Monday, 13 May 2013

Screening to Assess who is at Risk for Suicide Falls Short - Screening to Assess Depression Likely More Constructive in Managing the Risk of Suicide

Annals of Internal Medicine; Published first online April 23, 2013

Suicide and how to prevent it is a hot topic. From the evidence that we have, investing in primary care to improve the detection and treatment of depression would appear to be the place where you get the biggest bang for your buck. Depression is clearly related to suicide, so you would think that screening for suicide in primary care might be helpful in suicide prevention.

However, a recent systematic review of “Screening for and Treatment of Suicide Risk Relevant to Primary Care” in the Annals of Internal Medicine concluded that screening in primary care was of limited usefulness. The authors searched for English language studies only (again!) up to December 2012 which looked at two questions:

“What are the benefits and accuracy of screening instruments in primary care?”

“What is the effectiveness of suicide prevention interventions in primary care or mental health settings?”

Addressing the first question, the authors found five studies which showed no clear short term benefits (within two weeks) of screening and that the accuracy of screening instruments was poor. It should be noted that while the authors talk about screening, this is not screening as it would be applied to other disorders in medicine. In other disorders screening refers to the time between biological onset (say the presence of cancerous cells) and developing symptoms (for example breast lumps).

For screening to be effective, treatment given before symptoms develop needs to be more effective than treatment given after symptoms appear. Clearly if people respond positively to questions about suicide then “symptoms” have already developed, so what the authors are really talking about here is case finding rather than screening. Perhaps more effort should be put into screening people for depression rather than suicide specifically.

The second part of this review looked at interventions in both primary care and mental health settings that might reduce suicide risk. As one of the authors of a study included in this review I was interested to see their conclusions. What the authors found were 49 trials looking at reducing suicidal risk.

Psychotherapies reduced suicide attempts in adults but had little effect on suicidal ideas whereas interventions which tried to enhance usual care had little effect on suicide risk. Nearly all the studies were not done in primary care and recruited patients at high risk of suicide from general hospitals (usually people who presented with self-harm to the emergency department) so the results cannot really inform what to do with people detected as being suicidal in primary care.

So what next? Risk assessment tools do not predict who will commit suicide or repeat self-harm. What are needed are better risk management systems rather than yet another risk assessment form. Screening for depression and offering brief effective treatments – possibly computerized therapies – that can be used in primary care may prove to be a more useful strategy than simply screening to find “suicidal” people.

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