Despite lack of guidelines, doctors screen for suicide
■ Evidence shows that tools used in primary care may help identify adults at increased risk but have limited ability to detect the risk in adolescents.
By Christine S. Moyer — Posted April 29, 2013
Some physicians are disheartened that a federal panel again declined to issue recommendations on screening patients for suicide in primary care, despite data that show it is a major public health issue.
Many of those doctors plan to continue inquiring about thoughts of self-harm among their patients using tools and questions they have found to be effective. The tools include the nine-item Patient Health Questionnaire, which screens for depression, and the HEADSS for Adolescents assessment.
“Our job as a primary care physician is to look at the whole person and find areas of strength and areas where they need help,” said Michelle S. Barratt, MD, MPH, a professor of pediatrics in the Division of Adolescent Medicine at the University of Texas Medical School at Houston. “For [many patients, and particularly] teens, there are lots of areas where they need to be screened even if it doesn’t have scientific evidence.”
At issue is a U.S. Preventive Services Task Force’s draft statement, which was posted online April 23. The statement said there is insufficient evidence to recommend for or against suicide screening among patients of any age in primary care. The guidance applies to people who don’t have a mental health disorder or history of mental illness, the task force said. The expert panel’s position remains unchanged from its 2004 guidance on the matter.
Comments on the proposed recommendation will be accepted on the task force’s website until May 20 and considered as the panel develops its final statement.
In making its decision, the task force conducted a systematic review of data on whether screening all adolescent, adult and elderly patients for risk factors of suicide is effective. The review indicates that there is limited evidence that primary care-feasible screening tools probably could identify adults at increased risk for suicide and who might need treatment. Screening tools, however, have limited ability to detect suicide risk in adolescents, said the review, in the April 23 Annals of Internal Medicine.
Treatment with psychotherapy reduced the risk of suicide attempts by 32% in high-risk adults (those with a recent suicide attempt) but didn’t appear to benefit adolescents, data show. No drug treatments were proven effective at reducing suicide risk in adults or adolescents, the report said.
“We all would like to find ways to prevent the suffering of those who commit or attempt suicide, as well as the families and communities they may leave behind,” said task force member David C. Grossman, MD, MPH. He also is senior investigator and medical director for population and purchaser strategy at the Group Health Research Institute in Seattle.
“Unfortunately, at this time, we don’t know if asking everyone who visits their doctor or nurse about their risk factors for suicide leads to fewer suicides and suicide attempts,” Dr. Grossman said.
A talk instead of a tool
Suicide was the 10th-leading cause of death in the United States in 2010, according to the most recent data from the Centers for Disease Control and Prevention. That year, suicide accounted for 38,364 deaths, which translates to 12.4 suicides per 100,000 population.
The CDC said the leading methods of suicide are firearm (51%), suffocation (25%), and poisoning (17%).
In light of those statistics, coupled with the high prevalence of depression and chronic illness that internist Rodney Schainis, MD, sees in his practice, the Chicago-area doctor said he will continue screening patients for suicide.
“I think it’s a very important responsibility for us,” said Dr. Schainis, chair of internal medicine and family practice at Gottlieb Memorial Hospital in Melrose Park, Ill.
He doesn’t use any particular screening tool but focuses on asking questions that assess the patient’s mood and level of social activity. A lack of social support and a sense of isolation are key risk factors for committing suicide, according to the American Foundation for Suicide Prevention.
Dr. Schainis asks questions that address whether patients are getting out of their house, spending time with friends and family, and taking care of themselves. He inquires about those matters every time he sees a patient with depression, chronic illness or chronic pain.
Baltimore internist Dana Simpler, MD, screens for suicide by administering the PHQ-9 to patients who exhibit symptoms of depression such as fatigue and insomnia. She also considers depression as a diagnosis when patients have an assortment of somatic problems, such as chronic pain, earaches and stomachaches.
Dr. Simpler stays in the room while the individual fills out the questionnaire because she said it takes only one or two minutes. She focuses on the patient’s response to question No. 9, which asks whether the individual has “thoughts that you would be better off dead or of hurting yourself.”
For individuals who say they have such thoughts, Dr. Simpler asks whether they have planned how they will commit suicide. She said patients with a plan are more at risk of suicide than those who have simply thought about it.
In those types of instances, it’s important that physicians know what resources are available to help care for the patient, Dr. Barratt said. She urges physicians to admit patients to the hospital when they feel the individual probably will try to take his or her own life. In less urgent cases, where people are thinking about suicide but haven’t made a plan on how to do it, doctors should refer patients to a nearby psychiatrist or psychologist.
If the wait time for a specialist is too long, doctors should know what other options are available, Dr. Barratt said. Those options could include a school counselor for adolescents or a recommendation that the patient call the national suicide prevention line at 800-273-8255.
Dr. Barratt gives her adolescent and young adult patients the HEADSS assessment during well-child visits. The tool consists of several questions the physician asks patients about their home and environment, education and employment, activities, drug use, sexual activity and suicide/depression.
In September 2012, the National Strategy for Suicide Prevention urged physicians to screen patients at increased risk of taking their lives and to educate family members about ways to support such individuals. The strategy was issued by the Dept. of Health and Human Services Office of the Surgeon General and the National Action Alliance for Suicide Prevention.
In Dr. Simpler’s 26 years of practice, only one of her patients has committed suicide. “Because it’s still [relatively] unusual, I don’t know that it makes sense to ask every single patient” about suicide, she said. “But certainly anyone exhibiting symptoms of depression, of course they should be screened.”