Note: This draft Recommendation Statement is not the final recommendation of the U.S. Preventive Services Task Force. This draft is distributed solely for the purpose of pre-release review. It has not been disseminated otherwise by the USPSTF. It does not represent and should not be interpreted to represent a USPSTF determination or policy.
This draft Recommendation Statement is based on an evidence review that was published on April 23, 2013 (available at http://www.uspreventiveservicestaskforce.org/uspstf13/suicide/suicideart.htm).
The USPSTF makes recommendations about the effectiveness of specific clinical preventive services for patients without related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service, and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
This draft Recommendation Statement is available for comment from April 23 until May 21, 2013, at 6:00 PM ET. You may wish to read the entire Recommendation Statement before you comment. A fact sheet that explains the draft recommendations in plain language is available here.
Screening for Suicide Risk in Adolescents, Adults, and Older Adults: U.S. Preventive Services Task Force Recommendation Statement
Summary of Recommendation and Evidence
The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in a primary care setting.
This is an I statement.
Go to the Clinical Considerations section for additional information about suggestions for practice regarding the I statement.
Suicide was the 10th leading overall cause of death in the United States in 2009. Rates of suicide attempts and deaths vary by sex, age, and race/ethnicity. Psychiatric disorders and previous suicide attempts increase suicide risk (1, 2).
There is insufficient evidence to conclude that screening adolescents, adults, and older adults in primary care adequately identifies patients at risk for suicide who would not otherwise be identified based on an existing mental health disorder, emotional distress, or previous suicide attempt.
Benefits of Detection and Early Intervention/Treatment
There is insufficient evidence on the benefits of screening adolescents, adults, and older adults for suicide risk in the primary care setting.
Evidence is inadequate on whether interventions reduce suicide risk in patients identified through primary care screening or comparable methods; most evidence for treatment effectiveness is in very high-risk populations who were not discovered through screening, such as those who present to an emergency department because of a suicide attempt.
Harms of Detection and Early Intervention/Treatment
There is insufficient evidence regarding the possible harms of screening adolescents, adults, and older adults for suicide risk.
The USPSTF concludes that the evidence is lacking on screening for suicide risk, and the balance of benefits and harms cannot be determined.
Patient Population Under Consideration
This recommendation applies to adolescents, adults, and older adults in the general U.S. population without an identified psychiatric disorder.
Suggestions for Practice Regarding the I Statement
Preventable burden. In 2007, suicide accounted for over 1.3 million years of potential life lost (YPLL) before age 85 years, which is nearly 4% of the total YPLL in the United States (3). Suicide is one of the top five leading causes of death for teens and adults ages 10 to 54 years (1). Past studies estimate that 38% of adults (50% to 70% of older adults) visited their primary care provider within 1 month of committing suicide (4). Nearly 90% of suicidal youth were seen in primary care during the previous 12 months (5). Given that most people who die from suicide have a psychiatric disorder and many have been seen recently in primary care, clinicians should consider asking these patients about suicidal ideation and referring them for psychotherapy and/or case management.
Potential harms. There is insufficient evidence on the potential harms of screening for suicide risk.
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 (unbeknownst to their providers) screened positive for suicidal ideation (6). Similarly, 36% of U.S. primary care physicians explored suicide in encounters with standardized patients portraying major depression or adjustment disorder, or those who sought out antidepressants (7). 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.
Assessment of Risk
Suicide risk varies by age, sex, and race/ethnicity. The following groups have rates of suicide deaths that are generally above the average rate: American Indian/Alaskan Natives ages 14 to 65 years and nonHispanic whites older than age 18 years, whose risk continues to rise past the age of 75 years. The highest rates are seen in American Indian/Alaskan Natives ages 19 to 24 years and nonHispanic whites older than age 75 years. Among adolescents, Hispanic girls are at especially high risk for attempting suicide (8).
Elevated risk is also associated with the presence of a mental health disorder, such as depression, schizophrenia, posttraumatic stress disorder (PTSD), and substance use disorders. About 87% of patients who die as a result of suicide meet the criteria for one or more mental health disorders before their death. A lifetime history of depression more than doubles the odds of a suicide attempt among U.S. adults, and depression is likely present in 50% to 79% of youth attempting suicide, though it may not always be recognized. Other important risk factors for suicide attempts include serious adverse childhood events; lesbian, gay, bisexual, and transgender status; access to lethal means; and possibly a history of being bullied, sleep disturbances, and chronic medical conditions such as epilepsy and chronic pain. In males, socioeconomic factors such as low income, occupation, and unemployment are also related to suicide risk (8).
Among older adults, additional risk factors such as social isolation, spousal bereavement, neurosis, affective disorders, physical illness, and functional impairment all 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, PTSD, and other mental health conditions (8).
Although there is inadequate evidence to determine if screening for suicide in the general asymptomatic population should or should not be done, providers should consider identifying patients with risk factors or who appear to be experiencing high levels of emotional distress and referring them for further evaluation (8).
The screening tools used in the studies reviewed varied. One example is the Suicide Risk Screen, which uses a 20-item screener embedded in a broader self-report questionnaire administered in high schools to youth at risk of dropping out. Another tool consists of three suicide-related items targeting primary care patients with prescheduled appointments. The sensitivity and specificity of tools generally ranged from 52% to 100% and 60% to 80%, respectively. The instruments showed a wide range in accuracy, but data were very limited, and no instruments were examined in more than one study (8).
Most effective treatments to reduce suicide risk include psychotherapy. The most commonly studied psychotherapy intervention was cognitive behavioral therapy (CBT) and related approaches, including dialectical behavior therapy (DBT), problem-solving therapy, and developmental group therapy. Other nonCBT approaches included psychodynamic or interpersonal therapy. Whereas most of these specific treatments are not customarily administered by the primary care provider in the office, patients can be referred for these therapies. The primary care provider can play a continued role in the care of these patients by monitoring them during the process, providing followup, and coordinating with other care providers (8).
Other Approaches to Prevention
In addition to approaching the problem of suicide from an individual level in primary care, other approaches are being implemented at community, regional, and national levels. In the health care system, laws requiring coverage parity between mental health and physical health disorders will give more people the ability to access care for psychiatric problems associated with suicide, such as depression. Efforts to coordinate care between programs that address mental health, substance use, and physical health can also increase access to care. Global 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 highly toxic pesticides in Sri Lanka. These actions were associated with 30% and 50% reductions in suicide, respectively, providing evidence that engineering controls can be effective. Activities such as installing barriers at frequent suicide jump spots may also be effective (9, 10).
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 and other weapons, household chemicals or poisons, or materials that can be used for hanging or suffocation (9).
The USPSTF recommends that physicians screen adolescents and adults for depression when appropriate systems are in place to ensure adequate diagnosis, treatment, and followup (available at http://www.uspreventiveservicestaskforce.org). Additionally, in 2012, the 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 http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf).
The Community Preventive Services Task Force also has related recommendations regarding collaborative care approaches to managing depression, mental health parity policy, and home-based depression care for older adults (available at http://www.thecommunityguide.org/mentalhealth/index.html).
Research Needs and Gaps
A number of key areas need further research to improve the evidence base for screening. For screening to be effective, more information is needed on the performance characteristics of screening tests, particularly among average-risk adolescents. Studies examining the benefits and potential harms of targeted versus general screening would also be helpful. The possibility of incorporating technology into large-scale screening studies should also be explored.
Treatment studies in screen-detected populations are needed in all age groups. Targeting those at high risk, such as Native Americans and Hispanics, may be important to determine if there are tailored therapies that are more effective in these populations. It is critical that more investigations be conducted on the benefits and risks of interventions targeting both general and high-risk adolescents. Trials including interventions aimed at parents have shown some promise and should be further explored.
It would also be valuable to replicate trials in adults that focus primarily on the process of care (including quality of care and patient adherence), rather than the specific content of the treatment sessions, as the latter have shown moderate-sized but statistically nonsignificant effects.
Investigating ways to link clinical and community resources might also lead to other possible methods to help patients at risk for suicide.
Burden of Disease
In 2009, suicide was the 10th leading cause of death in the United States, leading to almost 37,000 deaths, for a rate of 11.8 deaths per 100,000 individuals (1). Although suicide rates in the United States held steady from 1990 through the early 2000s, the rates have generally been increasing over the last decade, particularly between 2005 and 2009 (11).
Scope of Review
In 2004, the USPSTF concluded that the evidence was insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population, and issued an I statement, given that there was no evidence at that time that screening for suicide risk reduced suicide attempts or mortality. The USPSTF noted that there was limited evidence on the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify individuals at high risk. The USPSTF also found insufficient evidence that treatment of individuals at high risk reduces suicide attempts or mortality. The USPSTF found no studies that directly addressed the harms of screening and treatment for suicide risk. As a result, the USPSTF could not determine the balance of benefits and harms of screening for suicide risk in the primary care setting.
In updating the 2004 recommendation, the USPSTF reviewed a systematic review of current evidence on screening adolescents, adults, and older adults for suicide risk in a primary care setting.
Accuracy of Screening Tests
The USPSTF reviewed four studies that evaluated the accuracy of screening instruments to identify individuals at increased risk for suicide. Of these, two were conducted in adolescent populations that were considered at increased risk for suicide. One was conducted in an outpatient mental health setting in patients who had a prior diagnosis of depression (12). The second was conducted in a school setting and consisted of a questionnaire administered by research staff to students at risk for school dropout (13). A single additional study involved primary care patients age 65 years or older (14), and the final study involved primary care patients ages 18 to 70 years (15).
Each study used a different tool to screen patients for increased risk of suicide. All four studies were considered to be fair quality. A strength of these studies was that they each applied the same reference standard to all screened participants and recruited the sample from a single identified population. As mentioned previously, however, neither of the adolescent studies was conducted in a primary care setting and both recruited participants who were already at increased risk of suicide. Only one of the four studies reported that the reference test was independent of the screening test (14). An additional concern was the lag time between the screening and the reference tests, with only one study conducting both the screening and reference tests within 24 hours of each other. Lag times for other studies were either not reported or ranged from 2 to 35 days.
Effectiveness of Early Detection
The USPSTF found no direct evidence that screening for suicide risk is associated with improved health outcomes in asymptomatic adolescents or adults. Although studies evaluating screening were more likely to be conducted in a primary care population, studies assessing the effectiveness of treatment were predominantly conducted in patients known to be at high risk. In particular, many treatment studies were of patients with previous suicide attempts or who had a history of mental illness, such as borderline personality disorder or depression. The proportion of patients in control groups with a history of suicide attempts in treatment studies ranged from 11% to 68%, evidence that the study populations were at high risk for suicide (8).
Three broad treatment approaches to suicide prevention have been evaluated: psychotherapy, enhanced usual care (approaches designed to improve the quality or format of recommended treatment, or improve patient adherence to usual care), and medications. Of those, psychotherapy providing specific treatment approaches showed better outcomes than enhanced usual care, and very few studies addressed medications. Suicide attempts were reduced by a pooled average of 32% in 11 psychotherapy trials in adults. Interventions that focused on enhancing usual care showed little impact on suicide deaths, suicide attempts, or related outcomes. A single large trial of older primary care patients reported a 20% reduction in the relative risk of a combined outcome of suicide attempts and ideation; however, the study involved education and training of a volunteer sample of general practitioners, who may have been more motivated to improve their practice than a random sample of general practitioners (16).
Minimal data are available on the effectiveness of using medications in preventing suicidal behavior. The lone study was a short-term, fair-quality trial that assessed the use of lithium (17). The study reported hazard ratios that suggest a possible benefit for suicide attempts but were not statistically significant. There was a statistically significant lower rate of suicide deaths per patient-year in the intervention group; however, the study had high attrition rates and there were only three suicide deaths.
There is a limited evidence base for treatment interventions in adolescents. Study populations primarily consist of participants at high risk for suicide, most with recent suicide attempts or acute suicidal ideation. The effect of treatment to prevent suicide on suicide deaths could not be determined, as there was only one death in any of the three trials that reported this outcome. Suicide attempts were not reduced with psychotherapy treatment at 6 to 18 months. The confidence interval on the pooled effect was wide and crossed zero, ranging from a 25% reduction in risk to a 31% increase. Therefore, the possibility of harm or benefit cannot be ruled out with the existing evidence on psychotherapy trials (8).
The one enhanced usual-care study in adolescents also had a population of high-risk patients, all of whom had a history of suicide attempts, threats, or ideation (18). Although the study was rated fair quality, the groups were not entirely comparable at baseline, and retention was somewhat variable. The study did not find any differences between the groups in suicidal ideation, depression, or hopelessness at the 12-month followup, thus providing no evidence of treatment benefit.
Potential Harms of Screening
Three studies reported on the potential adverse effects of screening. One was a trial of depressed adults in four primary care practices in the United Kingdom. The other two were conducted in high school settings.
In the adult study, no statistically significant increases in suicide attempts or ideation were seen at 2 weeks following screening (19). The trial, however, had a relatively small sample size (n=443) and limited power. Additionally, differential ascertainment may have biased the results, as a higher proportion of participants who were screened withdrew consent for followup (6.6% of screened vs. 2.2% of unscreened).
In both high school-based studies, students were randomly assigned to screening for suicide risk on one of two occasions, 1 to 2 days apart. The items used to screen for suicide risk were embedded in an instrument that addressed broader mental health issues. The larger trial (n=2,342), conducted in six high schools in New York, randomized the students at the classroom level (20). No immediate increase was reported in students reporting suicidal ideation or mean suicidal ideation scores.
The second study, conducted in Australia, was much smaller (n=308) and found no differences between the two groups in anger, confusion, depression, fatigue, or tension, based on the Profile of Mood States, immediately after being screened for suicide risk or completing other mental health items (21). “Vigor” was the only characteristic that was reported to be higher in those screened. After both groups had completed the suicide risk screening items, 8.9% reported that the suicide-related items were moderately or very distressing, whereas 31.5% found them to be “a little distressing.”
Because of the paucity of data and study limitations, the possibility of short-term harms from participation in suicide screening itself cannot be dismissed. Other potential harms of screening include harms that may result from treatment in screen-detected individuals after referral.
Very few treatment trials among adults reported any adverse events. One CBT trial reported that none of the suicide attempts were thought to be a result of study participation (22). In a study of a video-based problem-solving intervention, none of the participants withdrew because of worsening symptoms (23). A study of writing as a means for reducing suicidal ideation reported that three participants asked to speak with a supervisor because they had become upset after writing or because their writing reflected current suicidal ideation (24). Not enough data were available to draw conclusions on whether harms occurred due to screening in adults.
Of the 11 adolescent psychotherapy treatment trials reporting suicide attempts, four noted nonstatistically significant increases in suicide attempts, ranging from 22% to 113% (25-27). One was a very small trial that had few events and very wide conference intervals associated with the effect; however, the others likely had enough events to represent stable, though still statistically nonsignificant, effects. Thus, the possibility of harm due to treatment cannot be ruled out in currently or recently suicidal adolescents undergoing therapy.
In the one medication trial that evaluated treatment with lithium, a higher percentage of participants in the treatment group withdrew from the study due to adverse events compared with the placebo group (13% vs. 2%), though the statistical significance was not reported and overall dropout rates were similar between the two groups (17).
Estimate of Magnitude of Net Benefit
The USPSTF found inadequate evidence on the diagnostic accuracy of screening tests for suicide risk, the effectiveness of treatment, and the harms of screening or treatment. In attempting to build a chain of indirect evidence from screening to treatment to beneficial health outcomes, the link between screening and treatment is problematic, due to the poor fit between the populations in the two bodies 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.
Update of Previous Recommendation
In 2004, the USPSTF concluded that there was insufficient evidence to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population (I statement). After reviewing the new data from studies since the last review, the USPSTF again concludes that there is insufficient evidence to determine the balance of benefits and harms of screening for suicide risk.
Recommendations of Others
Several groups have recommendations or have commented on screening patients for suicide risk. The American Academy of Child and Adolescent Psychiatry recommends that clinicians be aware of patients at high risk for suicide (28). The American Academy of Pediatrics recommends that pediatricians ask questions about mood disorders, sexual orientation, suicidal thoughts, and other risk factors associated with suicide during routine health care visits (29). The American Medical Association states that all adolescents should be asked annually about behaviors or emotions that indicate recurrent or severe depression or risk of suicide, and physicians screen for depression or suicidal risk in those with risk factors such as family dysfunction, declining school grades, and history of abuse (30). The American Academy of Family Physicians is currently updating its recommendation. The recommendation of the Canadian Task Force on Preventive Health Care mirrors the 2004 USPSTF recommendation, in that it found poor evidence to include or exclude routine evaluation of suicide risk during a periodic health examination (31).
Table 1: What the Grades Mean and Suggestions for Practice
Table 2: Levels of Certainty Regarding Net Benefit
|Level of Certainty*||Description|
|High||The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.|
|Moderate||The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as:
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
|Low||The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:
More information may allow an estimation of effects on health outcomes.
*The U.S. Preventive Services Task Force defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.
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AHRQ Publication No. 12-05188-EF-2
Current as of April 2013
U.S. Preventive Services Task Force. Screening for Suicide Risk in Adolescents, Adults, and Older Adults: Draft Recommendation Statement. AHRQ Publication No. 12-05188-EF-2. http://www.uspreventiveservicestaskforce.org/draftrec3.htm