“Suicide risk screening in primary care results in very high false-positive rates, according to previous research,” explains Craig J. Bryan, PsyD, ABPP. “More than 95% of patients who screen positive on the Patient Health Questionnaire-9 (PHQ-9) do not attempt or die by suicide. These false positives can lead to misallocation of limited clinical and treatment resources and potentially increase patient exposure to risks associated with unnecessary treatment (eg, medication side effects and additional financial costs). Improving the accuracy of suicide risk screening can therefore help focus treatments and interventions to those patients who have the greatest need.”
For a paper published in the Annals of Family Medicine, Dr. Bryan and colleagues sought to establish whether suicide risk screening can be improved to recognize patients at highest risk. “Our primary aim was to provide evidencebased recommendations for conducting suicide risk screening in primary care,” Dr. Bryan says. “A crucial step toward achieving this aim was to improve the accuracy of suicide risk screening. We positioned research assistants in the waiting rooms of six separate military primary care clinics, where they invited patients to complete an online survey battery during routine clinic visits. We then contacted participating patients 6 and 12 months later to determine if they had engaged in any suicidal behaviors since their initial visit.”
Suicide Screening Approach Not Very Specific or Accurate
Suicide risk screening has traditionally focused on asking patients about their suicidal thoughts, plans, and urges, but this approach is not very specific or accurate, Dr. Bryan notes. Therefore, the study team sought to find new methods for screening that are practical and convenient when used in actual clinical settings. “We assessed the utility of multiple self-report items from the PHQ9 and the Suicide Cognitions Scale (SCS), a relatively new assessment tool that has been shown in multiple studies to differentiate patients who will attempt suicide better than typical screening tools that ask about suicidal ideation,” he says.
A key takeaway, according to the study team, is that screening for suicidal ideation and planning has only limited efficacy, but screening can be improved by supplementing existing approaches with an evidence-based tool like the SCS. Although the SCS does not directly ask about suicidal thoughts and behaviors, it reliably distinguishes patients at highest risk in multiple healthcare settings, including primary care (Table). “Most importantly, the SCS items helped to reduce the false-positive rate associated with screening for suicidal ideation,” Dr. Bryan says. “Our findings suggest that patients at highest risk can be more readily identified with a single SCS item—a very cost-effective and low-burden tool.”
Suicide Ideation Only a Modest Indicator of Patient Risk
Dr. Bryan and colleagues hope that healthcare professionals will begin to move beyond the mental health field’s nearly exclusive focus on suicidal ideation as an indicator of suicide risk. “Suicidal ideation is only a modest indicator of patient risk, but we can improve detection and assessment with fairly simple strategies,” he says.
An important next step, according to the researchers, is linking screening results with treatment outcomes. “Suicide prevention screening may identify vulnerable patients, but screening alone will not prevent suicidal behavior unless patients are linked with effective, evidence-based treatments and interventions,” Dr. Bryan points out. “The most effective interventions are psychotherapies that are typically delivered outside of primary care clinics, but only a small number of mental health clinicians have training to deliver these specialized treatments and patients often face many barriers to specialized care. As a result, we do not yet know if screening in primary care results in patients receiving the treatments that could meaningfully reduce rates of suicidal behavior.”
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