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Evidence Summary

Other Supporting Document for Suicide Risk in Adolescents, Adults and Older Adults: Screening

Preface

Screening for and Treatment of Suicide Risk Relevant to Primary Care

A Systematic Review for the U.S. Preventive Services Task Force

Release Date: April 23, 2013


By Elizabeth O’Connor, PhD; Bradley N. Gaynes, MD, MPH; Brittany U. Burda, MPH; Clara Soh, MPA; and Evelyn P. Whitlock, MD, MPH


The information in this article is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This article is intended as a reference and not as a substitute for clinical judgment.

This article may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This article was first published in Annals of Internal Medicine on April 23, 2013 (Ann Intern Med 2013; http://www.annals.org).

Abstract

Background: In 2009, suicide accounted for 36,897 deaths in the United States.

Purpose: To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care.

Data Sources: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012).

Study Selection: Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings.

Data Extraction: One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality.

Data Synthesis: Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths.

Limitation: Treatment evidence was derived from high-risk rather than screen-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited.

Conclusion: Primary care–feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven.

Primary Funding Source: Agency for Healthcare Research and Quality.

Introduction

Suicide was the 10th leading cause of death in the United States in 2009, accounting for 36,897 deaths with an age-adjusted rate of 11.8 per 100,000 persons1, 2. It accounted for more than 1.4 million years of potential life lost before age 85 years3. Suicide attempts and death rates vary substantially by sex; age; race; and other risk factors, such as psychiatric disorders4–7, prior suicide attempts8–11, a history of nonsuicidal self-harm 7, and a serious adverse childhood experience 12–15. Individual risk factors have a limited ability to predict suicide in a person at a particular time, but risk for a suicide attempt and death increases with multiple risk factors (covering psychosocial, biomedical, and developmental realms) and high levels of distress16, 17.

Thirty-eight percent of U.S. adults who completed suicide visited their primary care providers in the prior month; this rate was even higher (50% to 70%) in older adults18. Nearly 90% of suicidal youth had primary care visits during the previous 12 months, compared with 70% to 80% of nonsuicidal youth19, 20. Screening tools that are accurate and feasible for use in primary care could represent an important opportunity to identify persons at increased risk for suicide so that it can be prevented through appropriate treatment.

In 2004, the U.S. Preventive Services Task Force (USPSTF) concluded that evidence was insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population (I statement). That review found limited evidence that screening tests can reliably detect suicide risk in primary care population 21. A large body of evidence (33 randomized, controlled trials and 2 cohort studies) examined the effects of treatment on suicide attempts and suicide deaths in adolescents or adults.

Few trials showed benefit of treatment, and many were underpowered for these rare outcomes. Evidence also showed that nonpharmacologic treatment could reduce depressive symptoms and suicidal ideation in high-risk older adolescents and adults. Evidence was lacking on harms of screening and treatment.

Methods

We developed an analytic framework (Appendix Figure 1) with 6 key questions to guide our work (Appendix Table 1). Our full report describes the methods in detail22.

Data Sources

We considered all studies from the previous review for inclusion. We searched MEDLINE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials for studies published between January 2002 and 17 July 2012 to bridge and update from the previous review. We hand-searched bibliographies of relevant reviews and searched Web sites of government agencies and professional organizations to identify relevant research published outside of peer-reviewed journals. We also conducted a surveillance search of MEDLINE through December 2012 to identify additional screening trials.

Study Selection

Two investigators independently reviewed the abstracts and articles against specified inclusion and exclusion criteria. We resolved disagreements through consultation with the larger project team. We included English-language studies in general primary care or specialty mental health populations (or similar populations) of any age. We also included studies limited to patients with depression, substance misuse, posttraumatic stress disorder, or borderline personality disorder. We excluded studies limited to patients with other mental health conditions.

For questions related to harms and benefits of screening or treatment, we included randomized and nonrandomized clinical trials. To address effects of treatment, we included trials of behavior-based or pharmacologic treatment with a primary aim of reducing suicide deaths, suicide attempts or self-harm, or suicidal ideation. We included studies of screening instrument accuracy that reported sensitivity, specificity, or related statistics of brief screening instruments to detect current increased suicide risk (usually suicidal ideation) relative to a reference standard. The reference standard had to be a more in-depth assessment of suicide risk by a trained mental health professional or a trained interviewer using a standardized instrument to determine whether suicide risk was increased. We would have included suicide attempts in the immediate period after screening (for example, 1 month) as a gold standard if we had found any studies that did this. We also would have included comparative cohort studies addressing harms of pharmacologic treatment in suicidal populations if we had found any.

Data Extraction and Quality Assessment

One investigator abstracted data from all included studies into a standard evidence table, and a second investigator checked the data for accuracy. Two investigators independently assessed the methodological quality of each study by using predefined design-specific quality criteria based on methods developed by the USPSTF (23). We supplemented these criteria with the Quality Assessment of Diagnostic Accuracy Studies tool (24) to evaluate the quality of diagnostic accuracy (screening) studies, resulting in a rating of good, fair, or poor. We resolved disagreements in quality assessment through discussion and, if necessary, consultation with a third reviewer. We excluded poor-quality trials.

Data Synthesis and Analysis

For all key questions, we created results tables with important study characteristics. We critically examined these tables to identify the range of results and potential associations with effect size. We examined trials limited to adolescents or limited to older adults separately from other adult trials.

For key questions 4 and 5 only, we conducted random-effects meta-analyses to estimate the effect size of suicide prevention interventions on suicide attempts or self-harm, suicidal ideation, and depression. We used Stata, version 11.2 (StataCorp, College Station, Texas), for all statistical analyses. Risk ratios were analyzed for suicide attempts. All trials reported at least 1 suicide attempt or self-harm episode in each intervention group, so no correction for empty cells was needed. We analyzed standardized mean differences (SMDs) in change from baseline for the continuous outcomes (suicidal ideation and depression). We calculated SDs of change from baseline by using a standard formula25.

We assessed the presence of statistical heterogeneity among the studies by using standard chi-square tests and the I2 statistic26. We applied the Cochrane Collaboration27 rules of thumb for interpreting I2 (probably unimportant, <40%; moderate, 30% to 60%; and substantial, 50% to 90%) and Cohen28 rules of thumb for interpreting effect sizes (small, 0.2 to 0.5; medium, 0.5 to 0.8; and large, ≥0.8).

Role of the Funding Source

This research was funded by the Agency for Healthcare Research and Quality (AHRQ). AHRQ staff provided oversight for the project and assisted in external review of the companion draft evidence synthesis. AHRQ staff had no role in study selection, quality assessment, synthesis, or development of conclusions. The investigators are solely responsible for the content of the manuscript and the decision to submit for publication.

Results

We included 56 studies that reported results in 86 publications, from 3925 abstracts and 303 full-text articles (Appendix Figure 2). We included 7 trials that addressed screening (key questions 1, 2, and 3): 1 examined short-term benefits of screening29, 4 examined performance characteristics of screening instruments30–33, and 3 examined adverse effects of screening29, 34, 35. We included 49 trials that addressed the benefits of treatment (key questions 4 and 5)—36 were conducted in adults or mixed adolescent and adult populations36–71, and 13 were done in adolescents72–84. A subset of these trials (κ = 12) also reported on adverse events or a (statistically nonsignificant) paradoxical increase in suicide attempts, which is discussed under key question 636, 40, 41, 49, 51, 55–57, 66, 73, 76, 77.

Benefits of Screening (Key Question 1)

We identified 1 short-term, fair-quality trial (n = 443) that addressed key question 1. This trial found no clear short-term (that is, within 2 weeks) benefit of screening29. It was published after the 2004 USPSTF review on this topic and thus was not included in the previous review.

Screening Instrument Accuracy (Key Question 2)

Appendix Table 2 shows data from the 4 studies that reported the accuracy of screening instruments for identifying persons at increased risk for suicide30–33. Two of these trials were conducted in adult or older adult primary care populations32, 33. One study (the only diagnostic accuracy study also included in the 2004 review) examined the clinical utility of 3 suicide-related items in primary care patients aged 18 years or older with prescheduled appointments for any reason (n = 1001)32.

Items had sensitivities of 83% to 100% and specificities of 81% to 98% relative to a nurse-administered structured interview on the same day. The positive predictive values were low, ranging from 6% to 30%. Accuracy was lower in the study of the Geriatric Depression Scale-Suicidal Ideation subscale in general primary care patients aged 65 years or older (n = 626)33. The optimal cutoff yielded a sensitivity and specificity of 80% for suicidal ideation during the previous 2 weeks, and the positive predictive value was fairly low (33%).

Two trials reported instrument accuracy in adolescent samples (combined n = 799). Although these studies used different instruments and approaches to assemble their samples, both represented high-risk groups that had 22% to 27% prevalence of suicidal ideation or behavior. In these studies, sensitivity ranged from 52% to 87% and specificity ranged from 60% to 85%. These results are only generalizable to high-risk populations.

Harms of Screening (Key Question 3)

Three trials reported on potential adverse effects of screening (all published since the previous review). None identified serious adverse effects of screening29, 34, 35.

Health (Key Question 4) and Intermediate (Key Question 5) Benefits of Treatment

Table 136–112 lists brief population and intervention characteristics of all included trials, and Table 236–112 lists all outcomes reported by each trial. The previous review included only 11 of these 49 trials; almost all of the new trials were published in 2003 or later, well after the end of the search window of the 2004 review. We organized treatment trials into 3 broad intervention groups: psychotherapy, enhanced usual care, and medication.

Psychotherapy

Thirty-one trials investigated a specific psychotherapeutic treatment approach, generally compared with usual care. Nineteen of these trials were conducted in adults37, 38, 41, 44, 47, 50–52, 54–56, 58–60, 62–65, 67, and 12 were conducted in adolescents72–81, 83, 84. Most psychotherapy trials were done in high-risk populations, usually identified because these persons had a recent suicide attempt or selected mental health disorders (for example, borderline personality disorder) and a history of suicide attempts. The only study that identified patients through population-based screening was conducted in Sri Lanka.

In adults, evidence was insufficient to evaluate the effect on suicide deaths, because only 6 of the 19 psychotherapy trials reported suicide deaths. Psychotherapy recipients had a 32% reduction in the likelihood of a suicide attempt or deliberate self-harm compared with usual care recipients (relative risk, 0.68 [95% CI, 0.56 to 0.83]; κ = 11; n = 1583; I2, 16.1%) (Figure 1). However, a single estimate of absolute benefit would be misleading, given the highly variable rate of suicide attempts or self-harm (15% to 71% of control group participants had a suicide attempt or self-harm episode at follow-up). When the trials with the most extreme suicide attempt rates were excluded38, 50, 54, 55, absolute differences ranged from a low of 46% in the control group and 39% in the intervention group (65) to a high of 47% in the control group and 23% in the intervention group59.

Psychotherapy did not show greater improvement than usual care for suicidal ideation (SMD, −0.10 [CI, −0.27 to 0.06]; κ = 8; n = 964; I2, 26.3%) (Figure 2), and most trials reported reduced suicidal ideation in both intervention and control groups. Psychotherapy had a small beneficial effect on depression relative to usual care (SMD, −0.37 [CI, −0.55 to −0.19]; κ = 12; n = 1653; I2, 60.5%) (Figure 3). Other outcomes were sparsely reported and had mixed results.

In adolescents, we could not determine the effects of suicide prevention treatment on deaths because only 1 death occurred in the 3 trials reporting this outcome. Psychotherapy did not reduce suicide attempts in adolescents at 6 to 18 months (relative risk, 0.99 [CI, 0.75 to 1.31]; κ = 9; n = 1331; I2, 49.1%) (Figure 1). The CI of the pooled effect was wide, ranging from a 25% reduction in risk to a 31% increase in risk for suicide attempts.

The absolute proportion of participants with a suicide attempt or self-harm episode varied greatly across trials, as did the difference between groups. For example, in the 3 trials reporting suicide attempts or self-harm in 20% to 23% of control group participants, the proportion of youth in the intervention groups with suicide attempts or self-harm ranged from 11.4% to 36.1%72, 78, 84. Given the wide range of results, we cannot rule out the possibility of harm (or benefit) on the basis of existing evidence.

Psychotherapy had no beneficial effect on suicidal ideation beyond usual care (SMD, −0.22 [CI, −0.46 to 0.02]; κ = 6; n = 629; I2, 41.2%) (Figure 2); both the psychotherapy and usual care groups generally showed substantial improvement. Psychotherapy had a small beneficial effect on depression (SMD, −0.36 [CI, −0.63 to −0.08]; κ = 6; n = 631; I2, 53.6) (Figure 3). Although statistical heterogeneity was high, all effects suggested that psychotherapy benefitted persons with depression (but most effects were not statistically significant). Other health outcomes were sparsely reported and rarely showed beneficial effects for the interventions.

Among psychotherapy studies, we found no clear predictors of effect size other than target age (adults vs. adolescents), where trials in adults more consistently showed larger beneficial effects than those in adolescents. Among adolescent trials, limited data suggested that interventions targeting parents and youth, either separately or together, seemed to be more beneficial than those targeting only adolescents.

Enhanced Usual Care

We defined trials of “enhanced usual care” as those that attempted to improve the quality or format of recommended treatment (in primary or specialty care) or patient adherence to usual care while providing little to no direct therapeutic counseling or specific prescription for psychotherapy. Treatments varied widely, from mail-only to case management interventions, but most involved considerably less contact with patients than psychotherapy. One enhanced usual care trial was limited to adolescents and young adults (aged 15 to 24 years)82, 2 were limited to older adult primary care patients42, 71, and the remaining trials included wide age ranges covering primarily adults.

Most trials targeted participants who had an emergency department visit or inpatient stay related to a suicide attempt or self-harm. However, 3 trials were conducted in primary care settings, including both trials in older adults. PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) addressed only depressed older adults (aged 60 to 94 years) and was the sole trial that used primary care–based screening for depression in the United States to identify eligible participants42. The other trial of older adults was a large cluster randomized trial (patients were randomly assigned at the level of provider) that included all patients older than 60 years on the panels of participating providers; this trial thus was not limited to patients who screened positive for suicidal ideation or had known risk factors for suicide, but was representative of a general Australian primary care population71.

The third trial with high applicability to primary care was a nonrandomized, population-based intervention trial that compared intervention and control regions of the county in Hungary with the highest suicide rates. This trial reported suicide rates per 100,000 persons as its outcome, rather than following an identified sample70. It involved a 5-year provider-education intervention that also offered free consultation and a depression clinic for referral.

Although 7 of the 17 enhanced usual care trials reported deaths, only 1 fair-quality trial reported significant group differences. This fairly large trial (n = 843) sent participants 24 letters over 5 years expressing concern and encouraging treatment and reported a 49% reduction in suicide deaths at 2-year follow-up (1.8% in the intervention group vs. 3.5% in the control group; 1-tailed P = 0.043)61. The large population-based trial in primary care practices seemed sufficiently powered to examine suicide deaths and found no reduction in suicide70. Aside from this population-based trial, very few deaths occurred across the remaining trials, and deaths were frequently not reported so we could not conclude that suicide deaths decreased.

Thirteen of the 17 adult trials of enhanced usual care reported on suicide attempts, and all but 153 found no difference in suicide attempts between 4 and 24 months (relative risk, 0.91 [CI, 0.80 to 1.02]; κ = 13; n = 6592; I2, 0.0%) (Figure 4). These results are consistent with a small to moderate (20% at most) decrease in suicide attempts or no effect, compared with suicide attempt rates in the control groups ranging from 1% to 30% at 4 to 24 months.

Other health and intermediate outcomes were sparsely reported. The trials in older primary care patients reduced suicide attempts by 20% to 23%42, 71, but the results were significant only in the larger trial71.

Medication

We included 1 fair-quality, placebo-controlled trial of lithium to prevent suicide in patients with depression-spectrum disorders and a recent suicide attempt (167 randomly assigned patients)57. Retention in this trial was low (only 31% of participants remained at the final 13-month follow-up). Although all 3 suicide deaths in the study occurred in placebo recipients, the groups did not differ in cumulative survival without a suicide attempt (hazard ratio, 0.517; P = 0.21, adjusted for age, sex, and prior suicide attempts) or suicidal ideation.

Harms of Treatment (Key Question 6)

Although no harms were identified in any of the adult trials, 4 of the 12 trials reporting suicide attempts in adolescents reported statistically nonsignificant increases in suicide attempts of 22% to 113%73, 76, 77, 82. The possibility of harm cannot be ruled out in treatment of currently or recently suicidal adolescents.

The trial of lithium treatment reported that 13% of the lithium recipients withdrew from the study because of adverse effects, compared with 2% of placebo recipients. However, the statistical significance of this difference was not reported57. Overall withdrawal rates for any reason were similar between groups. Specific adverse effects were not reported.

Discussion

Suicide risk can be difficult to accurately assess because some persons may attempt to conceal suicidal thoughts (creating false-negative results on screening) and some may express suicidal thoughts without serious intention to kill themselves (creating false-positive results on screening)113. Even in high-risk populations, suicide is comparatively rare. Furthermore, the known risk factors associated with suicide are relatively common and individually not very strong predictors of suicide, even in persons at high risk. This combination of factors makes accurately predicting who will die by suicide on the basis of known risk factors very difficult. Nonetheless, suicide prevention is of high national importance, so it is critical to know whether primary care–based screening is likely to help reduce suicide in the United States by identifying patients in need of treatment and referring them to appropriate care. Table 3 summarizes the evidence from this review for all key questions.

Summary of Findings

Screening

Although screening instruments have been developed for quick risk assessment, few studies have reported diagnostic accuracy characteristics of sensitivity, specificity, or related statistics relative to an interview with a clinician or other trained questioner. Minimal evidence (2 studies) suggested that screening tools can identify adults and older adults in primary care who are at increased risk for suicide, although these tools produce many false-positive results. Data on the accuracy of screening were even more limited in adolescents. Neither instrument performed well in adolescents, and the screening populations in which they were tested had relatively poor applicability to general primary care patients.

An important limitation of these data is the unknown accuracy of a full clinical interview in predicting suicide-related events, which are relatively rare and inherently difficult to predict17. Instrument accuracy aside, we identified minimal data that examined whether suicide risk screening increased or decreased the likelihood of suicidality or other distress. Our results are consistent with those of an earlier review of suicide screening in adolescents, which concluded that data were very limited and future research was essential to determine whether and how screening can reduce suicide in young persons114.

Treatment in Adults

Although the included studies involved too few deaths to determine whether a particular treatment reduced the risk for suicide deaths, they provided useful evidence about attempts. Combined assessment of all psychotherapy studies found that psychotherapy targeting suicide prevention reduced the risk for attempts by an estimated average of 32%. Psychotherapy also showed small beneficial effects on depression, although other beneficial outcomes were sparsely reported or showed no consistent group differences. Interventions that primarily focused on enhancing usual care had little effect on suicide deaths, suicide attempts, or related outcomes.

The participants in the included adult treatment trials who reported suicide attempts were at high risk for suicide, usually based on a history of multiple attempts, which resulted in a very high incidence of suicide attempts (for example, 11% to 68% in the control groups of the psychotherapy trial). This finding contrasts with the screening accuracy studies that were done in general primary care patients, where attempt rates are substantially lower (probably <1% over 1 year)115. Thus, the indirect evidence linking screening accuracy with benefits of treatment is not good.

There are several possible explanations for why psychotherapy seemed to be effective in adults, whereas practice-based approaches or other enhanced usual care interventions were not. First, the care provided in enhanced usual care trials was generally less time-intensive than that provided in the psychotherapy trials, which may be associated with smaller effects. In addition, the enhanced usual care trials may have included slightly lower-risk samples than the psychotherapy trials, as evidenced by a smaller proportion of control group participants who attempted suicide at follow-up (0.5% to 28% of control participants).

Alternatively, usual care may have been more effective in these studies, which would also attenuate the effect (but which we could not examine with available evidence). Assuming that these interventions are less likely, on average, to be effective, some of the enhanced usual care interventions may nevertheless be useful components of a larger system-wide approach that includes psychotherapy.

We found minimal data on medication's effectiveness in preventing suicidal behavior. These data were limited to a single, short-term, fair- to poor-quality lithium trial that had high attrition. Lithium is commonly used for treating bipolar disorder and has been shown to reduce the risk for suicide in observational studies116, 117 and in controlled trials of patients with unipolar and bipolar depression who were not necessarily suicidal, compared with placebo or other agents (pooled Peto odds ratio of randomized trials, 0.26 [CI, 0.09 to 0.77])18. We found no studies on lithium use in patients identified through screening for suicidality. Lithium is associated with important adverse effects that were not described in the 1 trial included in this review119–121.

Our findings were generally consistent with other recent reviews of treatment to prevent suicide or self-harm122–125. Each of these recent reviews generally included similar bodies of research but grouped the trials differently. Nonetheless, they all found insufficient evidence for an effect on suicide deaths because of the small number of events. They also generally found small to moderate (usually nonsignificant) reductions in suicide attempts or self-harm, and all were limited by the included trials' sparse reporting of other outcomes. The most comprehensive of these reviews, published by the National Institute for Health and Clinical Excellence, concluded that psychological and psychosocial interventions may be effective compared with usual care. However, variations in populations, treatment methods, and comparison groups created uncertainty.

Treatment in Adolescents

Psychotherapy did not reduce the risk for suicide attempts in adolescents in contrast to adults. Data did not allow us to rule out the possibility that the risk for suicide attempts was paradoxically increased. Psychotherapy showed small beneficial effects on depression for adolescents, as it did for adults. Other outcomes either showed no consistent beneficial effects or were sparsely reported.

The research on iatrogenic suicidality related to antidepressants suggests that adolescents react differently from adults to pharmacologic treatment126. Research also suggests that risk factors and methods of committing suicide differ between younger versus older teenagers127. Thus, different age groups seem to have different treatment needs and risks. The evidence base in adolescents is still small, and few approaches have been replicated. Replication is important, as shown by the trials of developmental behavior therapy in this review; beneficial results in a first trial (80) were not replicated in 2 subsequent good-quality trials75, 77. Overall, our findings were consistent with the National Institute for Health and Clinical Excellence review, in which only 1 trial showed a beneficial effect in adolescents125.

Psychotherapy trials primarily involved high-risk youth, most with a recent suicide attempt or acute suicidal ideation. These samples are consistent with those in the screening studies but may have low applicability to youth identified through primary care screening. Suicidal youth need treatment, but caution, close monitoring, and care coordination are also warranted128. These trials suggest that active parental involvement in treatment may be important. Further research is urgently needed.

Limitations

One important limitation is that most of the treatment literature was in high-risk populations, so the generalizability of these results to screening-detected populations is unknown. In addition, there was very little evidence on the effectiveness of treatment in older adults and racial or ethnic minorities. Differences in suicide rates among ethnic groups suggest that cultures vary, both in motivation for and meaning of suicide; thus, culturally tailored risk-based screening and interventions may be important129.

The lack of power and reports of suicide death is another important limitation. Suicide attempts and self-harm are not good surrogates for suicide death. As a result, we cannot assume that the reduced attempts seen with psychotherapy interventions will decrease the number of deaths130. Because suicide death is relatively rare and predicting such deaths is difficult, very large collaborative trials are probably required for sufficient power to see an effect on suicide deaths131. For example, if all participants in all psychotherapy trials that reported suicide deaths were treated as a single study that found a 57% reduction (0.62% in the intervention group vs. 1.44% in the control group), 4 times the number of actual participants would be needed to achieve statistical significance.

Power would probably be even more dramatically limited in studies of screening-detected patients. Assuming an annual suicide rate of 100 per 100,000 persons (twice as high as that of older white men, who have the highest rates of any age, sex, or racial subgroup) and the ability of a treatment to reduce suicide by 40%, more than 83,000 persons per group would be required to generate a statistically significant result. Thus, building a coherent chain of evidence from broad population-based screening through treatment to reduce suicide deaths will be difficult, because treatment studies will necessarily be limited to very high-risk groups in order to have sufficient power to detect a treatment effect.

Conclusion

Suicide prevention is a topic of high national importance in which primary care providers may have a role. Although evidence was limited, primary care–feasible screening tools could probably identify adult patients at increased risk for suicide who may need treatment. A larger body of evidence showed that psychotherapy can reduce the risk for suicide attempts in high-risk populations.

Unfortunately, whether similar benefits would be found in screening-detected patients is unknown. There was little evidence on the accuracy of screening in adolescents, and what little data are available showed that treatment did not demonstrate a positive effect. Results in adolescents also did not rule out the possibility of harm (that is, increased suicide attempts) with some forms of psychotherapy. More research on how to effectively identify and treat adolescents at increased risk for suicide is urgently needed. There is also a need for research on the effect of psychotherapy to prevent suicide attempts in primary care patients who screen positive for suicide risk, as well as whether treatments actually lead to lower suicide death rates, even in high-risk populations.

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Copyright and Source Information

Source: This article was first published in Annals of Internal Medicine (Ann Intern Med 2013).

Note: Ms. Soh accepted a position at the Pharmaceutical Research and Manufacturers of America during the finalization of the full report and drafting and final submission of this manuscript; she contributed most of her intellectual content to this review while she was employed with the Oregon Evidence-based Practice Center at Kaiser Permanente Center for Health Research.

Disclaimer: The views and opinions expressed in this article are those of the authors, who are responsible for its content, and do not necessarily reflect the views of the Pharmaceutical Research and Manufacturers of America or of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

Acknowledgment: The authors thank AHRQ staff; the USPSTF; J. Michael Bostwick, MD; David A. Brent, MD; Gregory Simon, MD, MPH, who provided expert review of the report; Kevin Lutz, MFA; Daphne Plaut, MLS; and Heather Baird at the Kaiser Permanente Center for Health Research.

Grant Support: By the Oregon Evidence-based Practice Center under contract to AHRQ, Rockville, Maryland (contract HHS-290-2007-10057-I).

Potential Conflicts of Interest: Dr. O’Connor: Grant (money to institution): AHRQ; Support for travel to meetings for the study or other purposes (money to institution): AHRQ; Payment for writing or reviewing the manuscript (money to institution): AHRQ; Provision of writing assistance, medicines, equipment, or administrative support (money to institution): AHRQ. Dr. Gaynes: Grant (money to institution): AHRQ. Ms. Burda: Grant (money to institution): AHRQ; Consultancy: Oregon Health & Science University; Employment: Howard Hughes Medical Institute, Vollum Institute (Oregon Health & Science University); Other: Pennsylvania State University, Howard Hughes Medical Institute. Ms. Soh: Grant (money to institution): AHRQ; Support for travel to meetings for the study or other purposes (money to institution): AHRQ; Provision of writing assistance, medicines, equipment, or administrative support (money to institution): AHRQ. Dr. Whitlock: Grant (money to institution): AHRQ; Support for travel to meetings for the study or other purposes (money to institution): AHRQ; Payment for writing or reviewing the manuscript (money to institution): AHRQ; Provision of writing assistance, medicines, equipment, or administrative support (money to institution): AHRQ. Disclosures can be viewed at https://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2880.

Corresponding Author: Elizabeth O’Connor, PhD, Center for Health Research, Kaiser Permanente NW, 3800 North Interstate Avenue, Portland, OR 97227; e-mail, elizabeth.oconnor@kpchr.org.

AHRQ Publication No. 13-05188-EF-3
Current as of April 2013

Figure 1. Suicide attempts in psychotherapy trials.*

Text Description is shown below

CB = cognitive behavioral; D = dialectical; DG = developmental group; DSH = deliberate self-harm; ODT = other therapy, direct; OTND = other therapy, nondirect; P = psychodynamic; PS = problem solving; SA = suicide attempt.
* Weights are from random-effects analysis

Text Description.

Figure 1 displays a forest plot of the relative risk (RR) of suicide attempts in adult and adolescent psychotherapy trials, stratified by type of psychotherapy. The overall RR for adults was 0.68 (95% CI, 0.56 to 0.83) and for adolescents it was 0.99 (95% CI, 0.75 to 1.31). For cognitive behavior therapy trials, the RR for adults was 0.80 (95% CI, 0.67 to 0.97) and the RR for adolescents was 0.95 (95% CI, 0.28 to 3.16). For problem-solving therapy trials, the RR for adults was 0.83 (95% CI, 0.56 to 1.24) and the RR for adolescents was 0.96 (95% CI, 0.62 to 1.48). For dialectical behavior therapy trials, the RR for adults was 0.47 (95% CI, 0.30 to 0.74). For psychodynamic/interpersonal therapy trials, the RR for adults was 0.47 (95% CI, 0.23 to 0.95) and the RR for adolescents was 1.01 (95% CI, 0.30 to 3.39). For other direct therapy trials, the RR for adults was 0.41 (95% CI, 0.04 to 3.82). For other nondirect therapy trials, the RR for adolescents was 0.82 (95% CI, 0.53 to 1.29).

Figure 2. Suicidal ideation in psychotherapy trials.*

Text Description is shown below.

CB = cognitive behavioral; D = dialectical; DG = developmental group; DSH = deliberate self-harm; ODT = other therapy, direct; OTND = other therapy, nondirect; P = psychodynamic; PS = problem solving; SA = suicide attempt.
* Weights are from random-effects analysis

Text Description.

Figure 2 displays a forest plot of the standardized mean difference (SMD) of suicidal ideation in psychotherapy trials, stratified by type of psychotherapy. The overall SMD for adults was -0.10 (95% CI, -0.27 to 0.06) and for adolescents it was -0.22 (95% CI, -0.46 to 0.02). For cognitive behavior therapy trials, the SMD for adults was -0.10 (95% CI, -0.78 to 0.58) and the SMD for adolescents was -0.15 (95% CI, -0.85 to 0.56). For problem-solving therapy trials, the SMD for adults was -0.17 (95% CI, -0.34 to 0.01). For dialectical behavior therapy trials, the SMD for adults was 0.18 (95% CI, -0.24 to 0.60). For psychodynamic/interpersonal therapy trials, the SMD for adults was -0.46 (95% CI, -0.87 to -0.06) and the SMD for adolescents was -0.52 (95% CI, -1.15 to 0.11). For other nondirect therapy trials, the SMD for adults was 0.15 (95% CI, -0.41 to 0.72). For developmental group therapy trials, the SMD for adolescents was -0.08 (95% CI, -0.26 to 0.10).

Figure 3. Depression in psychotherapy trials.*

Text Description is shown below.

CB = cognitive behavioral; D = dialectical; DG = developmental group; OTND = other therapy, nondirect; P = psychodynamic; PS = problem solving; SD = standard deviation; SMD = standard mean difference.
* Weights are from random-effects analysis

Text Description.

Figure 3 displays a forest plot of the standardized mean difference (SMD) of depression in psychotherapy trials, stratified by type of psychotherapy. The overall SMD for adults was -0.37 (95% CI, -0.55 to -0.19) and for adolescents it was -0.36 (95% CI, -0.63 to -0.08). For cognitive behavior therapy trials, the SMD for adults was -0.39 (95% CI, -0.70 to -0.08) and the SMD for adolescents was -0.43 (95% CI, -1.15 to 0.28). For problem-solving therapy trials, the SMD for adults was -0.26 (95% CI, -0.52 to 0.00). For dialectical behavior therapy trials, the SMD for adults was -0.22 (95% CI, -0.64 to 0.20). For psychodynamic/interpersonal therapy trials, the SMD for adults was -0.77 (95% CI, -1.32 to -0.22) and the SMD for adolescents was -0.68 (95% CI, -1.39 to 0.02). For other nondirect therapy trials, the SMD for adults was -0.18 (95% CI, -0.74 to 0.38). For developmental group therapy trials, the SMD for adolescents was -0.17 (95% CI, -0.35 to 0.01).

Figure 4. Suicide attempts in enhanced usual care studies.

Text Description is shown below.

DSH = deliberate self-harm; SA = suicide attempt.
* Weights are from random-effects analysis

Text Description.

Figure 4 displays a forest plot of the relative risk (RR) of suicide attempts in enhanced usual care studies, which includes practice-based interventions and direct and indirect interventions to improve treatment adherence. In the PROSPECT trial among older adults, the RR was 0.77 (95% CI, 0.13 to 4.56). Among the trials in adults, the RR was 0.90 (95% CI, 0.80 to 1.02), and among the trials in adolescents, the RR was 1.44 (95% CI, 0.36 to 5.76). The overall RR was 0.91 (95% CI, 0.80 to 1.02).

Table. Summary of Evidence

Key Question Population Studies (Observations), n Design Major Limitations Consistency Applicability Overall Quality Summary of Findings
Key question 1 (benefits of screening) Adults and older adults 1 (443) RCT Single trial; only 2 wk follow-up; limited to adults NA Moderate: primary care patients with positive screening result for depression in the United Kingdom Fair Among primary care patients with positive screening result for depression, screening for suicide risk (compared with other health screening) did not reduce suicidal ideation after 2 wk; only 1 suicide was attempted in the trial. Data were not reported separately for older adults.
Adolescents No data NA NA NA NA NA No data
Key question 2 (accuracy of screening) Adults 1 (1001) Diagnostic accuracy Few studies; no replication of specific screening instruments; only 1 study had brief period between screener and reference (≤24 h)32; median time lag between tests ≥6 d in other studies NA High: primary care in the United States 32 Fair Three suicide items were examined separately; sensitivity was ≥83% and specificity was ≥81% relative to a nurse-administered structured interview on the same day.
Older adults 1 (626) Diagnostic accuracy   NA High: primary care in the United States 33 Fair Sensitivity and specificity of suicide-related items on the GDS were ≤80% for suicidal ideation in the past 2 wk.
Adolescents 2 (799) Diagnostic accuracy   Low Low to moderate: at risk for dropout from U.S. high school31;
Finnish mental health patients30
Fair The study with the best applicability to U.S. primary care reported sensitivity of 87% and specificity of 60% for the SRS.
Key question 3 (harms of screening) Adults and older adults 1 (443) RCT Single trial with only 2-wk follow-up NA Moderate: primary care patients in the United Kingdom Fair There was no increase in suicide attempts or ideation after screening, and a slightly higher proportion of those who were screened withdrew consent for follow-up (6.6% of screened vs. 2.2% of unscreened). Data were not reported separately for older adults.
Adolescents 2 (2650) RCT Only 2 trials using different instruments; maximum follow-up of 2 d Moderate Low to moderate: Australian and U.S. high school students screened in classroom setting Fair There were no adverse effects on mood. Australian youths with a positive screening result found screening more distressing and less worthwhile than those with a negative screening result.
Key questions 4 and 5 (benefits of treatment): psychotherapy Adults 19 (2460) RCT Populations inconsistently described; no data specifically on racial/ethnic minority groups Moderate Low to moderate: many conducted outside of the United States; only trial that involved population-based screening was done in Sri Lanka63 Fair Sample sizes were insufficient to determine group differences in suicide deaths. Psychotherapy reduced the risk for suicide attempts by 32% (relative risk, 0.68 [95% CI, 0.56 to 0.83]). Pooled effects showed a small benefit for depression but not suicidal ideation. Most data were from trials of CBT or related interventions.
Older adults No data specific to older adults NA NA NA NA NA No trials were limited to older adults, and no subgroup analyses examined effects in older adults.
Adolescents 12 (2392) RCT Little replication of interventions; populations inconsistently described; no data specifically on racial/ethnic minority groups Moderate Low to moderate: many done outside of United States; the few involving screening were conducted in school settings Good (developmental group therapy)
Fair (other therapies)
Data on suicide deaths were insufficient. Few approaches reduced suicide attempts or ideation compared with UC. Pooled effects showed a small benefit for depression but not suicidal ideation. Some trials showed a nonsignificant increase in suicide attempts (22% to 113%), raising the possibility of harm.
Key questions 4 and 5 (benefits of treatment): medication Adults (lithium) 1 (167) Placebo-controlled RCT Only 1 trial with high attrition beyond 3 mo NA Moderate: German adults identified through ED and inpatient screening Fair There were 3 suicide deaths, all in the placebo group. A short-term nonsignificant reduction in suicide attempts was seen (hazard ratio for time to suicide attempt, 0.52; P = 0.20). There was no benefit for suicidal ideation compared with placebo.
Older adults No data NA NA NA NA NA No trials were limited to older adults, and no subgroup analyses examined effects in older adults.
Adolescents No data NA NA NA NA NA No trials were limited to adolescents, and no subgroup analyses examined effects in adolescents.
Key questions 4 and 5 (benefits of treatment): enhanced UC Adults 13 (8555); 1 population-based study (approximately 127,000 residents) RCT and 1 CCT70 Populations inconsistently described; no data specifically for racial/ethnic minority groups; little replication of interventions Moderate Low to moderate: many trials conducted outside of the United States Fair One of 7 trials found reduced risk for death at 2-y follow-up (1.8% in intervention group vs. 3.5% in control group) in participants who were sent periodic letters expressing interest in their well-being and among persons who refused treatment after a suicide attempt, but effects were reduced and no longer significant beyond 2 y 61. Reductions in suicide attempts or other health outcomes were generally not seen. Suicidal ideation and depression were rarely reported.
Older adults 2 (22,360) RCT One trial limited to patients with depression, with insufficient power for suicide deaths and attempts42; large study only reported composite outcome of suicide attempts plus ideation71 NA High: one done in general primary care patients71; the other identified participants through primary screening for depression42 Fair Primary care–based intervention in depressed older adults that included a care manager showed benefits for depression and mixed results for suicidal ideation but no benefit for suicide deaths, attempts, or nonsuicidal deaths42. Education and training for providers reduced the risk for suicide attempts and ideation combined by 20% in a general primary care population of older adults but had no effect on depression71.
Adolescents 1 (165) RCT Single trial with highly selective population; groups not entirely comparable at baseline; insufficient power for suicide attempts NA Low: highly selective population in Australia Fair There were no group differences in suicide attempts, suicidal ideation, depression, or hopelessness.
Key question 6 (harms of treatment) Adults Psychotherapy: 3 (351)
Medication: 1 (167)
Enhanced UC: 2 (727)
Plus remaining key question 4 and 5 trials for paradoxical effects
RCT Sparse reporting of harms; methods of data collection not described Moderate Low to moderate: most trials reporting on harms were done in the United States, but 2 of the U.S.-based trials were in university students participating in the study for class credit Fair No psychotherapy or enhanced UC trials identified any harmful effects. Participants receiving lithium were more likely to withdraw from the study because of adverse effects (13% receiving lithium vs. 2% receiving placebo). Several trials for key questions 4 and 5 reported statistically nonsignificant increases in suicide attempts or DSH, although most of these trials had few events and wide CIs. One trial in the United Kingdom of a practice-based intervention found a 32% (CI, 1.02 to 1.70) increase in the odds of DSH in patients with no history of self-harm.
Older adults No data specific to older adults NA NA NA NA NA No trials were limited to older adults, and no subgroup analyses examined effects in older adults.
Adolescents Psychotherapy: trials related to key questions 4 and 5 for paradoxical effects RCT No direct reporting of harms Low Low to moderate: many conducted outside of the United States; the few involving screening were conducted in school settings Good (developmental group therapy)
Fair (other therapies)
No trials directly reported harms; 4 of 11 trials related to key questions 4 and 5 reported statistically nonsignificant increases of 22% or more in suicide attempts or self-harm. The trial with the largest increase was small (n = 31 with follow-up) and had few events but reported 22% to 33% increases in suicide attempts in the remaining 2 trials73.

BPD = borderline personality disorder; CBT = cognitive behavioral therapy; CCT = controlled clinical trial; DBT = dialectic behavioral therapy; DSH = deliberate self-harm; ED = emergency department; GDS = Geriatric Depression Scale; NA = not applicable; RCT = randomized, controlled trial; SRS = Suicide Risk Scale; UC = usual care.

Appendix Figure 1. Analytic framework for suicide risk relevant to primary care.

Text Description is shown below.

KQ = key question (see Appendix Table 1).
* All studies must report at least 1 suicide-specific outcome measure.

Text Description.

Appendix Figure 1 is an analytic framework that depicts the six key questions described in the report. In general, the figure illustrates how screening for suicide risk in primary care (adolescents, young adults, middle-aged adults, and older adults) may result in the identification of individuals at high risk for suicide or deliberate self-harm who may be candidates for intervention. Interventions may result in changes in intermediate outcomes (such as decreased suicide ideation) or health outcomes (such as decreased suicidal behavior, decreased suicide deaths). The analytic framework also depicts the possible adverse events occuring after screening or treatment.

Appendix Table 1. Key Questions

Number Question
1 Do screening programs to detect suicide risk among adolescents, adults, and older adults in primary care settings result in improved health outcomes (decreased suicide attempts, decreased suicide deaths, improved functioning, improved quality of life, or improved health status) or intermediate outcomes (decreased suicidal ideation, depressive symptomatology, or hopelessness)? Does the effect of screening programs vary by population characteristics (i.e., sex, age, race/ethnicity, other)*?
2 Do instruments to screen for increased risk of suicide accurately identify adolescents, adults, and older adults who are at increased risk in primary care populations? Does the accuracy of the screening instruments vary by population characteristics*?
3 Are there harms associated with screening for suicide risk in primary care settings? Do the harms vary by population characteristics*?
4 For those identified as being at increased risk of suicide, do interventions to reduce suicide risk (behaviorally-based, including home visits or counseling for environmental change, or pharmacologic) result in improved health outcomes (decreased suicide attempts, decreased suicide deaths, improved functioning, improved quality of life, or improved health status)? Does the effect of the interventions vary by population characteristics*?
5 For those identified as being at increased risk of suicide, do interventions to reduce suicide risk (behaviorally-based, including home visits or counseling for environmental change, or pharmacologic) result in improved intermediate outcomes (suicidal ideation, decreased access to means of suicide, increased treatment of previously undiagnosed mental health conditions, decreases in depressive symptomatology or hopelessness)? Does the effect of screening programs vary by population characteristics*?
6 For those identified as being at increased risk of suicide, what are the harms of behaviorally-based or pharmacologic treatment to reduce suicide risk? Do the harms vary by population characteristics*?

* Population characteristics include sex; age; race/ethnicity; comorbid medical illness; history of previous suicide attempts; social, mental health, or other psychological factors

Appendix Figure 2. Summary of evidence search and selection.*

Text Description is shown below.

* Surveillance search of MEDLINE only from July 2012 through December 2012 for trials related to screening are not included. No additional trials were identified.

Text Description.

Appendix Figure 2 is a flow chart that summarizes the search and selection of articles. There were 6,638 citations identified by searching MEDLINE, PsycInfo, Cochrane Center Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature. An additional 264 citations were identified from other sources, such as reference lists and suggestions from peer reviewers. After duplicates were removed, 3,925 unique citations were screened at the title/abstract stage. The full text of 303 citations were examined for inclusion for one or more of the six key questions. One article was included for key question 1, 4 articles for key question 2, 5 articles for key question 3, 71 articles for key question 4, 64 articles for key question 5, and 14 articles for key question 6.

Appendix Table 2. Test Performance Characteristics of Suicide Screening Instruments (Key Question 2)

Population Study, Year (Reference) Study Quality Sample Prevalence of Higher
Suicide Risk*
Reference Test Time to Test Instrument Threshold Items, n Time Frame Positive Test Result, % Sensitivity (95% CI), % Specificity (95% CI), % PPV (95% CI), % NPV (95% CI), %
Adolescents Holi et al, 200830 Fair Depressed adolescent outpatients aged 13 to 19 y at a psychiatry clinic (n = 218) Suicidal or self-harming act, 27.1% K-SADS-PL Median, 6 d Mental health clinicians' suicidality assessment Categorized as suicidal or not suicidal 2 In the past 2 wk 25.2 51.6 (38.6–64.5) 85.3 (78.7–90.4) 58.2 (44.1–71.3) 81.6 (74.8–87.2)
Adolescents Thompson and Eggert, 199931 Fair High school students aged 14 to 20 y who are at risk for dropping out of high school (n = 581) High risk for suicide, 21.7% CRA after computer-assisted interview with clinician 7–10 d SRS 4 risk categories; categories I, II, and III considered positive screen 20 NR 50.5 87 (80.2–92.6) 60 (55.1–64.3) 37.8 (32.2–43.6) 94.4 (91.0–96.8)
Adults Olfson et al, 199632 Fair Primary care patients aged 18 to 70 y (n = 1001) Suicidal ideation, 3.3% Nurse-administered structured interview 24 h SDDS-PC Affirmative response:
1. thoughts of death
2. wishing one were dead
3. feeling suicidal
3 In the past month Response 1: 20.2
Response 2: 7.9
Response 3: 3.3
Response 1: 100 (NR)
Response 2: 91.7 (76.1–100.0)
Response 3: 83.3 (62.2–100.0)
Response 1: 81.0 (78.5–83.5)
Response 2: 93.1 (91.5–94.7)
Response 3: 97.7 (69.8–98.6)
Response 1: 5.9 (2.6–9.2)
Response 2: 13.9(6.3–21.5)
Response 3: 30.3(14.6–46.0)
Response 1: 100 (NR)
Response 2: 99.8
(99.5–100.0)
Response 3: 99.8
(99.5–100.0)
Older adults Heisel et al, 201033 Fair Primary care patients aged 65 to 95 y (n = 626) Suicidal ideation, 11% Suicide items from SCID or HAM-D NR Suicide subscale of GDS 1. Cut score ≥1
2. Cut score ≥2
3. Cut score ≥3
5 NR Cut score 1: 26.2
Cut score 2: 12.5
Cut score 3: 5.8
Cut score 1: 9.7 (68.3–88.4)
Cut score 2: 55.1 (42.6–67.1)
Cut score 3: 34.8 (23.7–47.2)
Cut score 1: 80.4 (76.9–83.6)
Cut score 2: 92.8 (90.3–94.8)
Cut score 3: 97.8 (96.2–98.9)
Cut score 1: 33.5 (26.4–41.3)
Cut score 2: 48.7 (37.2–60.3)
Cut score 3: 66.7 (49.0–81.4)
Cut score 1: 97 (95.0–98.3)
Cut score 2: 94.3 (92.1–96.1)
Cut score 3: 92.4 (89.9–94.4)

CRA = clinician risk assessment; GDS = Geriatric Depression Scale; HAM-D = Hamilton Rating Scale for Depression; K-SADS-PL = Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version; NPV = negative predictive value; NR = not reported; PPV = positive predictive value; SCID = Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders; SDDS-PC = Symptom-Driven Diagnostic System for Primary Care; SRS = Suicide Risk Screen.
* Percentage of participants with a positive result for suicidal behavior on the reference test.
Combined suicidal ideation variable (6.5% endorsed the HAM-D suicidal ideation item and 9.9% endorsed the SCID suicidal ideation item; 94.4% concordance).

Appendix Table 3. Study Population and Intervention Characteristics of Included Studies: Key Questions 4 and 5

Intervention Category Primary Study, Year (Reference) Related Study, Year (Reference) Age Range (Mean Age), y Women, %
Adults and older adults
CBT Brown et al, 200541 Tepper and Whitehead, 200585
Ghahramanlou-Holloway et al, 201286
18–66 (35) 61
Evans et al, 199950
Hawton et al, 198755
Marasinghe et al, 201260
  16–50 (NR)
16+ (29)
15–74 (31)
NR
66
50
Rudd et al, 199662   “Young adult” (22) 18
Samaraweera et al, 200763
Slee et al, 200864
Slee et al, 200887 15–64 (36)
15–35 (24)
60
90
Tyrer et al, 200365 Tyrer et al, 200388
Tyrer et al, 200489
Davidson et al, 200490
Arensman et al, 200491
16–65 (32) 68
Dialectical behavioral therapy Carter et al, 201044
Linehan et al, 199158
Linehan et al, 200659
Harned et al, 201092
Reynolds, 200693
18–65 (24)
18–45 (NR)
18–45 (29)
100
100
van den Bosch et al, 200567 Verheul et al, 200394 18–65 (35) 100
Problem-solving therapy Bannan, 201037
Fitzpatrick et al, 200551
Hatcher et al, 201154
  18–53 (29)
18–24 (19)
16+ (34)
NR
54
69
Psychodynamic or interpersonal therapy Bateman and Fonagy, 199938 Bateman and Fonagy, 200195 16–65 (32) 50
Guthrie et al, 200152 Guthrie et al, 200396 18–65 (31) 56
Other therapy, with direct therapeutic contact Comtois et al, 201147   19–62 (37) 62
Other therapy, without direct therapeutic contact Kovac and Range, 200256   18–42 (23) 73
Medication (lithium) Lauterbach et al, 200857   18+ (39) 57
Practice-based interventions Almeida et al, 201271 Williamson et al, 200797 60–101 (72) 59
Bennewith et al, 200240   16–95 (32) 59
Clarke et al, 200246   20+ (33) 56
Bruce et al, 200442 Alexopoulos et al, 200998
Bogner et al, 200799
Thombs and Ziegelstein, 2008100
Coyne, 2004101
Gallo et al, 2007102
Bao et al, 2011103
Byers et al, 2009104
60–94 (70) 72
Szanto et al, 200770   NR (NR) NR**
Improving treatment adherence with direct person-to-person contact Allard et al, 199236   NR (NR) 57
Cedereke et al, 200245   NR (41) 66
Crawford et al, 201048   18–65 (37) 49
Currier et al, 201049   18–69 (33) 57
Vaiva et al, 200666   18–65 (36) 73
Van Heeringen et al, 199568   15+ (34) 57
Welu, 197769   16+ (29) NR
Improving treatment adherence without direct person-to-person contact Beautrais et al, 201039   16+ (34) 66
Carter et al, 200743 Carter et al, 2005105 16+ (33) 68
Hassanian-Moghaddam et al, 201153   12+ (24) 66
Motto and Bostrom, 200161   NR (33) 56
Adolescents
CBT Donaldson et al, 200573   12–17 (15) 82
Esposito-Smythers et al, 201183 Esposito-Smythers et al, 2012106 13–17 (16) 67
Greenfield et al, 200276   12–17 (14) 69
Developmental group therapy Green et al, 201175
Hazell et al, 200977
Wood et al, 200180
Ougrin, 2011107 12–17 (NR)
12–16 (15)
12–16 (14)
88
90
78
Psychodynamic or interpersonal therapy Chanen et al, 200884
Diamond et al, 201072
Tang et al, 200979

Barnes, 2011108
15–18 (16)
12–17 (15)
12–18 (15)
76
83
66
Other therapy with direct therapeutic contact Eggert et al, 200274 Goldney, 2002109
Thompson et al, 2001110
Randell et al, 2001111
14–19 (16) 49
Hooven et al, 201281   14–19 (16) 60
Other therapy without direct therapeutic contact King et al, 200978   13–17 (16) 71
Improving treatment adherence without direct person-to-person contact Robinson et al, 201282 Robinson et al, 2009112 15–24 (19) 64

 

Table 1 (continued)

Intervention Category Primary Study, Year (Reference) Depressive or Mood
Disorder Diagnosis, %
Previous SA or SH, % (Average Number of Previous SAs or SH Episodes) Brief Description of Intervention Sessions, n
Adults and older adults
CBT Brown et al, 200541 77 SA: 72 (NR) Individual cognitive therapy 10
Evans et al, 199950
Hawton et al, 198755
Marasinghe et al, 201260
NR
NR
NR
DSH: 100 (NR)
SA: 31 (NR)
NR
Brief, manual-based, problem-focused individual cognitive therapy
Brief, problem-focused individual therapy
Brief, mobile telephone–based counseling and prerecorded messages; 1 initial in-person session
2–6
1–8
11
Rudd et al, 199662 18 SA: 41 (NR) 2-wk partial hospitalization (9 h/d), psychoeducational and psychotherapeutic groups, and (as needed) individual crisis counseling 18
Samaraweera et al, 200763
Slee et al, 200864
NR
89
NR
SA: 58 (NR)*
DSH: NR (13)*
Individual CBT with option for partner or parent participation 3–6
12
Tyrer et al, 200365 NR DSH: 100 (NR) Brief, manual-based, problem-focused individual cognitive therapy 5–7
Dialectical behavioral therapy Carter et al, 201044
Linehan et al, 199158
Linehan et al, 200659
NR
NR
72
DSH: 100 (20)*
DSH: 100 (NR)
DSH: 100 (NR)
Team-based, manualized, directive group and individual treatment
Team-based, manualized, directive group and individual treatment
Team-based, manualized, directive group and individual treatment
100+ (estimate)
104
104
van den Bosch et al, 200567 NR SA: 71 (NR)
DSH: 93 (14)
Team-based, manualized, directive group and individual treatment 104
Problem-solving therapy Bannan, 201037
Fitzpatrick et al, 200551
Hatcher et al, 201154
50
NR
NR
DSH: 100 (2)§
NR
DSH: 55 (NR)
Problem-solving therapy group
Problem-solving video/slide presentation
Manual-based individual problem-solving therapy
8
1
4–9
Psychodynamic or interpersonal therapy Bateman and Fonagy, 199938 57 DSH: NR (8-9) Long-term partial hospitalization, guided by psychoanalytic model and twice-weekly long-term psychoanalytic group 400 (estimate)
Guthrie et al, 200152 NR SA: 60 (NR) Psychodynamic individual interpersonal therapy 4
Other therapy, with direct therapeutic contact Comtois et al, 201147 NR SA: NR (5.4) Collaborative assessment and management of suicidality 4–12
Other therapy, without direct therapeutic contact Kovac and Range, 200256 54 (previous treatment
for depression)
SA: 14 (NR)& Writing about difficult times with or without encouragement to “reinterpret” the stressful events through writing 4
Medication (lithium) Lauterbach et al, 200857 76 SA: 44 (NR) 200 mg/wk increase until sufficient blood level attained (0.6 to 0.8 mmol/L) (with usual care) NA
Practice-based interventions Almeida et al, 201271 8 (per PHQ-9 screen) SA: 4.2 (NR) An educational intervention targeting GPs that included a practice audit with personalized automated feedback, printed educational materials, and 6 monthly newsletters NA
Bennewith et al, 200240 NR NR (NR) Notified GP of DSH episode, provided a letter that GP could send to patient and practice guidelines for assessment and treatment NA
Clarke et al, 200246 56 (per HADS screen) DSH: 47 (NR) PCP given treatment guidelines for depression in older adults, assigned care manager to advise PCP and provide psychotherapy if needed; informed if patient reported suicidal ideation NA
Bruce et al, 200442 66 NR Case management: comprehensive assessment and determination of treatment needs, monitoring treatment and patient status NA
Szanto et al, 200770 NR NR 5-y depression management educational program for GPs and nurses with consultation service, special depression treatment clinics 4 main provider education sessions with additional optional lectures
Improving treatment adherence with direct person-to-person contact Allard et al, 199236 87 SA: 50 (2) Specific schedule of treatment prescribed (starting with weekly visits, then tapering off), outreach in case of missed appointments, content of treatment left to discretion of provider ≤19
Cedereke et al, 200245 42 (mood disorder) SA: NR (1.1) Telephone contacts to assess and provide encouragement to stay in or return to treatment if needed 2
Crawford et al, 201048 NR NR Appointment card with alcohol counselor; counselor visit included assessment and advice on alcohol reduction and referral to treatment 1
Currier et al, 201049 19 SA: “majority” (NR) Extensive clinical assessment within 48 h of discharge at location of participant's choice, referral to community resource 1
Vaiva et al, 200666 NR SA: 9 (NR)†† Single telephone contact 1 or 3 mo after discharge to revisit recommended treatment, encourage reengagement in treatment if needed, provide crisis counseling as needed 1
Van Heeringen et al, 199568 15 (mood disorder) SA: 30 (NR)
DSH: 89 (NR)§
Home visits for patients not adherent to initial treatment referral, follow-up to check on adherence 1–2
Welu, 197769 NR SA: 60 (NR) Contact immediately after ED discharge by telephone; home visit for
assessment and treatment plan/referral, continued monitoring
NR
Improving treatment adherence without direct person-to-person contact Beautrais et al, 201039 NR DSH: 18 (0.4)‡‡ Sent postcards at 2 wk, 6 wk, 3 mo, 6 mo, 9 mo, and 12 mo after DSH episode wishing patients well and inviting them to contact provider 0
Carter et al, 200743 NR DSH: 17 (NR)§ Sent postcards at 1, 2, 3, 6, 8, 10, and 12 mo after DSH episode wishing patients well and inviting them to contact provider 0
Hassanian-Moghaddam et al, 201153 NR SA: 34 (NR) Sent postcards at 1, 2, 3, 6, 8, 10, and 12 mo after DSH episode in addition to receiving one on birthday wishing patients well and inviting them to contact provider 0
Motto and Bostrom, 200161 NR NR 24 letters over 5 y expressing concern and inviting participant to contact staff member 0
Adolescents
CBT Donaldson et al, 200573 29 SA: 48 (NR) Individual skills-based treatment and brief contact with parents at each session and 1 to 3 family sessions 12–16
Esposito-Smythers et al, 201183 94 SA: 75 (NR)
DSH: 72 (NR)
Individual skills development with youth; parenting and other skills development for parents with separate therapist; and family sessions, targeting suicidality and substance misuse 34+
Greenfield et al, 200276 48 SA: 37 (NR)§§ Phone contact immediately after ED visit, involving in-depth assessment and treatment NR
Developmental group therapy Green et al, 201175
Hazell et al, 200977
Wood et al, 200180
62
57
83
DSH: 100 (21)‡‡
DSH: 100 (NR)
DSH: 79 (4.1)§
Developmental group psychotherapy
Developmental group psychotherapy
Developmental group psychotherapy
6+
6+
6+
Psychodynamic or interpersonal therapy Chanen et al, 200884
Diamond et al, 201072
Tang et al, 200979
15
47 NR
100
DSH: 94 (9.5)&&
SA: 62 (NR)
NR
Cognitive analytic therapy
Process-oriented and emotion-focused attachment-based family therapy
Intensive individual interpersonal psychotherapy
24
NR
18
Other therapy with direct therapeutic contact Eggert et al, 200274 NR SA: NR (0.2)¶¶ Computer-assisted suicide assessment; motivational counseling session; and identification of school-based case manager to support connection among school, parents, and youth 1
Hooven et al, 201281 NR NR C-CARE: Computer-assisted suicide assessment; motivational counseling session; and identification of school-based case manager to support connection among school, parents, and youth
P-CARE: 2 parent sessions reviewing suicide risk, support and communication skills, conflict reduction, and youth mood management
C + P-CARE: Both of the above
C-CARE: 1
P-CARE: 2
Other therapy without direct therapeutic contact King et al, 200978 88 SA: 75 (NR) Youth-nominated support person trained to provide support to the youth NA
Improving treatment adherence without direct person-to-person contact Robinson et al, 201282 67 SA: 16 (NR)
DSH: 68 (10.7)
Monthly postcards for 12 mo, expressing interest in the person's well-being, reminding him or her about previously identified sources of help, and describing 1 of 6 rotating self-help strategies (e.g., physical activity, books, and Web sites) 0

CBT = cognitive behavioral therapy; DSH = deliberate self-harm; ED = emergency department; GP = general practitioner; HADS = Hospital Anxiety and Depression Scale; NA = not applicable; NR = not reported; PCP = primary care provider; PHQ-9 = Patient Health Questionnaire-9; SA = suicide attempt.
* In the past 3 mo.
Participants were parasuicidal.
Median number of self-mutilation acts.
§ Self-poisoning.
& Previous treatment for suicide attempt.
Combined outcome of suicide attempts and suicidal ideation.
** 2 regions were similar in proportion of women (52%) and older residents (22%).
†† 4 or more attempts in the past 3 y.
‡‡ In the past 12 mo.
§§ In the past 6 mo.
&& Median number of lifetime “parasuicide” episodes.
¶¶ In the past month.

Appendix Table 4. Outcomes Reported in Included Trials for Benefits and Harms of Treatment (Key Questions 4 and 5)

Intervention Category Primary Study, Year (Reference) Related Study, Year (Reference) Population
Adults and older adults
CBT Brown et al, 200541 Tepper and Whitehead, 200585
Ghahramanlou-Holloway et al, 201286
Adults (aged 18–66 y) with a suicide attempt within 48 h of visit to ED, identified in ED
Evans et al, 199950   Adults (aged 16–50 y) presenting to participating mental health center or hospital after DSH
Hawton et al, 198755   Adults (16+ y) admitted to general hospital after overdose and “continuing problems which they were willing to tackle with the help of the counselors”
Marasinghe et al, 201260   Adults (aged 15–74 y) admitted to hospital after attempting self-harm; displayed clinically significant suicidal intent at the interview or on the BSSI
Rudd et al, 199662   Young adults with suicide attempt or suicidal ideation with mood disorder or suicidal ideation plus alcohol use (age range NR)
Samaraweera et al, 200763   Adult (aged 15–64 y) sample from a population study, screening positive for suicidality
Slee et al, 200864 Slee et al, 200887 Adults (aged 15–35 y) visiting a mental health center because of self-harm
Tyrer et al, 200365 Tyrer et al, 200388
Tyrer et al, 200489
Davidson et al, 200490
Arensman et al, 200491
Adults (aged 16–65 y) presenting to accident and emergency department after episode of DSH, with 1+ previous attempts
Dialectical behavioral therapy Carter et al, 201044   Adult (aged 18–65 y) female patients with BPD with at least 3 DSH episodes in the past year
Linehan et al, 199158   Adult (aged 18–45 y) female patients with BPD with at least 2 episodes of DSH in the past 5 y, including 1 in the past 8 wk
Linehan et al, 200659 Harned et al, 201092
Reynolds, 200693
Adult (aged 18–45 y) female patients with BPD with at least 2 episodes of DSH in the past 5 y, including 1 in the past 8 wk
van den Bosch et al, 200567 Verheul et al, 200394 Adult (aged 18–65 y) female patients with BPD recruited from mental health institutions and addiction treatment services
Problem-solving therapy Bannan, 201037   Adults (aged 18–53 y) with a self-poisoning episode, previous DSH within the past 12 mo
Fitzpatrick et al, 200551   University students (aged 18–24 y) screening positive for suicide (with BSS), participated in the study for extra class credit
Hatcher et al, 201154   Adults (aged 16+ y) presenting to the hospital for self-harm but not hospitalized for more than 48 h
Psychodynamic or interpersonal therapy Bateman and Fonagy, 199938 Bateman and Fonagy, 200195 Adult (aged 16–65 y) patients with BPD referred to psychiatric unit
Guthrie et al, 200152 Guthrie et al, 200396 Adults (aged 18–65 y) presenting to ED after episode of DSH
Other therapy, with direct therapeutic contact Comtois et al, 201147   Adults (aged 19–62 y) evaluated for suicide attempt or imminent risk but judged safe for discharge; no mental health care available for 2 wk
Other therapy, without direct therapeutic contact Kovac and Range, 200256   University students (aged 18–42 y) who screened positive for increased risk for suicide
Medication (lithium) Lauterbach et al, 200857   Adults (aged 18+ y) with a suicide attempt in past 3 mo and depressive spectrum disorder, identified through screening at psychiatric ED and inpatient unit
Practice-based interventions Almeida et al, 201271 Williamson et al, 200797 General practitioners recruited older adult patients (aged 60–101 y)
Bennewith et al, 200240   Adult (aged 16–95 y) patients with DSH identified through case registry updated weekly of all DSH patients in hospital accident and ED
Clarke et al, 200246   Adults (aged 20+ y) presenting to accident and ED after DSH
Szanto et al, 200770   General practitioners (age range NR) providing services to inhabitants of region with high suicide rates
Bruce et al, 200442 Alexopoulos et al, 200998
Bogner et al, 200799
Thombs and Ziegelstein, 2008100
Coyne, 2004101
Gallo et al, 2007102
Bao et al, 2011103
Byers et al, 2009104
Depressed older adults (aged 65–94 y), recruited from primary care screening for depression
Improving treatment adherence with direct person-to-person contact Allard et al, 199236   Persons with an ED visit for suicide attempt at study hospitals (age range NR)
Cedereke et al, 200245   Persons treated at ED for suicide attempt, recruited 1 mo after attempt (age range NR)
Crawford et al, 201048   Adults (aged 18–65 y) presenting to ED after DSH and misusing alcohol
Currier et al, 201049   Suicidal adults (aged 18–69 y), identified in ED
Vaiva et al, 200666   Adults (aged 18–65 y) with a suicide attempt by drug overdose, cleared for discharge from ED
Van Heeringen et al, 199568   Adults (aged 15+ y) who attempted suicide referred to accident and ED
Welu, 197769   Adults (aged 16+ y) who attempted suicide brought to ED
Improving treatment adherence without direct person-to-person contact Beautrais et al, 201039   Adults (16+ y) presenting to psychiatric ED with suicide attempt or DSH
Carter et al, 200743 Carter et al, 2005105 Adults (aged 16+ y) presenting to toxicology service for self-poisoning
Hassanian-Moghaddam et al, 201153   Adolescents and adults (aged 12+ y) with a hospital admission for self-poisoning
Motto and Bostrom, 200161   Persons refusing further treatment 1 mo after discharge from inpatient stay after suicide attempt (age range NR)
Adolescents
CBT Donaldson et al, 200573   Adolescents (aged 12–17 y) presenting to ED or inpatient unit after suicide attempt
Esposito-Smythers et al, 201183 Esposito-Smythers et al, 2012106 Adolescent (aged 13–17 y) psychiatric inpatients with a suicide attempt in past 3 mo or clinically significant suicidal ideation in the past month and an alcohol or cannabis use disorder
Greenfield et al, 200276   Adolescents (aged 12–17 y) presenting to ED after suicide attempt
Developmental group therapy Green et al, 201175 Ougrin, 2011107 Adolescents (aged 12–17 y) with 2 DSH episodes in past 12 mo, recruited from mental health services centers
Hazell et al, 200977   Adolescents (aged 12–16 y) with 2 DSH episodes in past 12 mo (including 1 in past 3 mo), referred to mental health services
Wood et al, 200180   Adolescents (aged 12–16 y) referred to mental health services after DSH
Psychodynamic or interpersonal therapy Chanen et al, 200884   Adolescents (aged 15–18 y) with 2 or more symptoms of BPD referred to mental health services for acute, severe mental health problems
Diamond et al, 201072 Barnes, 2011108 Adolescents (aged 12–17 y) identified as suicidal by screening during primary care or ED visits
Tang et al, 200979   Adolescents (aged 12–18 y) with moderate to severe depression, suicidal ideation, previous suicide attempt, moderate to severe anxiety, or substantial hopelessness, based on school-based screening; random sample from participating schools selected for study
Other therapy with direct therapeutic contact Eggert et al, 200274 Goldney, 2002109
Thompson et al, 2001110
Randell et al, 2001111
Adolescents (aged 14–19 y) at increased risk for dropping out of high school who screened positive for increased risk for suicide
Hooven et al, 201281   Adolescents (aged 14–19 y) who screened positive for suicide risk or at least 2 of the following: moderate depression, moderate suicidal ideation/threats, and/or alcohol and drug use
Other therapy without direct therapeutic contact King et al, 200978   Hospitalized adolescents (aged 13–17 y) with suicidal ideation or attempt within the past 4 wk
Improving treatment adherence without direct person-to-person contact Robinson et al, 201282 Robinson et al, 2009112 Young persons (aged 15–24 y) with a history of suicide threats, ideation, attempts and/or DSH who did not meet entry criteria for service, either because they were not unwell enough or were receiving treatment elsewhere

 

Table 2 (continued)

Intervention Category Primary Study, Year (Reference) Participant
Randomly
Assigned, n
Country Suicide Deaths Suicide
Attempts/
DSH Episodes
Hospitali-
zation
or ED Use
Other
Health
Outcome
Suicidal
Ideation
Depression Hope-
lessness
Adults and older adults
CBT Brown et al, 200541 120 United States   X*     XXX X XX
Evans et al, 199950 34 United Kingdom   XXX   XXX   X  
Hawton et al, 198755 77 United Kingdom XXX XXX   XXX   XXX  
Marasinghe et al, 201260 68 Sri Lanka         X X  
Rudd et al, 199662 302 United States         XXX XXX XXX
Samaraweera et al, 200763 10 Sri Lanka         X*    
Slee et al, 200864 90 The Netherlands XXX X XX     X  
Tyrer et al, 200365 480 United Kingdom XXX XXX   XXX   XXX  
Dialectical behavioral therapy Carter et al, 201044 73 Australia   XXX X        
Linehan et al, 199158 63 United States   XXX X   XXX XXX XXX
Linehan et al, 200659 111 United States XXX X* X   XXX XXX  
van den Bosch et al, 200567 64 The Netherlands   XXX          
Problem-solving therapy Bannan, 201037 20 Ireland         XXX X* X
Fitzpatrick et al, 200551 110 United States XXX       X* X* XXX
Hatcher et al, 201154 522 New Zealand   XXX       X X
Psychodynamic or interpersonal therapy Bateman and Fonagy, 199938 44 United Kingdom   X* X X   X  
Guthrie et al, 200152 119 United Kingdom XXX X     X XX  
Other therapy, with direct therapeutic contact Comtois et al, 201147 32 United States XXX XXX X X      
Other therapy, without direct therapeutic contact Kovac and Range, 200256 121 United States         XXX XXX  
Medication (lithium) Lauterbach et al, 200857 167 Germany X XXX          
Practice-based interventions Almeida et al, 201271 373 general practitioners,
21,762 patients
Australia   X       XXX  
Bennewith et al, 200240 1932 United Kingdom   XXX          
Clarke et al, 200246 526 United Kingdom   XXX          
Bruce et al, 200442 2 geographic locations (n = ~ 127,000) Hungary X            
Szanto et al, 200770 598 United States X XXX   X XX X  
Improving treatment adherence with direct person-to-person contact Allard et al, 199236 150 Canada XXX XXX          
Cedereke et al, 200245 216 Sweden XXX XXX   XXX X    
Crawford et al, 201048 103 United Kingdom   XXX          
Currier et al, 201049 122 United States   XXX   XXX XXX XXX  
Vaiva et al, 200666 605 France XXX XXX          
Van Heeringen et al, 199568 516 Belgium XXX XXX          
Welu, 197769 143 United States   XXX          
Improving treatment adherence without direct person-to-person contact Beautrais et al, 201039 327 New Zealand   XXX          
Carter et al, 200743 772 Australia   XXX XXX        
Hassanian-Moghaddam et al, 201153 2300 Iran   X     X    
Motto and Bostrom, 200161 843 United States XX     XXX      
Adolescents
CBT Donaldson et al, 200573 39 United States   XXX     XXX XXX  
Esposito-Smythers et al, 201183 40 United States   X X   XXX XXX  
Greenfield et al, 200276 286 Canada XXX XXX X XXX XXX    
Developmental group therapy Green et al, 201175 366 United Kingdom XXX XXX XXX XXX XXX XXX  
Hazell et al, 200977 72 Australia   XXX   XXX XXX XXX  
Wood et al, 200180 63 United Kingdom   X   XXX XXX XXX  
Psychodynamic or interpersonal therapy Chanen et al, 200884 86 Australia   XXX   XXX      
Diamond et al, 201072 66 United States   XXX   XXX X* XXX  
Tang et al, 200979 73 Taiwan         X X X
Other therapy with direct therapeutic contact Eggert et al, 200274 238 United States         X X X
Hooven et al, 201281 615 United States         X XX XX
Other therapy without direct therapeutic contact King et al, 200978 448 United States XXX XXX XXX   XX X X
Improving treatment adherence without direct person-to-person contact Robinson et al, 201282 165 Australia   XXX     XXX XXX XXX

BPD = borderline personality disorder; BSSI = Beck Scale for Suicidal Ideation; CBT = cognitive behavioral therapy; DSH = deliberate self-harm; ED = emergency department; NR = not reported.
X Significant group differences for one half or more of reported outcomes/follow-ups.
XX Significant group differences for at least 1 but fewer than one half of reported follow-ups or analyses.
XXX No significant group differences reported.
* Difference in statistical significance of results between meta-analysis and original study, usually because of differences in outcomes analyzed (e.g., change from baseline in meta-analysis vs. repeated measures group X time effect in study; analyzing risk ratios in meta-analysis vs. odds ratios in study; use of unadjusted results in meta-analysis but adjusted P values are presented in study).
Included in meta-analysis, shown on Figures 1 to 4.
Combined outcomes of suicide attempts and suicidal ideation.

Current as of: April 2013

Internet Citation: Evidence Summary: Suicide Risk in Adolescents, Adults and Older Adults: Screening. U.S. Preventive Services Task Force. April 2013.
https://www.uspreventiveservicestaskforce.org/Page/Document/evidence-summary20/suicide-risk-in-adolescents-adults-and-older-adults-screening

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