Skip to navigation bar Skip to breadcrumbs Skip to page content
clear place holder
Envelope icon E-mail Updates Teal square Text size:  a A A
Choose another version >>

Archived Final Evidence Summary

Other Supporting Document for Suicide Risk: Screening

Originally published on: August 19, 2014

This recommendation statement is currently archived and inactive. It should be used for historical purposes only. Click here for copyright and source information .

Disclaimer:Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Archived: Preface

Summary of the Evidence

Bradley N. Gaynes, M.D., M.P.Ha; Suzanne L. West, Ph.D.b; Carol A. Ford, M.D.c; Paul Frame, M.D.d; Jonathan Klein, M.D., M.P.H.e; Kathleen N. Lohr, Ph.D.f

The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Address correspondence to: Bradley N. Gaynes, M.D., M.P.H.; Department of Psychiatry; CB 7160; University of North Carolina; Chapel Hill, NC 27599; E-mail

Select for copyright information. The USPSTF recommendations based on this review are online.

The summaries of the evidence briefly present evidence of effectiveness for preventive health services used in primary care clinical settings, including screening tests, counseling, and chemoprevention. They summarize the more detailed Systematic Evidence Reviews, which are used by the U.S. Preventive Services Task Force (USPSTF) to make recommendations.

Archived: Structured Abstract

Background: Suicide is the 11th leading cause of death and the seventh leading cause of years of potential life lost in the United States. Although suicide is of great public health significance, its clinical management is complicated.

Purpose: We systematically reviewed the literature to determine whether screening for suicide risk in primary care settings decreases morbidity, mortality, or both.

Data Sources: MEDLINE® (1966 to October 17, 2002), PsycINFO, Cochrane databases, hand-searched bibliographies, and experts.

Study Selection: For screening, we examined only English-language studies performed in primary care settings. For treatment, we included randomized controlled trials (RCTs), and cohort studies were included if they were performed in any setting where suicide completions, suicide attempts, or suicidal ideation were reported.

Data Extraction: A primary reviewer abstracted data on key variables of study population, design, and outcomes; a second reviewer checked information accuracy against the original articles.

Data Synthesis: No study directly addressed whether screening for suicide in primary care reduces morbidity and mortality; the remainder of the review focused on the questions of reliable screening tests for suicide risk and the effectiveness of interventions to decrease depression, suicidal ideation, and suicide attempts or completion. One screening study provided limited evidence for the accuracy of suicide screening in a primary care setting. Intervention studies provide fair and mixed evidence that treating those at risk for suicide reduces the number of suicide attempts or completions. The evidence suggests mild to moderate improvement for interventions addressing intermediate outcomes such as suicidal ideation, decreased depressive severity, decreased hopelessness, or improved level of functioning.

Conclusion: Because of the complexity of studying the risk for suicide and the paucity of well-designed research studies, only limited evidence guides the primary care clinician's assessment and management of suicide risk.

Archived: Introduction

Suicide is a major public health problem in the United States. In 2001, suicide was the 11th leading cause of death in the United States, accounting for approximately 30,000 deaths with an age-adjusted rate of 10.7 per 100,000 persons.1 Suicide accounts for 1.3 percent of total deaths, more than double the number due to HIV infection and AIDS.2 It is the seventh leading cause of years of potential life lost, surpassing diabetes, liver disease, and HIV infection.1 Annually, approximately 500,000 individuals require emergency department treatment in U.S. medical centers following attempted suicide.3 One of every 6 young adults describes having suicidal ideation at some point in their lives, and 5.5 percent report ever having made a suicide attempt.4 The public health significance of this problem was underscored by The Surgeon General's Call to Action to Prevent Suicide,3 which proposed completion of a National Strategy for Suicide Prevention.5

Relevant demographic risk factors have been identified. Individuals aged 65 and older are at the highest risk for completed suicide; white men aged 85 and older have an especially high rate (59/100,000).5 Suicide also affects adolescent and young adults; it is the third leading cause of death among persons aged 15 to 24 (10.3/100,000), following unintentional injuries and homicide.1 Rates of suicide attempts and completions differ by sex; men have a higher rate of suicide completion, whereas women have a higher rate of attempts.6 Finally, suicide behaviors vary widely by race and ethnicity. Nearly 75 percent of all completed suicides are by white males,2 who have a 2-fold higher risk for suicide than black men (11.7/100,000 vs. 5.5/100,000).1

Clinical risk factors have also been identified. Suicide is closely related to psychiatric illness. More than 90 percent of those who complete suicide have a diagnosable psychiatric illness at the time of death, usually depression, alcohol abuse, or both.7 Hopelessness, often present in those with severe depressive illness and a history of previous suicide attempts are particularly strong and independent prospective risk factors for a suicide.8 Although prior suicide attempts are a key risk factor, two-thirds of suicides occur on the first attempt,9 and suicide attempts remain substantially more common than completed suicides by a factor between 10 and 20.7 Other identified risk factors for completed suicide include being widowed or divorced, living alone, having a recent harmful event (such as job loss or death of loved one), having severe anxiety, having a chronic medical illness (especially a central nervous system disorder), and having a family history of suicide attempts or completions (Hirschfield and Russell7 and Mann9 provide more detailed reviews).

Primary care physicians have a key role in identifying and managing suicidal tendency. Patients endorsing suicidal ideation, a key factor in the assessment of suicide risk, are not uncommon in primary care; between 2 percent and 3 percent of primary care patients report suicidal ideation in the pervious month.10, 11 Furthermore, most patients completing suicide have recently visited their primary care physician. Approximately one-half to two-thirds of individuals who commit suicide visit physicians within 1 month of taking their lives; 10 percent to 40 percent visit in the week before.12-15

The clinical management of suicide risk is complicated. Suicide is a rare event. It has a low prevalence in the general population (0.01 percent)16 and, despite a 10-fold increase in adults with depression, most depressed patients (99.9 percent) do not commit suicide.17 As a result, many clinical trials on the management of suicide risk have focused on high-risk patients, such as those with a history of deliberate self-harm.

Deliberate self-harm, understood as an intentionally initiated act of self-harm with nonfatal outcome (including self-poisoning and self-injury), encompasses terms such as attempted suicide and parasuicide.18 Deliberate self-harm is not synonymous with attempted suicide. Attempted suicide, understood as a self-initiated act with the intent of ending one's life, is only a single example of deliberate self-harm. Still, deliberate self-harm is a recurrent behavior with important long-term risks. Between 15 percent and 23 percent of patients who are seen for deliberate self-harm will be seen for treatment of a subsequent episode within 1 year19and are at high risk for repeat deliberate self-harm in the weeks following an episode.20 Of those with an episode of deliberate self-harm, 3 percent to 5 percent die by suicide within 5 to 10 years.21 Identification of deliberate self-harm is relevant to primary care practice, since two-thirds of patients who deliberately harm themselves visit their general practitioner within 12 weeks of the episode.22 Patients with borderline personality disorder are at increased risk for deliberate self-harm, with groups from psychiatric and primary care settings having similar self-harm profiles.23

Given the Surgeon General's call to action, clarification of the available evidence base guiding the clinical management of suicide risk is especially pertinent. As part of the USPSTF update of its 1996 recommendation,24 we examined the evidence addressing whether primary care identification and treatment of suicide risk improves outcomes in patients whose risk had previously been unidentified. Our full systematic evidence review set out to answer 8 key questions (Appendix Figure 1). In this article, we report on the 3 key questions for which we found data meeting our selection criteria:

  1. Can a screening test reliably detect suicide risk in primary care populations?
  2. For those at risk, does treatment result in decreased suicide attempts or completions?
  3. For those at risk, does treatment result in improved intermediate outcomes (e.g., decreased suicidal ideation or depressive severity)?

Archived: Methods

Using USPSTF methods,25 we developed an analytic framework and 8 key questions to guide our literature searches. (Appendix Table 1, Appendix Table 2, Appendix Table 3, and Appendix Figure 1.) Our population of interest was primary care patients with previously unidentified suicide risk.

To identify relevant articles, we searched the MEDLINE® database from 1966 to October 17, 2002, beginning with the terms suicide or suicide, attempted. We supplemented these sources by using the same search terms in PsycINFO; searching the Cochrane Collaboration Library; and hand searching the bibliographies of systematic reviews, relevant original articles, and the 1996 edition of the Guide to Clinical Preventive Services.24 We additionally reran searches using deliberate self-harm as a search term and identified no further articles. In this paper, we present our findings for studies involving adults.

We found 1 well-conducted, recent systematic review by Hawton et al. concerning treatment of deliberate self-harm, which was relevant to reducing suicide attempts or completions, our primary outcome.18 We found another recent, well-done systematic review relevant to intermediate outcomes.26 We checked our study results against the studies in these reviews, and we examined in detail only those studies that had not been included in the systematic reviews.

Two of the authors independently reviewed all titles and abstracts. If either reviewer determined that the study met inclusion criteria, we retrieved the full paper for further evaluation. Two of the authors subsequently reviewed the studies to determine final inclusion, adjudicating disagreements by consensus discussion.

A primary reviewer abstracted relevant information into evidence tables. As part of this abstraction, the primary reviewer rated the internal and external validity for each article using criteria developed by the USPSTF Methods Work Group.25 A second reviewer checked the accuracy of the abstracted information against the original articles, while the first author reviewed all quality ratings to ensure consistency.

We required that screening studies be performed within a primary care setting, but treatment studies could be performed in either primary or specialty care settings. This strategy reflected our idea that screening must be performed in primary care but should suicide risk be identified, a primary care physician could refer patients for subsequent treatment.

For screening studies, inclusion required comparison with a gold standard. For treatment studies, inclusion required that trials report suicide completions, suicide attempts, or suicidal ideation as primary outcomes. We excluded the following: clinical trials targeting patients with chronic psychotic illnesses because these patients would already be identified as having increased suicide risk; randomized controlled trials (RCTs) that did not supply sufficient detail to allow direct comparison of outcomes between intervention and control groups; and cohort studies that did not have either a similar clinical presentation for intervention and control groups or an independent control group.

This research was funded through a contract to the RTI International-University of North Carolina Evidence-based Practice Center from the Agency for Healthcare Research and Quality (AHRQ). Agency staff and Task Force members participated in the study design and reviewed draft and final manuscripts A more comprehensive report was distributed for review to content experts and revised accordingly before preparation of this manuscript.27

Archived: Results

Can a Screening Test Reliably Detect Suicide Risk in Primary Care Populations?

Our evaluation identified 1 relevant article assessing an instrument's operating characteristics for identifying suicide risk in primary care.10 The Symptom-Driven Diagnostic System for Primary Care (SDDS-PC),28 a 62-item self-report instrument designed to help identify psychiatric illness in primary care settings, contains 3 items assessing suicide risk (all within the past month).10 Data on suicidal thoughts, plans, and past attempts were systematically collected using a nurse-administered, face-to-face structured interview conducted immediately before the medical visit. The individual operating characteristics of the 3 items were compared with a structured interview for identifying a plan to commit suicide (the gold standard).

"Thoughts of death" had 100 percent sensitivity, 81 percent specificity, and 5.9 percent positive predictive value for detecting patients with a plan to commit suicide. Endorsing "wishing you were dead" had 92 percent sensitivity, 93 percent specificity, and 14 percent positive predictive value; "feeling suicidal" had 83 percent sensitivity, 98 percent specificity, and 30 percent positive predictive value. Of those "feeling suicidal," 85 percent had a psychiatric disorder as determined by structured clinical interviews.29 Only major depression (odds ratio [OR], 33.1; 95 percent confidence interval [CI], 10.9-99.6) and drug abuse or dependence (OR, 16.7; 95% CI, 3.9-71.4) were independently associated with suicidal ideation. Of note, only 46 percent of those eligible for this study agreed to participate.

Given the rarity of suicide attempts in the primary care population, finding an accurate screening strategy for suicide risk in a primary care setting is a daunting challenge. This is illustrated by the following hypothetical situation. Consider a screening instrument (e.g., endorsing "feeling suicidal") that identifies patients at high risk and has reasonable test characteristics (e.g., sensitivity of 80 percent and specificity of 70 percent, figures similar to screening tools for depression).30, 31 Apply this tool to a population of 10,000 in which 10 patients will attempt suicide (10-fold more than the 10 in 100,000 persons who will complete suicide), it will produce 8 true-positive results, 2 false-negative results, and 2,997 false-positive results, a positive predictive value of 0.3 percent. This high proportion of false-positive results could generate a substantial time and cost burden. Using the higher specificity result (98 percent) from the prior study produces substantially fewer false-positive results (n = 200), but only a slightly improved positive predictive value (3.8 percent).

Does Treatment Reduce Suicide Attempts or Completions?

We report findings first from RCTs and then from cohort studies. Within each study design section, we provide the evidence stratified by age whenever possible.

Randomized Controlled Trials

All 30 RCTs that met our inclusion criteria27 involved high-risk groups as identified by a deliberate self-harm episode, a diagnosis of borderline personality disorder, or admission to a psychiatric unit. However, only Motto and Bostrom32 and Rudd et al.33 identified depressive illness as part of their eligibility criteria, and no studies focused primarily on depressed patients with suicidal ideation. Of the 2 studies directly involving primary care, 1 recruited some of its patients from a primary care setting (although the intervention occurred in a psychiatric outpatient setting)34 and the other conducted its intervention in a primary care setting.35

Trials focusing on adolescents or young adults and elderly adults, the 2 populations of greatest clinical concern, were limited. The included studies involved either adults only or adults and older adolescents but did not differentiate further by age in the analyses; we review them together.

We found no published intervention study for the elderly population. However, the Prevention of Suicide in Primary Care Elderly-Collaborative Trial (PROSPECT) is currently being conducted.36 PROSPECT aims to determine whether placement of a depression health specialist in primary care practices has a favorable impact on rates of depression, hopelessness, and suicidal ideation in elderly primary care patients with depressive illness. Initial outcomes for the 4- and 8-month followup periods were expected in 2003.

We organized our review of the 30 RCTs as follows. Because Hawton et al.18 had systematically reviewed 21 of these trials,37-57 we first briefly summarize the results of their meta-analysis (Table 1). We then provide greater detail on the 9 additional RCTs of deliberate self-harm that our literature search identified (Table 2).32-35, 58-63 two articles58, 59 were from a single trial and are counted as 1 trial. Given the substantial heterogeneity of the populations enrolled, the interventions tested, the length of followup periods, and the outcomes measured, we concluded that integrating the new studies into the prior summary was not warranted.

Prior Review of RCTs for Deliberate Self-Harm

Of the 21 studies of adults receiving treatments for deliberate self-harm (Table 1),37-57 12 included older adolescents.37-44, 46, 47, 52, 54 Although some trends suggested incremental benefit from certain interventions compared with usual care, interventions for which more than 1 study was performed produced no statistically significant effects by meta-analysis. The most promising intervention was problem-solving therapy, a short-term, cognitively-oriented psychotherapy. In 5 studies of this intervention versus standard aftercare, the summary OR showed a trend toward decreasing deliberate self-harm (OR, 0.70; 95% CI, 0.45-1.11).37-41 Of note, both the form and duration of treatment varied considerably within these 5 studies.

Intensive care plus outreach versus standard aftercare (6 studies)42-47 produced a summary OR of 0.83 (95% CI, 0.61-1.14). Again, the form and duration of treatment varied substantially among the studies. One large trial comparing provision of both physician contact and crisis intervention assistance showed a trend toward a decreased likelihood of repeating deliberate self-harm in favor of the intervention (OR, 0.43; 95% CI, 0.15-1.27) compared with standard care.48

Two interventions, each supported by a single study involving a maximum of 20 patients in each group, reported statistically significant reduced repetition of deliberate self-harm. Dialectical behavior therapy (DBT), a comprehensive treatment program developed to treat severely dysfunctional individuals with borderline personality disorders by improving emotional and behavioral management skills, significantly reduced repetition of deliberate self-harm for patients with borderline personality disorder and recent deliberate self-harm compared with standard care (OR, 0.24; 95% CI, 0.06-0.93).49 Administration of the antipsychotic flupenthixol significantly reduced the proportion of repeated deliberate self-harm for those with a history of at least 2 prior suicide attempts compared with placebo (OR, 0.09; 95% CI, 0.02-0.50).53

Additional RCTs of Deliberate Self-Harm

Of the 9 additional studies involving repetition of deliberate self-harm identified in our literature search (Table 2),32-35, 58-63 2 showed benefit. Guthrie et al. found significant benefit from interpersonal psychotherapy, a time-limited method that focuses on resolving current interpersonal problems to improve symptoms, compared with standard care.60 Patients who presented to an emergency department with deliberate self-harm, but did not require medical or psychiatric hospitalization, were enrolled. Participants were randomized to either 4, 50-minute sessions of interpersonal psychotherapy delivered by nurse therapists in the patient's home, or usual care. Of those eligible (n = 119), 51 percent participated; those refusing were at a greater suicide risk as indicated by clinical measures. In an intention-to-treat analysis, those in the interpersonal psychotherapy group were less likely to have a repeat episode of deliberate self-harm in the subsequent 6-month period (8.6 percent vs. 27.9 percent, P <0.001).

Bateman and Fonagy compared psychoanalytically oriented partial hospitalization with standard psychiatric outpatient aftercare for patients with borderline personality disorder.58, 59 Treatment occurred for a maximum of 18 months. Twenty-two patients were initially randomized to each group; analysis was not intention-to-treat. After 18 months of treatment, the percentage of those with suicide attempts within the prior 6 months was significantly lower in the treatment group than in the control group (53 percent for intervention group, no rate given for control group, but a graph suggests approximately 40 percent [P <0.001]). At the 36-month followup, a significantly smaller proportion of the partial hospitalization group made a suicide attempt compared with the usual care group (18.2 percent vs. 63.2 percent; no OR calculated; P <0.004).

The remaining 7 studies identified no benefit from interventions (Table 2). In 6 studies in which treatment was provided in the primary care setting, interventions included providing an emergency information card,62 a letter,32 outpatient day hospitalization,33 antidepressant medication,61 antipsychotic medication,63 and DBT.34 All interventions were compared with usual care or placebo (for the 2 medication studies). Of interest, a subgroup analysis in the Evans et al. emergency information card study suggested a need to examine the data by whether previous deliberate self-harm had occurred; for those with a history of deliberate self-harm, the intervention increased the likelihood of repeat deliberate self-harm.62

In the only study that tested an intervention for suicide risk in the primary care setting, Bennewith et al. compared a 3-part, 1-time intervention with usual care.35 The intervention provided general practitioners with:

  1. A letter informing them of a patient's deliberate self-harm episode.
  2. A letter the physicians could forward to the patient inviting him or her to make an appointment.
  3. Guidelines on assessing and managing deliberate self-harm in general practice.

In an intention-to-treat analysis at a 12-month followup, the groups did not differ significantly in the proportion of patients who attempted suicide (21.9 percent vs. 19.5 percent). Adherence to this low-intensity intervention was poor; only 58 percent of the intervention-group physicians sent letters to the patients.

Of note, the investigators reported a subgroup analysis with results opposite to those of Evans et al.62 For patients with prior deliberate self-harm, this primary care intervention significantly decreased the likelihood of repeat deliberate self-harm, whereas for those with no prior deliberate self-harm, the intervention increased the likelihood of repetition (Table 2). The variability of adherence in the Bennewith et al. study and the differences in the 2 trials' study populations may partially explain the contradictory results.

Cohort Studies

Two cohort studies, each using depression as part of how they selected participants, met our inclusion criteria.64, 65 Neither study produced statistically significant differences involving repeated suicidal behavior (Table 3).

Using a nested case-control design, Coryell et al. evaluated suicide risk in a long-term cohort of patients with major affective disorders.64 In this small study, case-patients were compared with controls for use of lithium in the week before the suicide completion (15 case-patients vs. 15 matched controls) or suicide attempt (41 case-patients vs. 41 matched controls); all were receiving some type of treatment at the time of the episode. The investigators found no relationship between lithium use and suicide or suicide attempts.

Raj et al. compared the use of 10 weekly sessions of cognitive-behavioral counseling with routine medical treatment for patients admitted to the intensive care unit (ICU) of a general hospital following their first or second suicide attempt.65 Upon ICU admission, the 40 enrolled patients were sequentially assigned to either the counseling intervention or routine medical care with the option to attend therapy sessions. None of the intervention group repeated a suicide attempt at 2 to 3 months of followup; 1 patient in the control group made a repeated suicide attempt.

Does Treatment Result in Improved Intermediate Outcomes?

We identified 1 systematic review26 and 4 additional articles that studied intermediate outcomes in patients at high risk for suicide.34, 60, 65, 66 Again, study heterogeneity (interventions tested, treatment duration, followup length, and outcomes used) precluded integration of the new studies into the prior review.

Prior Review of RCTs Involving Intermediate Outcomes

Townsend et al. conducted a systematic review of 6 RCTs37-41, 67 involving brief problem-solving therapy in patients with deliberate self-harm, in which the outcomes included depressive severity, hopelessness, and improvement in problems (Table 4).26 Treatment duration and length of followup varied substantially across studies, and the analyses were not stratified according to age. The 4 studies that evaluated depressive outcomes37-39, 41 used 2 different scales for depression, requiring the authors to calculate a standardized mean difference (SMD; the mean difference divided by the pooled sample standard deviation) to evaluate depressive symptoms. The summary SMD indicated a significantly lower depression score of about one-third of a standard deviation for patients offered problem-solving therapy compared with those receiving usual care (-0.36; 95% CI, -0.61 to -0.11). Three trials measured hopelessness, which is strongly correlated with suicidal ideation39, 40, 67 using the Beck Hopelessness Scale.68 The authors calculated a weighted mean difference with those receiving problem-solving therapy averaging approximately 3 points less on hopelessness scores at followup than did those receiving standard care (-2.97 points; 95% CI, -4.81 to -1.13). Two trials measured whether problems had improved (a dichotomous measure rated by assessors blinded to treatment).37, 38 Improvement in problems was more likely in those receiving problem-solving therapy compared with those receiving usual care (OR, 2.31; 95% CI, 1.29-4.13) (Table 4).

Additional RCTs Involving Intermediate Outcomes

As shown in Table 5, Guthrie et al. measured suicidal ideation in an RCT comparing interpersonal psychotherapy with usual care.60 Suicidal ideation, as measured by the Scale for Suicidal Ideation (SSI)69 at 6-month followup, was significantly lower for the psychotherapy group (mean difference, -4.9; 95% CI, -8.2 to -1.6; P <0.001). A priori, the authors had identified a difference of 5 points as being clinically significant.

Koons et al. measured suicidal ideation and depressive severity in their 6-month RCT of women veterans with borderline personality disorder.34 For those completing treatment, DBT was superior to usual care in decreasing suicidal ideation as measured by the SSI69 (10-point decrease vs. 4-point decrease; P <0.05). As measured by the self-report Beck Depression Inventory,70 DBT produced a significantly greater decrease in depressive symptoms than usual care (2-way analysis of variance, P <0.05), which is inconsistent with the authors' findings using the Hamilton Depressive Rating Scale (HAM-D),71 which showed no significantly greater decrease for DBT versus usual care.

Montgomery et al. performed a 4-week cohort study comparing the antidepressants mianserin, amitriptyline, and maprotiline.66 Suicidal ideation, as measured by the Montgomery-Asberg Depression Rating Scale, was decreased by a significantly greater degree by mianserin compared with maprotiline (P <0.01); a trend favoring mianserin over amitriptyline was also observed (P <0.10). The 3 study drugs showed no differences for the analogous "suicidal thoughts" on the HAM-D, and the overall quality of the study was poor.

Raj et al. also measured the effect of a cognitive-behavioral intervention on suicide ideation.65 Assessing the difference in SSI scores between baseline and 2 to 3 months post-discharge for the 2 groups, they found that those who received counseling had a substantially greater reduction in suicidal ideation than the usual care group (mean decrease 15 vs. 2.75; P <0.001).


Archived: Discussion

Evidence for or against the value of screening for suicide risk in primary care settings must be considered within a complex practice and epidemiological context. Suicide is a rare outcome, even among high-risk groups; this fact alone creates methodological challenges. RCTs, the gold standard for showing efficacy in evidence reviews, ethically cannot include a true placebo arm; consequently, all interventions are being compared with treatment arms that in fact may or may not be effective. Finally, patterns of suicide behaviors are very complex. Although a prior suicide attempt is a strong risk factor for completed suicide, sociodemographic characteristics and behaviors clearly differ across groups of those who attempt suicide, practice repetitive deliberate self-harm, and successfully complete suicide. To focus exclusively on completed suicide reveals dramatic differences in rates and methods across the life span, between males and females, and between different race and ethnicity groups. Current research, in large part, does not address this complexity.

Within this context, we have reviewed literature published since 1966 with the goal of better defining the clinician's role in screening for suicide risk in primary care settings. Despite the public health import of suicide and the Surgeon General's call to action, evidence to guide the primary care clinician's assessment and management of suicide risk is extremely limited. No studies address the overarching question of whether screening for suicide risk in primary care patients improves outcome. Consequently, we must approach this issue by analyzing studies examining the intervening linkage questions.

Very little is known about use of screening instruments for suicide risk in primary care populations. One prospective study identified reasonable test characteristics for persons reporting that they were "feeling suicidal" compared with responses indicating the presence of a plan. This study has not been replicated, nor has the specific question identified ("feeling suicidal") been tested independently of the longer instrument.

Regarding whether interventions for those at risk reduce suicide attempts or completions, the poor generalizability of the studies makes the overall strength of evidence fair, at best, while the results are mixed.25Although some trends suggest incremental benefit from several interventions, no consistent statistically significant effects have emerged for interventions for which more than 1 study has been done. Of the interventions for which only 1 study has been done, promising interventions included DBT for borderline personality disorder49 and interpersonal psychotherapy for deliberate self-harm.60 These interventions, however, require further confirmation.

We should emphasize that our review did not include all of the available clinical trial literature involving suicide attempts or completions. Some literature has examined the effectiveness of medications, such as lithium, in the prevention of suicide among psychiatric patients with major mood disorders, as reflected in a recent meta-analysis by Tondo et al.72 We excluded these studies because they did not meet our inclusion criteria of controlled trials with adequate comparison groups.

Several studies showed improvement for intermediate outcomes, primarily for persons at high risk for deliberate self-harm. Specifically, meta-analyses of RCTs using problem-solving therapy have shown benefit, as indicated by improved mood, decreased hopelessness, and improvement in problems.26 In addition, 1 RCT involving interpersonal psychotherapy60 and 1 RCT involving DBT34 documented decreased suicidal ideation; finally, 1 cohort study of cognitive-behavioral therapy showed decreased suicidal ideation.65

Priorities for a Research Agenda

Our review highlights several important issues involving research on assessing and managing suicide risk. First, the challenge of studying interventions for a rare event is underscored by the fact that, even in a population with a relatively high risk for deliberate self-harm, documenting incremental benefit relative to standard care has been difficult. This difficulty is attributable at least in part to the fact that most studies are underpowered to detect significant differences, thereby increasing the risk for falsely concluding that an effective intervention does not produce a statistically significant benefit, whereas studies that have larger sample sizes typically provide the least intense (and, arguably, likely less efficacious) interventions.35 Future research must consider the feasibility of large, multi-site studies that have sufficient power to identify the benefit of interventions for a substantial health problem that is a relatively rare event.

Second, the generalizability of the available evidence to a primary care population with unidentified suicide risk is poor. The great majority of research has been conducted in psychiatric populations with an already identified risk for suicide rather than among unidentified patients in primary care, who as a group are at lower risk. The existing literature includes only 1 screening study conducted in a primary care setting.10 Only 1 intervention study involved patients recruited from primary care practices,34 and all the intervention studies involved patients identified as being at high risk for harming themselves (and, consequently, are likely to be in treatment with a mental health professional). Only 1 study conducted the intervention in a primary care setting.35 High priorities for future research include examining the test characteristics of instruments used to determine suicide risk in primary care settings, recruiting patients for intervention studies from primary care settings, and testing interventions in primary care settings.

Third, the available studies focused on those with relatively moderate risk for suicide and, for ethical and clinical reasons, excluded patients at the highest risk. Most identified high-risk patients are likely admitted to a psychiatric unit for safety, which may or may not in itself be an effective intervention. Subsequent research should consider how to stratify at-risk primary care patients and target interventions to risk severity.

Fourth, the lack of evidence for incremental benefit from a particular intervention compared with standard care is not equivalent to saying that nothing works. Standard care in many instances may be a successful intervention; it may be "good enough." However, the components of standard care are poorly described in the existing literature and probably vary across studies, making the comparison to the experimental intervention difficult to evaluate. Subsequent research could address this shortcoming by more carefully monitoring and defining standard care.

Fifth, making meaningful conclusions specific to any particular age group is difficult. Available studies were not stratified by age; as a result, drawing conclusions specific to young adults or elderly adults is a challenge. In addition, despite the concern about increased risk for suicide in the elderly, there is a dearth of information to guide evidence-based assessment and management strategies in primary care. Results from the PROSPECT trial will begin to fill this void.36 Subsequent research should involve populations with more clearly defined age groups and analyses stratified by age to allow more meaningful interpretation for specific high-risk age groups.

Sixth, dramatic differences in suicide behaviors among men and women and among different racial and ethnic groups have drawn little attention. A better understanding of these variations may have direct implications for screening and treatment strategies, and they warrant further research.

Seventh, our review is relevant only to those individuals who access clinical care, which means that a large portion of the population may be ignored. Community-based research can presumably address this question.

Finally, we did not find studies meeting our inclusion criteria that addressed whether more adequate treatment of depressed patients or substance-abusing patients will decrease the risk for suicide. We think such a clinically guided approach is key for the primary care physician to balance effectively the public health import of suicide with the real challenge of improving the outcome of a rare event. Approximately 90 percent of patients who completed suicide have a diagnosable psychiatric illness, with the great preponderance having depression or substance abuse. A more feasible means of decreasing suicide may be to focus on the high-risk groups, such as depressed primary care patients for whom routine screening is already recommended,73 and to focus efforts to decrease risk toward improving the adequate management of depression.74 Improving depression management may both improve depressive outcomes and decrease suicide risk. This strategy is reasonable and practical from a clinical perspective and testable from a research perspective. It is also necessary. Assessing suicidal ideation is the standard of care in the evaluation for depression, and routine depression screening will likely identify more patients with suicidal ideation, for which primary care clinicians will need evidence-based management strategies. Retrospective analyses have suggested that educating general practitioners on better identification and treatment of depression may be an effective method of suicide prevention.75 Subsequent prospective clinical trials focusing on primary care are needed to develop this evidence base.

Archived: Acknowledgements

This study was performed by the RTI-University of North Carolina at Chapel Hill (RTI-UNC) Evidence-based Practice Center under contract to the AHRQ, Contract No 290-97-0011, Task Order No. 3, Rockville MD.

We acknowledge the continuing support of David Atkins, M.D., M.P.H., who is the Chief Medical Officer for AHRQ's Center for Practice and Technology Assessment; and Jean Slutsky, P.A., M.S.P.H., AHRQ Task Order Officer for the USPSTF project. We appreciate the considerable support and contributions of members of the RTI International staff: Sonya Sutton, B.S.P.H. and Loraine Monroe. In addition, we thank the staff from the University of North Carolina at Chapel Hill and the Cecil G. Sheps Center for Health Services Research: Carol Krasnov for administrative assistance and coordination and Timothy S. Carey, M.D., M.P.H., Director of the Sheps Center and Co-director of the RTI International-University of North Carolina Evidence-based Practice Center.

Archived: Notes

Author Affiliations

[a] Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC
[b] Department of Obstetrics and Gynecology, School of Medicine, Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
[c] Departments of Pediatrics and Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
[d] Tri-County Family Medicine, Cohocton, NY
[e] Department of Pediatrics, University of Rochester, Rochester, NY
[f] Department of Health Policy and Administration, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, and RTI International, Research Triangle Park, NC

Copyright and Source Information

This document is in the public domain within the United States.

Requests for linking or to incorporate content in electronic resources should be sent via the USPSTF contact form.

Source: Gaynes BN, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for suicide risk in adults. A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140:822-35.

The USPSTF recommendation based on this evidence review is online.

Archived: Appendix Figure 1. Screening for Suicide Risk: Analytic Framework

The analytic framework diagrams the 8 key questions addressed in the Systematic Evidence Review. Go to Text Description [D] for details.

[D] Select for Text Description.

The analytic framework diagrams the 8 key questions (KQs) that the authors set out to answer in their full Systematic Evidence Review.

(In this article, the authors only report on the 3 key questions for which they found data meeting their selection criteria: "Can a screening test reliably detect suicide risk in primary care populations"; "For those identified as being at risk, does treatment result in decreased suicide attempts and/or decreased mortality from suicide"; and "For those identified as being at risk, does treatment result in decreased suicidal ideation, decreased depressive severity, decreased hopelessness, or improved level of functioning?")

The diagram starts on the left with "undetected suicide risk in the primary care population" and "screening," and it ends on the right with "decreased attempts and decreased completions (mortality)."

An arrow representing KQ 1—"Does screening for suicide risk in primary care settings result in decreased attempts and/or decreased mortality?"—points directly from "screening" to "decreased attempts, decreased completions (mortality)."

An arrow for KQ 2—"Can a screening test reliably detect suicide risk in primary care populations?"—proceeds from "undetected suicide risk in primary care population" to "screening" to "population at risk" to "treatment" to "decreased attempts, decreased completions (mortality)."

KQ 3—"Main outcome: for those identified as being at risk, does treatment result in decreased suicide attempts and/or decreased mortality from suicide?"—shares the arrow with KQ 2, starting after "treatment" and ending at "decreased attempts, decreased completions (mortality)."

An arrow for KQ 4—"Intermediate outcome: For those identified as being at risk, does treatment result in decreased suicidal ideation, decreased depressive severity, decreased hopelessness, or improved level of functioning?"—springs from the KQ 2 arrow after "treatment" and proceeds to "decreased attempts, decreased completions (mortality)."

KQ 5—"What are the harms of screening?"—branches off "screening" and stops. KQ 6—"What are the costs of screening?"—branches off "screening" and stops.

The arrow for KQ 7—"What are the harms of treatment?"—branches off "treatment" and stops, as does KQ 8—"What are the costs of treatment?"

An asterisk at the word "treatment" on the KQ 2 arrow refers to a footnote: "Treatments were categorized by intervention type after the literature search."


Archived: Appendix Table 1. Key Questions for Screening for Suicide Risk

Number Question
1. Does screening for suicide risk in primary care settings result in decreased attempts and/or decreased mortality?
2. Can a screening test reliably detect suicide risk in primary care populations?
3. Main outcome: For those identified as being at risk, does treatment result in decreased suicide attempts and/or decreased mortality from suicide?
4. Intermediate outcome: For those identified as being at risk, does treatment result in decreased suicidal ideation, decreased depressive severity, decreased hopelessness, or improved level of functioning?
5. What are the harms of screening?
6. What are the costs of screening?
7. What are the harms of treatment?
8. What are the costs of treatment?

Archived: Appendix Table 2. Inclusion and Exclusion Criteria

Element Inclusion Criteria Exclusion Criteria
Databases MEDLINE®, PsycINFO Other databases
Languages English only Other languages
Populations Humans only Animal studies
Study design Randomized controlled trials; cross-sectional studies; cohort studies; systematic reviews; and meta-analyses Case-control studies, letters, editorials, and nonsystematic reviews
Study population Screening: primary care
Treatment: primary or specialty care
Screening: community settings and psychiatric settings
Treatment: community settings

Archived: Appendix Table 3. Literature Search Results

Category and Step Search Strategy Number of Articles in:
Screening MEDLINE® PsycINFO
1 Explode suicide/or explode suicide, attempted 24,512 17,269
2 Explode mass screening 51,454 15,074
3 1 and 2 83 456
4 Total unduplicated records from both databases 250
  Met inclusion criteria 1*
  Randomized Controlled Trials of Suicide Treatments MEDLINE® PsycINFO
1 Explode (suicide/or explode suicide, attempted) and (explode randomized controlled trial/explode single-blind or double-blind method/explode random allocation) 72 0
2 Explode suicide/or explode suicide, attempted 26,541 17,269
3 Limit 2 to randomized controlled trial 123 0
4 1 or 3 215 0
5 Randomized controlled trial 110,121 727
6 1 and 2 and 5 215 7
7 Limiting to human and English language, total unduplicated records from both databases 222
  Met inclusion criteria 33
  Cohort Studies of Treatment MEDLINE® PsycINFO
1 Explode suicide/or explode suicide, attempted 26,780 17,269
2 Limit 1 to (human and English language) 19,492 NA
3 Explode therapeutics/or 2,561,983 226,733
4 2 and 3 2,249 NA
5 Explode cohort studies 438,625 6,861
6 4 and 5 522 109
7 Total unduplicated records from both databases 507
  Met inclusion criteria 4
  Primary Care Reviews and Meta-Analyses MEDLINE® PsycINFO
1 Primary care reviews or meta-analyses 54 47
2 Total unduplicated records from both databases 54
  Met inclusion criteria 2

NA = not applicable.
*One additional article abstracted; see text.

Archived: Table 1. Randomized Controlled Trials of Interventions to Decrease Deliberate Self-Harm in Adults and Older Adolescents

Table 1. Randomized Controlled Trials of Interventions to Decrease Deliberate Self-Harm in Adults and Older Adolescentsa

Treatment Compared Study, Year Population Age Range (Yrs) Intervention and Control Groups Followup Period (After Enrollment) Number (%) of Participants with DSH during Followup Odds Ratio (95% CI)
Problem-solving Therapy vs Standard Aftercare Gibbons, et al., 197837 Southampton, UK

Self-poisoning patients with no immediate suicide risk and no formal psychiatric diagnosis

> 17 Intervention: Home-based crisis-oriented problem-solving therapy by social workers over 3 mos

Control: Standard aftercare

12 mos Intervention: 27/200 (13.5)

Control: 29/200 (14.5)

0.92 (0.52-1.62)
Hawton, et al., 198738 Oxford, UK

Deliberate self-poisoning patients who were not in psychiatric care, did not require treatment for alcohol or drug addiction, and did not need inpatient psychiatric care

> 16 Intervention: Outpatient therapy by non-medical clinicians for ≤ 8 sessions

Control: Standard aftercare

12 mos Intervention: 3/41 (7.3)

Control: 6/39 (15.4)

0.43 (0.10-1.87)
Salkovskis, et al., 199039 Leeds, UK

Non-psychotic patients referred by psychiatrist after admission to an emergency department after antidepressant self-poisoning; ≥4 on Buglass and Hawton Risk of Repetition Scale or ≥2 previous attempts

16-65 Intervention: Home-based therapy by community psychiatric nurse for 5 sessions

Control: Standard aftercare

12 mos Intervention: 3/12 (25.0)

Control: 4/8 (50.0)

0.33 (0.05-2.24)
McLeavey, et al., 199440 Cork, Ireland

Non-psychotic, non-suicidal patients without cognitive impairment and not needing psychiatric inpatient care who were admitted to an emergency department for self-poisoning

15-45 Intervention: Interpersonal problem-solving skills training by trained therapists for approximately 5 sessions

Control: Brief problem-solving therapy

12 mos Intervention: 2/19 (10.5)

Control: 5/20 (25.0)

0.35 (0.06-2.09)
Evans, et al., 199941 London, UK

Patients with self-harm episode in previous 12 mos with a personality disturbance but no alcohol or drug dependence or schizophrenia who were admitted to Paddington, Westminster or Chelsea, Westminister, emergency department

16-50 Intervention: Manual-assisted cognitive-behavioral therapy by trained therapists for 2-6 sessions

Control: Standard psychiatric treatment

6 mos Intervention: 10/18 (55.6)

Control: 10/14 (71.4)

OR not calculated
Overall         0.70 (0.45-1.11)  
Intensive Care Plus Outreach vs Standard Care Chowdhury, et al., 197342 Edinburgh, UK

Patients with a previous DSH episode admitted for DSH to a general hospital; included patients with psychiatric disturbance, alcohol dependence, and drug addiction

> 16 Intervention: Enhanced aftercare with aggressive outreach and followup

Control: Standard aftercare

6 mos Intervention: 17/71 (23.9)

Control: 19/84 (22.6)

1.08 (0.51-2.27)
Welu, 197743 Pittsburgh, PA

Patients admitted to an emergency department for DSH

≥16 Intervention: Special outreach program with weekly or bi-weekly contact with trained mental health professionals for 4 mos

Control: Standard aftercare

4 mos Intervention: 3/62 (4.8)

Control: 9/57 (15.8)

0.27 (0.07-1.06)
Hawton, et al., 198144 Oxford, UK

Patients not receiving current psychiatric care or treatment for alcohol or drug addiction admitted to a general hospital after DSH

≥15 Intervention: Home-based therapy as often as therapist felt necessary for ≤ 3 mos by mental health professionals

Control: Weekly outpatient therapy

12 mos Intervention: 5/48 (10.4)

Control: 7/48 (14.6)

0.68 (0.20-2.32)
Allard, et al., 199245 Montreal, Canada

Non-sociopathic patients with a recent suicide attempt who presented to hospital for another suicide attempt

NR Intervention: Enhanced aftercare with aggressive outreach and followup by mental health professionals for 12 mos

Control: Standard aftercare

12 mos

Intervention: 22/63 (34.9)

Control: 19/63 (30.2)

1.24 (0.59-2.62)
Van Heeringen, et al., 199546 Ghent, Belgium

Patients treated in an emergency department after a suicide attempt

≥15 Intervention: Enhanced aftercare with aggressive outreach and followup by mental health professionals for unspecified period

Control: Standard aftercare

12 mos Intervention: 21/196 (10.7)

Control: 34/195 (17.4)

0.57 (0.32-1.02)
van der Sande, et al., 199747 Utrecht, the Netherlands

Patients without drug or alcohol addiction and obvious psychiatric comorbidity admitted to the hospital after a suicide attempt

≥16 Intervention: Brief psychiatric admission with outpatient therapy by mental health professionals and 24 hr hospital access for unspecified period

Control: Standard aftercare

12 mos Intervention: 24/140 (17.1)

Control: 20/134 (14.9)

1.18 (0.62-2.25)
Overall           0.83 (0.61-1.14)
Emergency Care vs Standard Aftercare Morgan, et al., 199348 Bristol, UK

Patients admitted to the hospital after first DSH episode

Mean age, 30 Intervention: Standard care plus card indicating 24-hr access to mental health professional for 12 mos

Control: Standard aftercare

12 mos Intervention: 5/101 (5.0)

Control: 12/111 (10.8)

0.43 (0.15-1.27)
Dialectical Behavior Therapy vs Standard Aftercare Linehan, et al., 199149 Seattle, WA

Female patients with borderline personality disorder and ≥2 suicide attempts in last 5 yrs, current suicide attempt within past 8 wks

18-45 Intervention: Dialectical behavioral therapy (individual and group) with mental health professional for 1 yr

Control: Standard aftercare

12 mos Intervention: 5/19 (26.3)

Control: 12/20 (60.0)

0.24 (0.06-0.93)
Inpatient Behavior Therapy vs Inpatient Insight-Oriented Therapy Liberman and Eckman, 198150 Los Angeles, CA

Patients with ≥1 suicide attempt who were not psychotic or addicted to alcohol or drugs and were referred by psychiatrist after admission to emergency department for DSH

18-47 Intervention: Inpatient psychiatric treatment with behavior therapy for 10 days

Control: Inpatient psychiatric treatment with insight-oriented therapy for 10 days

12 mos Intervention: 2/12 (16.7)

Control: 3/12 (25.0)

0.60 (0.08-4.45)
Same Therapist (Continuity of Care) vs Different Therapist (Change of Care) Torhorst, et al., 198751 Munich, Germany

Non-psychotic patients hospitalized after a self-poisoning suicide attempt

NR Intervention: Outpatient appointment with same therapist as seen in hospital for 3-mo treatment

Control: Outpatient appointment with different therapist than seen in hospital for 3-mo treatment

12 mos Intervention: 12/68 (17.6)

Control: 4/73 (5.5)

3.70 (1.13-12.09)
General Hospital Admission vs Discharge Waterhouse and Platt, 199052 York, UK

Patients without current medical or psychiatric treatment needs admitted to an emergency department for DSH

≥16 Intervention: General hospital admission for about 1 day

Control: Discharge from hospital

4 mos Intervention: 3/38 (7.9)

Control: 4/39 (10.3)

0.75 (0.16-3.60)
Flupenthixol (Antipsychotic) vs Placebo Montgomery, et al., 197953 Maidstone, UK

Patients with ≥2 DSH episodes without overt depression or schizophrenia admitted to a general hospital after a suicide attempt

18-68 Intervention: Monthly intramuscular administration for 6 mos

Control: Monthly placebo administration

6 mos Intervention: 3/14 (21.4)

Control: 12/16 (75.0)

0.09 (0.02-0.50)
Antidepressants vs Placebo Hirsch, et al., 198254 London, UK

Patients with a GHQ score ≥20 and not on antidepressant or antipsychotic medication and were admitted to a hospital after deliberate self-poisoning

16-65 Intervention: Mianserin or nomifensine therapy for 6 wks

Control: Placebo

3 mos Intervention: 16/76 (21.1)

Control: 5/38 (13.2)

1.76 (0.59-5.24)
Montgomery, et al., 198355 London, UK

Patients with personality disorder and no depression or schizophrenia with previous DSH, admitted after DSH

Mean age, 35.7 Intervention: Mianserin therapy for 6 mos

Control: Placebo

6 mos Intervention: 8/17 (47.1)

Control: 12/21 (57.1)

0.67 (0.18-2.41)
Verkes, et al., 199856 Leiden, Rotterdam, the Netherlands

Patients with repeated DSH without current diagnosis of major depression who were admitted to emergency departments of university hospitals

≥18 Intervention: Paroxetine plus psychotherapy (therapy and therapist not described) for 12 mos

Control: Placebo plus psychotherapy

12 mos Intervention: 15/46 (32.6)

Control: 21/45 (46.7)

0.70 (no CI, P= 0.12)
Overall           0.83 (0.47-1.48)
Long-term Therapy vs Short-term Therapy Torhorst, et al., 198857

Munich, Germany

Patients with repeat DSH without psychosis, current psychiatric treatment, or drug addiction admitted for deliberate self-poisoning episode

NR Intervention: 1 session per month by a mental health professional for 12 mos

Control: 12 weekly therapy sessions by a mental health professional over 3 mos

12 mos Intervention: 9/40 (22.5)

Control: 9/40 (22.5)

1.0 (0.35-2.86)

Note: CI, confidence interval; DSH, deliberate self-harm; GHQ, Generalized Health Questionnaire; NR, not reported; OR, odds ratio.
a Adapted from Hawton, et al., 2001.18

Archived: Table 2. Additional Randomized Controlled Trials of Interventions to Reduce Deliberate Self-Harm in Adults and Older Adolescents

Table 2. Additional Randomized Controlled Trials of Interventions to Reduce Deliberate Self-Harm in Adults and Older Adolescentsa

Treatment Compared Study, Year Population Age Range (Yrs) Intervention and Control Groups Followup Period (After Enrollment) Number (%) of Participants with DSH during Followup Odds Ratio (95% CI) or Reported Statistics
Interpersonal Psychotherapy vs Standard Aftercare Guthrie, et al., 200160 Patients presenting to an emergency department with deliberate self-poisoning, but not requiring inpatient psychiatric treatment 18-65 Intervention: Weekly sessions of home-based interpersonal psychotherapy by nurse therapists for 1 mo

Control: Standard aftercare

6 mos Intervention: 5/58 (8.6)

Control: 17/61 (27.9)

No OR given; between-group difference, 19.3 (8.6-30.0); P <0.001
Psychoanalytically Oriented Partial Hospitalization vs Standard Aftercare Bateman and Fonagy, 1999,58 200159 b Patients with borderline personality disorder who did not have bipolar or psychotic disorder, substance abuse, mental impairment, or organic brain disorder attending a psychiatric clinic 16-65 Intervention: Partial hospitalization on psychiatric unit for 18 mos

Control: Standard aftercare for 18 mos

36 mos Intervention: 4/22 (18.2)

Control: 2/19 (63.2)

No OR given; P <0.004 (Fisher exact test)
Emergency Care vs Standard Aftercare Evans, et al., 199962 Bristol, UK

Patients referred from several general hospitals for psychiatric evaluation after DSH and who were not considered dangerous to self or others

Adults Intervention: Card offering 24-hr phone crisis consultation with psychiatrist for 6 mos

Control: Standard aftercare

6 mos Intervention: 70/417 (16.8)

Control: 59/410 (14.4)

Overall OR: 1.20 (0.82-1.75)
Subgroup analysis dichotomized by prior history of DSH           OR for prior DSH: 1.85(1.14-3.03)

OR for no prior DSH: 0.64 (0.34-1.22)

Brief Contact By Letter vs Standard Aftercare Motto and Bostrom, 200132 Persons admitted for depressive or suicidal illnesses to 9 psychiatric inpatient facilities in San Francisco, CA, who continued with therapy for ≥30 days post-discharge Mean age, 34.4 Intervention: Brief contact using letters sent over varying time periods for 5 yrs

Control: No further contact

≤ 15 yrs Intervention: 15/389 (3.9)

Control: 21/454 (4.6)

OR not reported; patients with suicide as cause of death 5 yrs post-intervention

Intervention: 3.9%

Control: 4.6%

Outpatient Day Hospitalization vs Usual Care Rudd, et al., 199633 Patients referred from 2 mental health clinics, 1 emergency department, and 1 inpatient psychiatric unit who had a suicide attempt, mood disorder and suicide ideation, or substance abuse and suicide ideation without psychosis or personality disorder Mean age, 22 (SD = 2.3 yrs) Intervention: Outpatient intensive structured group treatment by mental health professionals for 2 wks

Control: Standard aftercare

1 yr Several measures of suicidal ideation and behavior (including Modified Scale for Suicidal Ideation and the Suicide Probability Scale) analyzed; no difference between intervention and control groups
Fluoxetine (Antidepressant) vs Placebo Montgomery, et al., 199461 Patients without current major depression with a history of ≥2 suicide attempts, identified from a psychiatric clinic NR Intervention: Fluoxetine twice a wk in psychiatric clinic for 6 mos

Control: Placebo twice a wk for 6 mos

6 mos Intervention: 18/54 (33.3)

Control: 18/53 (34.0)

Fluphenazine (Antipsychotic) vs Placebo Battaglia, et al., 199963 Non-psychotic patients with a suicide attempt in the previous 30 days who had ≥2 prior suicide attempts recruited from a psychiatric emergency department 18-65 Intervention: Low-dose intramuscular injection monthly for 6 mos

Control: Ultra-low-dose intramuscular injection monthly for 6 mos

6 mos Intervention: Change of -0.16 in rate of serious self-harm behaviors per mo over 6 mos

Control: Change or -0.06 rate of serious self-harm behaviors per mo over 6 mos

P = 0.146 (Mann-Whitney test)
Dialectical Behavioral Therapy vs Usual Care Koons, et al., 200134 b Women veterans with borderline personality disorder without schizophrenia, bipolar disorder, substance abuse, or antisocial personality disorder 21-46 Intervention: Dialectical behavioral therapy by mental health professional for 6 mos

Control: Enhanced standard aftercare

6 mos Intervention: 1/10 (10)

Control: 2/10 (20)

Followup Letter and General Guidelines vs Standard Care Bennewith, et al., 200235  c Patients without substance abuse or DSH secondary to psychosis with a new episode of DSH; identified from a DSH case register based on weekly reports from local hospitals' accident and emergency departments 16-95 Intervention: One-time education and consultation letter on DSH management provided to primary care physicians whose patients had recent DSH episode

Control: Standard aftercare

12 mos Intervention: 211/964 (21.9)

Control: 189/968 (19.5)

Overall OR: 1.17 (0.94-1.47)
Subgroup analysis dichotomized by prior history of DSH           Prior DSH OR: 0.57 (0.33-0.98)

No prior DSH OR: 1.32 (1.02-1.70)

Note: CI, confidence interval; DSH, deliberate self-harm; NA, not available; NR, not reported; OR, odds ratio; SD, standard deviation.
a Not in Hawton, et al. review18
b Inclusion criteria required diagnosis of borderline personality disorder; all others required DSH.
c Primary care treatment setting; all other studies conducted in specialty care settings.

Archived: Table 3. Cohort Studies to Decrease Suicidal Behavior in At-risk Patients

Treatment Compared Study, Year Study Type Population Age Range (Yrs) Study Design Followup (After Enrollment) Number (%) of Participants with DSH during Followup Reported Statistic
Lithium Use in Week Preceding Suicide or Suicide Attempt vs No Lithium Use Coryell, et al., 200164 Nested case-control Patients treated for major affective disorders identified from 5 academic medical centers; 2 case groups: suicide completers and suicide attempters; controls were matched with cases on sex, polarity at intake, history of substance abuse, and extent of treatment ≥17 Two case groups (suicide completers and attempters) and 2 matched control groups to evaluate medication use at time of suicidal behavior Unclear period of time (≥14 yrs) Lithium use:

Completers: 40.0%

Controls of completers: 53.3%

Attempters: 22.0%

Controls of attempters: 19.5%

McNemar chi square: 0.667

McNemar chi square: 0.067

Cognitive Behavioral Counseling vs Usual Care Raj, et al., 200165 Cohort Patients who attempted suicide for the first or second time by overdosing on drugs or pesticides who also had anxiety or depression; patients were excluded if they had psychosis, dysthymia, bipolar affective disorder, substance abuse, eating disorder, or personality disorder 16-50 Sequential allocation to treatment; intervention: 10 sessions of cognitive behavioral therapy with mental health professional plus outreach for 3 mos

Control: standard aftercare

2-3 mos Intervention: 0/20 (0)

Control: 1/20 (5)


Note: DSH, deliberate self-harm; NA, not available.

Archived: Table 4. Prior Review of Randomized Controlled Trials Comparing Problem-solving Therapy vs Standard Aftercare for Intermediate Outcomes

Table 4. Prior Review of Randomized Controlled Trials Comparing Problem-solving Therapy vs Standard Aftercare for Intermediate Outcomesa

Study, Year Intervention and Treatment Duration Followup (After Enrollment) Depression: Standardized Mean Difference (95% CI) Hopelessness: Weighted Mean Difference (95% CI) OR for Improvement in Problems (95%CI)
Gibbons, et al., 197837 Mean number of 9 sessions over 12 wks 4 mos -0.18 (-0.52 to 0.15) NR 2.74 (1.40 to 5.36)
Hawton, et al., 198738 ≤8 sessions over 8 wks 9 mos -0.31 (-0.80 to 0.18) NR 1.38 (0.43 to 4.47)
Salkovskis, et al., 199039 5 sessions over 4 wks 12 mos -1.24 (-2.24 to -0.25) -3.25 (-5.31 to -1.19) NR
McLeavey, et al., 199440 5 sessions over 5 wks 7-8 mos NR 0.50 (-4.51 to 5.5) NR
Evans, et al., 199941 2-6 sessions over unclear period 6 mos -0.86 (-1.60 to -0.13) NR NR
Patsiokas and Clum, 198567 10 sessions over 3 wks About 1 mo NR -6.60 (-13.73 to 0.53) NR
Meta-analytic summary statistic     -0.36 (-0.61 to -0.11) -2.97 (-4.81 to -1.13) 2.31 (1.29 to 4.13)

Note: CI, confidence interval; NR, not reported; OR, odds ratio.
a Data are from Townsend, et al., 2001.26 Population and age range already described for each study in Table 1 except for Patsiokas and Clum, for which the study was conducted in "adult" deliberate self-harm patients recruited from a U.S. inpatient psychiatric ward.

Archived: Table 5. Additional Studies Involving Intermediate Outcomes

Treatment Compared Study, Year Study Type Intervention and Treatment Duration Followup (After Enrollment) Age Range (Yrs) Outcome Intervention Group Control Group Reported Statistic
Interpersonal Psychotherapy vs Standard Aftercare Guthrie et al, 200160 RCT 4 sessions over 1 mo 6 mos 18-65 Scale for SI score (69) 7.9 12.8 Mean difference, -4.9 (95% CI, -8.2 to -1.6, P <0.0005)
Dialectical Behavioral Therapy vs Usual Care Koons et al, 200134 RCT Weekly sessions over 6 mos 6 mos 21-46 Scale for SI (69)

Depressive severity

10-point decrease

BDI: 9.4-point decrease

HAM-D: 12.6-point decrease

4-point decrease

BDI: 5.4-point decrease

HAM-D: 8.3-point decrease

P <0.05 by 2-way repeated-measures analysis of variance

P <0.05 by 2-way repeated-measures analysis of variance


Mianserin (Mi) vs Amitryptyline (Am) vs Maprotiline (Ma) (All Antidepressants) Montgomery et al, 197866 Cohort 1 mo 1 mo NR Suicidal thoughts By HAM-D:
Mi: NA
Am: NA
Ma: NA

Mi: ~11
Am: ~ 5
Ma: ~ 6


No difference among 3 drugs

Greater SI decrease only with Mi vs Ma (P <0.01)

Cognitive-Behavioral Counseling vs Usual Care Raj et al, 200165 Cohort 2-3 mos 3 mos 16-50 Scale for SI 15-point mean decrease 2.75-point mean decrease P <0.00

Note: BDI, Beck Depression Inventory (self-report); CI, confidence interval; HAM-D, Hamilton Depressive Rating Scale; MADRS, Montgomery-Asberg Depression Rating Scale; NA, not available; NR, not reported; NS, not significant; RCT, randomized controlled trial; SI, suicidal ideation.

  1. National Center for Injury Prevention and Control. WISQARS (Web-based Injury Statistics Query and Reporting System). Available at: Accessed December 2, 2003.
  2. National Institute of Mental Health. Suicide facts. Available at: Accessed December 2, 2003.
  3. Office of the Surgeon General. The Surgeon General's Call to Action to Prevent Suicide. Washington, DC: Department of Health and Human Services, U.S. Public Health Service; 1999.
  4. Druss B, Pincus H. Suicidal ideation and suicide attempts in general medical illnesses. Arch Intern Med 2000;160:1522-6.
  5. National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2001. 
  6. Schmidtke A, Bille-Brahe U, DeLeo D, et al. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989-1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatr Scand 1996;93:327-38.
  7. Hirschfeld RM, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med 1997;337:910-5.
  8. Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol 2000;68:371-7.
  9. Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med 2002;136:302-11.
  10. Olfson M, Weissman MM, Leon AC, Sheehan DV, Farber L. Suicidal ideation in primary care. J Gen Intern Med 1996;11:447-53.
  11. Zimmerman M, Lish JD, Lush DT, Farber NJ, Plescia G, Kuzma MA. Suicidal ideation among urban medical outpatients. J Gen Intern Med 1995;10:573-6.
  12. Blumenthal SJ. Suicide: a guide to risk factors, assessment, and treatment of suicidal patients. Med Clin North Am 1988;72:937-71.
  13. Pirkis J, Burgess P. Suicide and recency of health care contacts. A systematic review. Br J Psychiatry 1998;173:462-74.
  14. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002;159:909-16.
  15. Robins E, Murphy GE, Wilkinson RH Jr, Gassner S, Kayes J. Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. Am J Pub Health 1959;49:888-99.
  16. Zametkin AJ, Alter MR, Yemini T. Suicide in teenagers: assessment, management, and prevention. JAMA 2001;286:3120-5.
  17. Murphy SL. Deaths: final data for 1998. Natl Vital Stat Rep 2000;48:1-105.
  18. Hawton K, Townsend E, Arensman E, et al. Psychosocial versus pharmacological treatments for deliberate self harm. Cochrane Database Syst Rev 2000:CD001764.
  19. Hawton K, Harriss L, Simkin S, Bale E, Bond A. Deliberate Self-Harm in Oxford 1999. Annual Report from Centre for Suicide Research. Oxford: Univ of Oxford; 2000.
  20. Gilbody S, House A, Owens D. The early repetition of deliberate self harm. J R Coll Physicians Lond 1997;31:171-2.
  21. Gunnell D, Frankel S. Prevention of suicide: aspirations and evidence. BMJ 1994;308:1227-33.
  22. Crockett AW. Patterns of consultation and parasuicide. Br Med J (Clin Res Ed) 1987;295:476-8.
  23. Sansone RA, Wiederman MW, Sansone LA, Monteith D. Patterns of self-harm behavior among women with borderline personality symptomatology: psychiatric versus primary care samples. Gen Hosp Psychiatry 2000;22:174-8.
  24. U.S. Preventive Services Task Force. Screening for Suicide Risk. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996:547-54.
  25. Harris RP, Helfand M, Woolf SH, et al. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med 2001;20:21-35.
  26. Townsend E, Hawton K, Altman DG, et al. The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems. Psychol Med 2001;31:979-88.
  27. Gaynes BN, West SL, Ford C, Frame P, Klein J, Lohr KN. Screening for Suicide Risk. Systematic Evidence Review No. 32 (Prepared by the Research Triangle Institute-University of North Carolina Evidence-based Practice Center under Contract No. 290-97-0011). Rockville, MD: Agency for Healthcare Research and Quality. May 2004.
  28. Broadhead WE, Leon AC, Weissman MM, et al. Development and validation of the SDDS-PC screen for multiple mental disorders in primary care. Arch Fam Med 1995;4:211-9.
  29. Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 1992;49:624-9.
  30. Pignone M, Gaynes B, Rushton JL, et al. Screening for Depression. Systematic Evidence Review No 6 (Prepared by the Research Triangle Institute-University of North Carolina Evidence-based Practice Center under Contract No. 290-97-0011). Rockville, MD: Agency for Healthcare Research and Quality, AHRQ Publication No. 02-S002; 2001.  
  31. Williams JW Jr, Pignone M, Ramirez G, Perez Stellato C. Identifying depression in primary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry 2002;24:225-37.
  32. Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv 2001;52:828-33.
  33. Rudd MD, Rajab MH, Orman DT, Joiner T, Stulman DA, Dixon W. Effectiveness of an outpatient intervention targeting suicidal young adults: preliminary results. J Consult Clin Psychol 1996;64:179-90.
  34. Koons CR, Robins CJ, Tweed JL, Lynch TR. Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy 2001;32:371-90.
  35. Bennewith O, Stocks N, Gunnell D, Peters TJ, Evans MO, Sharp DJ. General practice based intervention to prevent repeat episodes of deliberate self harm: cluster randomised controlled trial. BMJ 2002;324:1254-7.
  36. Bruce ML, Pearson JL. Designing an intervention to prevent suicide: PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). Dialogues in Clin Neuroscience 1999;1:100-12.
  37. Gibbons JS, Butler J, Urwin P, Gibbons JL. Evaluation of a social work service for self-poisoning patients. Br J Psychiatry 1978;133:111-8.
  38. Hawton K, McKeown S, Day A, Martin P, O'Connor M, Yule J. Evaluation of out-patient counseling compared with general practitioner care following overdoses. Psychol Med 1987;17:751-61.
  39. Salkovskis PM, Atha C, Storer D. Cognitive-behavioural problem solving in the treatment of patients who repeatedly attempt suicide. A controlled trial. Br J Psychiatry 1990;157:871-6.
  40. McLeavey BC, Daly RS, Ludgate JW, Murray CM. Interpersonal problem-solving skills training in the treatment of self-poisoning patients. Suicide Life Threat Behav 1994;24:382-94.
  41. Evans K, Tyrer P, Catalan J, et al. Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm. Psychol Med 1999;29:19-25.
  42. Chowdhury N, Hicks RC, Kreitman N. Evaluation of an after-care service for parasuicide (attempted suicide) patients. Soc Psychiatry 1973;8:67-81.
  43. Welu TC. A follow-up program for suicide attempters: evaluation of effectiveness. Suicide Life Threat Behav 1977;7:17-20.
  44. Hawton K, Bancroft J, Catalan J, Kingston B, Stedeford A, Welch N. Domiciliary and out-patient treatment of self-poisoning patients by medical and non-medical staff. Psychol Med 1981;11:169-77.
  45. Allard R, Marshall M, Plante MC. Intensive follow-up does not decrease the risk of repeat suicide attempts. Suicide Life Threat Behav 1992;22:303-14.
  46. Van Heeringen C, Jannes S, Buylaert W, Henderick H, De Bacquer D, Van Remoortel J. The management of non-compliance with referral to out-patient after-care among attempted suicide patients: a controlled intervention study. Psychol Med 1995;25:963-70.
  47. van der Sande R, van Rooijen L, Buskens E, et al. Intensive in-patient and community intervention versus routine care after attempted suicide. A randomised controlled intervention study. Br J Psychiatry 1997;171:35-41.
  48. Morgan HG, Jones EM, Owen JH. Secondary prevention of non-fatal deliberate self-harm. The green card study. Br J Psychiatry 1993;163:111-2.
  49. Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991;48:1060-4.
  50. Liberman RP, Eckman T. Behavior therapy vs insight-oriented therapy for repeated suicide attempters. Arch Gen Psychiatry 1981;38:1126-30.
  51. Torhorst A, Moller HJ, Burk F, Kurz A, Wachtler C, Lauter H. The psychiatric management of parasuicide patients: a controlled clinical study comparing different strategies of outpatient treatment. Crisis 1987;8:53-61.
  52. Waterhouse J, Platt S. General hospital admission in the management of parasuicide. A randomised controlled trial. Br J Psychiatry 1990;156:236-42.
  53. Montgomery SA, Montgomery DB, Jayanthi-Rani S. Maintenance therapy in repeat suicidal behaviour: a placebo controlled trial [Abstract]. Proceedings of the 10th International Congress for Suicide Prevention and Crisis Intervention. Ottawa, Canada. 1979:227-9.
  54. Hirsch SR, Walsh C, Draper R. Parasuicide. A review of treatment interventions. J Affect Disord 1982;4:299-311.
  55. Montgomery SA, Roy D, Montgomery DB. The prevention of recurrent suicidal acts. Br J Clin Pharmacol 1983;15 Suppl 2:183S-188S.
  56. Verkes RJ, Van der Mast RC, Hengeveld MW, Tuyl JP, Zwinderman AH, Van Kempen GM. Reduction by paroxetine of suicidal behavior in patients with repeated suicide attempts but not major depression. Am J Psychiatry 1998;155:543-7.
  57. Torhorst A, Moller HJ, Schmid-Bode KW. Comparing a 3-month and a 12-month-outpatient after-care program for parasuicide repeaters. In: Moller HJ, Schmidtke A, Welz R, eds. Current Issues of Suicidology. Berlin, Germany: Springer-Verlag; 1988:19-24.
  58. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 1999;156:1563-9.
  59. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 2001;158:36-42.
  60. Guthrie E, Kapur N, Mackway-Jones K, et al. Randomised controlled trial of brief psychological intervention after deliberate self poisoning. BMJ 2001;323:135-8.
  61. Montgomery DB, Roberts A, Green M, Bullock T, Baldwin D, Montgomery SA . Lack of efficacy of fluoxetine in recurrent brief depression and suicidal attempts. Eur Arch Psychiatry Clin Neurosci 1994;244:211-5.
  62. Evans MO, Morgan HG, Hayward A, Gunnell DJ. Crisis telephone consultation for deliberate self-harm patients: effects on repetition. Br J Psychiatry 1999;175:23-7.
  63. Battaglia J, Wolff TK, Wagner-Johnson DS, Rush AJ, Carmody TJ, Basco MR. Structured diagnostic assessment and depot fluphenazine treatment of multiple suicide attempters in the emergency department. Int Clin Psychopharmacol 1999;14:361-72.
  64. Coryell W, Arndt S, Turvey C, et al. Lithium and suicidal behavior in major affective disorder: a case-control study. Acta Psychiatr Scand 2001;104:193-7.
  65. Raj M AJ, Kumaraiah V, Bhide AV. Cognitive-behavioural intervention in deliberate self-harm. Acta Psychiatr Scand 2001;104:340-5.
  66. Montgomery S, Cronholm B, Asberg M, Montgomery DB. Differential effects on suicidal ideation of mianserin, maprotiline and amitriptyline. Br J Clin Pharmacol 1978;5 Suppl 1:77S-80S.
  67. Patsiokas AT, Clum GA. Effects of psychotherapeutic strategies in the treatment of suicide attempters. J Psychother. 1985;22:281.
  68. Beck AT, Schuyler D, Herman I. Development of suicidal intent scales. In: Beck AT, Resnick HLP, Lettieri DJ, eds. The Prediction of Suicide. Philadelphia: Charles Press; 1974:45-56.
  69. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol 1979;47:343-52.
  70. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;41:561-71.
  71. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.
  72. Tondo L, Hennen J, Baldessarini RJ. Lower suicide risk with long-term lithium treatment in major affective illness: a meta-analysis. Acta Psychiatr Scand 2001;104:163-72.
  73. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;136:765-76.
  74. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095-105.
  75. Rihmer Z, Rutz W, Pihlgren H. Depression and suicide on Gotland. An intensive study of all suicides before and after a depression-training programme for general practitioners. J Affect Disord 1995;35:147-52.
Current as of: May 2004

Internet Citation: Final Evidence Summary: Suicide Risk: Screening. U.S. Preventive Services Task Force. August 2014.

USPSTF Program Office   5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857