U.S. Panel Finds Little Evidence to Support Universal Screening For Suicide

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Experts say that existing screening methods can identify at-risk individuals, but such tools may not help to prevent suicides.

According to the latest government statistics, more than 38,000 people commit suicide each year, so in 2004, the U.S. Preventive Services Task Force (USPSTF) analyzed studies on existing suicide screening methods to determine if it made sense for primary care physicians, who are the most likely to see adults on a regular basis and detect any changes in mental state, to start screening for those at risk of taking their own lives. Studies showed that 38% of adults and 90% of adolescents who committed suicide had visited their primary care physician within the previous year. At the time, however, the panel did not find enough evidence to recommend such universal screening.

And even now, following another review that included 56 studies on suicide screening published since the previous recommendation, the task force found little evidence that widespread screening would lead to a decline in suicide rates. The studies included tools such as the Suicide Risk Screen, which uses a 20-item assessment embedded in a larger questionnaire administered in high schools to students at risk of dropping out, and a method that incorporates three suicide-related items that doctors assess among patients in a primary care setting. While these tools can help to identify at-risk adults, there’s no evidence that such identification actually prevented suicide in adults. For adolescents, the USPSTF concluded that no proven tools to assess risk exist yet.

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The problem, the task force found, was that screening processes varied widely, with some used for high school students ranging considerably in accuracy. Before routine screening can yield benefits in lowering suicide rates, such screens need to become more accurate, and the researchers say that more data is needed to evaluate the efficacy of these screens, particularly among adolescents without a history of mental illness who are at average-risk of suicide.

The screens also aren’t refined enough to determine which at-risk individuals are most likely to harm themselves. While some tests can identify suicidal people relatively accurately, anywhere from 60% to 80% of those who meet these criteria do not actually take their own lives.

There’s also the concern over how patients who show signs of being vulnerable to suicide are treated. The link between screening and treatment, the panel found, was “problematic” due to lack of evidence. “Even in the treatment studies with high-risk populations, few studies had enough statistical power to detect differences in suicide deaths between control and intervention populations. Therefore, the USPSTF concludes that the evidence on the benefits and harms of screening is lacking for adolescents, adults, and older adults,” they write.

The researchers also looked at the data on drug-based treatments for those at highest risk and report that there is minimal evidence to support the effectiveness of these medications in preventing suicide. They found more encouraging data linked to psychotherapy among vulnerable adults; overall, studies showed adults receiving psychotherapy had a 32% decreased risk for committing suicide compared to control groups who received no extra care or medication. However, the same benefit was not shown among adolescents.

Still, the idea of including primary care physicians in efforts to identify and help people at risk of suicide is worth pursuing, say mental health experts. These doctors have the most direct and sustained contact with people about their health, so improving ways to help general and family practitioners  not just recognize but also refer those with mental health issues to effective treatments could eventually lower rates of suicide.

“Screening in primary care should be accompanied by available services,” says Matthew Wintersteen of the Thomas Jefferson University Department of Psychiatry and Human Behavior who has studied suicide screening in primary care settings. “Given the overwhelming abundance of responsibilities held by primary care providers, this requires the mental health community to reach out to them to offer support. Further, primary care providers need additional training in suicide risk assessment, triage, and intervention, if [they are] expected to carry this mission forward.”

The USPSTF conclusion applied only to universal screening, and the task force acknowledged that screening for suicidal tendencies by primary care physicians of a smaller cohort — people with a history of mental illness, post traumatic stress disorder, or childhood trauma who are at greater risk for depression and suicide — could still be useful. “The general population doesn’t commit suicide, it is those with mental illness [who are at higher risk], but most of those people are not in treatment, so primary care physicians need to identify those patients and they need to be screened,” says Dr. Douglas Jacobs, the president and medical director of Screening for Mental Health and the chairperson for the American Psychiatric Association practice guidelines on suicide.

But the panel also called for more research to determine if improved screening, properly done, could ultimately prevent more suicides by identifying those who don’t necessarily possess the most recognized risk factors. “While we simply do not have enough information to demonstrate that screening in asymptomatic youth absolutely saves lives, anyone who has embarked on this mission can recall numerous instances where universally screening youth has led to the detection of an individual at heightened risk for suicide, and this often happens in individuals that primary care providers never would have suspected,” he says. “Thus, indicated screening, or screening only those whom we believe to be at heightened risk, would have missed these youth.”

The USPSTF’s draft recommendation is available here.

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