsistent methods used were insufficient for a recommendation to be made. In addition, there was no evidence that screening for suicide risk reduced attempts or improved outcomes in asymptomatic adolescents and adults. Most of the evidence on screening was done in populations at high-risk of suicide, or even in cohorts that had made previous attempts.
Treatment modalities for suicide prevention include psychotherapy (e.g., cognitive behavioral therapy), enhanced usual care, and medication. Psychotherapy was better than enhanced usual care. Psychotherapy resulted in a 32% reduction in suicide attempts in adults across the 11 studies. One study explored pharmacologic approaches to suicide prevention. It showed that lithium in high-risk patients had a non-significant reduction in suicide rates based on its hazard ratio. Studies on treatment in adolescents were limited to high-risk groups; the effects of treatment on suicide death could not be determined and psychotherapy at 6 and 18 months did not reduce attempts. It is thought that screening for suicide could increase ideation and risk of suicide, though the three small, weak studies on the topic found no significant increases in ideation or attempts in adults at 2 weeks after screening. In the larger high school based studies, there was no statistically significant change in suicidal ideation. Due to the lack of evidence, the USPSTF was unable to make any conclusions regarding screening in adolescents, adults and older adults.
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