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 States3.
Past studies estimated that 38% of adults (50% to 70% of older adults)
visited their primary care provider within 1 month of dying by suicide4. Nearly 90% of suicidal youths were seen in primary care during the previous 12 months5.
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-harm6. 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 ideation7.
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 antidepressants8.
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])(9.
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 9.
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) 9.
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 2.
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 2.
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 2.
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 2.
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 2.
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 2.
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 effective10, 11.
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
suffocation11.
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.htmlThis link goes offsite. Click to read the external link disclaimer).
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.pdfThis link goes offsite. Click to read the external link disclaimer).
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.orgThis link goes offsite. Click to read the external link disclaimer).