Moutier is a psychiatrist and a leader in the field of suicide prevention.
Suicide is a rising public health crisis in the U.S. While we are seeing robust progress in public awareness, including destigmatizing mental health and treatment, real-world barriers such as lack of access to healthcare and structural inequities remain major impediments to reducing suicide. One arena ripe for change is in health systems — particularly primary care — where there is huge, mostly untapped opportunity to identify those at risk and save lives. Validated screening measures and evidence-based actions clinicians can take to reduce the likelihood of suicidal behavior exist. This is why the U.S. Preventive Services Task Force (USPSTF) finding of insufficient evidence for or against recommending suicide screening in adults is gravely concerning and generally flawed.
Last year, the USPSTF on youth suicide screening found “insufficient evidence to assess the balance of benefits and harms of screening for suicide risk” in pediatric populations. Last month, it found the same for adults. These findings may cast doubt among providers as well as payers on the importance of suicide screening and preventive care at a time when implementation is starting to take off. The American Academy of Pediatrics (AAP), American Foundation for Suicide Prevention (AFSP), and the National Institute of Mental Health (NIMH) released a “Blueprint for Youth Suicide Prevention” that, along with AAP’s preventive periodicity schedule, recommends universal screening for suicide risk in youth 12 years and older. Additionally, the Joint Commission recommends organizations screen individuals with mental health concerns of all ages for suicidal ideation. Evidence supports the practice of universal screening when health systems and staff are prepared to respond. The response should be compassionate, evidence-informed, customized, and collaborative, respecting patient autonomy and families’ input to every extent possible.
I find the USPSTF process of review problematic on several counts. Their methodology is so stringent with narrow criteria for the type of data they can include that it discounts real-world implementation science that actually demonstrates the validity and feasibility of universal screening. Clinicians and health system leaders should not mistake the USPSTF’s findings of “insufficient evidence for or against screening” as a recommendation against screening.
There is consensus in the suicide prevention field that implementing routine or indicated screening is a critical next step for health systems in making significant progress. This consensus is based on the findings below, summarized from suicide research:
Research indicates that suicide risk goes undetected for a large portion of those who die by suicide
A recent systematic review found that 80% of those who died by suicide had contact with primary care in the year preceding their death, and 44% had contact within the previous month. Most of their risk for suicide went undetected. Moreover, 60% of mental healthcare delivery occurs in the primary care setting. These data suggest that primary care visits present an opportune setting where screening with follow-up guidance can potentially save lives.
The validity and effectiveness of screening in primary care and other settings have been established
Because suicide risk often goes unexpressed by patients and largely undetected in primary care settings, suicidal distress is akin to other “silent stealth” health issues like hypertension or diabetes, lying quietly below the surface. For many reasons, the large majority of patients who are at risk may say nothing about it to their primary care provider unless asked. We now have tools that can help.
The feasibility and acceptability of screening and appropriate care steps have been demonstrated in primary care and other settings
Health systems that have implemented universal screening have found it feasible. Less than 5% of outpatients in general medical settings screen positive for suicidal ideation, and for this volume of patients, streamlined steps are manageable. Additionally, patients, families, and health professionals overwhelmingly view screening for suicide as important in medical settings.
Effective interventions for reducing suicide risk exist
Interventions have been developed by suicide researchers in recent years, and evidence for reductions in suicidal behavior and mortality continue to accumulate. Additional treatments, implementation studies, and evidence are invaluable to continue making progress, but we have enough data right now that supports acting rather than waiting for further research.
We need to take steps to address inequities in suicide prevention
Given health disparities for minoritized communities and concerning trends in suicide rates in Black, Hispanic, and other marginalized populations, universal screening would promote equity in preventing suicide.
The USPSTF decision focused on two of the above findings: whether suicide screening has been validated and whether effective interventions exist to reduce suicide risk. The answer to both is affirmative. Yet, USPSTF methodology made it such that the decision ignored critical pieces of evidence.
Has Suicide Risk Screening Been Validated?
Suicide risk screening instruments have demonstrated validity and reliability among youth and adults across both inpatient and outpatient medical settings. The National Action Alliance for Suicide Prevention, NIMH, the Substance Abuse and Mental Health Services Administration, the CDC’s Technical Package for Suicide Prevention, and AFSP all recommend screening in clinical settings as a method to identify people at risk for suicide. The Joint Commission has published a list of evidence-based assessments on its website. These tools include the Ask Suicide-Screening Questions (ASQ), the Columbia-Suicide Severity Rating Scale, and the Suicide Behavior Questionnaire-Revised (SBQ-R). A recent review summarizes the validity of these instruments, and together, they demonstrate effectiveness across urban, rural, and specialized population settings.
Are There Evidence-Based Interventions That Reduce Suicide Risk?
Evidence-based suicide-specific interventions designed for non-mental health settings have been developed and studied with positive findings for reducing suicide risk. These include Safety Planning Intervention, lethal means counseling, caring contacts, and appropriate follow up treatment. This approach showed a 45% reduction in suicidal behavior over 6 months following suicide-related emergency department visits in a VA study. Incorporating feasible ways for these brief interventions to be carried out in non-mental health settings is the key to advancing suicide prevention efforts in health systems. Beyond these brief steps, treatments with robust evidence for reducing suicide risk include cognitive behavioral therapy for suicide prevention, dialectical behavioral therapy, and Safe Alternatives for Teens & Youth (SAFETY), to name a few.
There has never been a more urgent time for implementing suicide screening and effective suicide prevention initiatives in primary care. We have enough data and evidence to act.
Christine Yu Moutier, MD, is chief medical officer at the American Foundation for Suicide Prevention.
If you or someone you know is considering suicide, call the 988 Suicide and Crisis Lifeline.
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