Improvement Insights

By Craig J. Bryan, PsyD, ABPP, Professor, The Ohio State University College of Medicine

Since 2000, the U.S. suicide rate has risen by more than 35%.¹ Nearly half of suicide decedents visit primary care in the months immediately prior to their deaths.² Some researchers and suicide prevention advocates have therefore encouraged the adoption of universal suicidal ideation screening in primary care.^3,4 The U.S. Preventive Services Task Force (USPSTF)⁵ has noted there is insufficient evidence to support universal screening for suicidal ideation, however, especially among patients who are not diagnosed with a mental health condition or displaying other signs of increased risk.

Our research team, including colleagues from The Ohio State University College of Medicine, University of Colorado School of Medicine, Naval Health Research Center and Wesleyan University, examined the effectiveness of suicidal ideation screening in primary care.

The findings, reported in the December 2023 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS), indicate the Patient Health Questionnaire-9 (PHQ-9) was the most effective screening strategy for identifying primary care patients who attempted suicide within the following year, outperforming suicidal ideation screening under most conditions.

Multiple Screening Methods

“Effectiveness” was defined as the ability of each screening method to correctly identify patients who would later attempt suicide, based on the rationale that screening can only prevent suicidal behaviors among patients who attempt suicide.

During routine clinic visits, primary care patients were asked to complete the PHQ-9 and a suicidal ideation screening item that asked, “Have you ever had thoughts of killing yourself?” Patients who positively endorsed the suicidal ideation item were then asked if they most recently had those thoughts within the past month or week. Suicidal ideation was screened separately because some researchers have critiqued the PHQ-9 and its suicide risk item, which assesses the frequency of “thoughts that you would be better off dead or of hurting yourself in some way,” as inadequate for the purposes of identifying at-risk patients.

Patients were next contacted by phone and interviewed at six and 12 months to determine if they had attempted suicide since being screened.

Is Suicidal Ideation Screening More Effective than Depression Screening?

Because the effectiveness of screening may vary across different follow-up periods (for example, effectiveness may be better in the near-term vs. the long-term, or vice versa), screening performance within one, three, six, and 12 months of screening was evaluated, as well as different scoring methods for each screening.

Depression screening with the PHQ-8 (omitting item nine asking about “thoughts that you would be better off dead or of hurting yourself in some way” within the past two weeks) or the full PHQ-9 (including item nine) performed better than suicidal ideation screening under most conditions.

Only lifetime suicidal ideation screening correctly identified more patients who would attempt suicide than the PHQ-9. This improvement came at a high cost, though, more than doubling the number of positive screens who did not attempt suicide. Lifetime suicidal ideation screening therefore did not improve the efficiency of screening results as compared to the PHQ-9.

Implications for Clinical Practice

Our research team’s findings hold important implications for primary care clinicians conducting suicide risk screening, including:

1. In many primary care clinics, the full PHQ-9 is administered only to those patients who first screen positive for depression on the shorter PHQ-2. The results suggest that replacing this two-step approach with the full PHQ-9 could improve clinical decision-making.
2. The PHQ-9 may have greater clinical utility than suicidal ideation screening tools for determining which patients warrant further assessment and possible intervention for elevated suicide risk.
3. Primary care clinicians should remain alert to the possibility of elevated suicide risk among patients who screen positive for depression, even if they screen negative for suicidal ideation.

For more information, please visit the JQPS website.

Craig J. Bryan, PsyD, ABPP, is the Trott Gebhardt Philips Endowed Professor in the Department of Psychiatry and Behavioral Health at The Ohio State University College of Medicine in Columbus, Ohio. Dr. Bryan is a board-certified clinical psychologist with expertise in cognitive-behavioral treatments for individuals experiencing suicidal thoughts and post-traumatic stress disorder (PTSD). As a military veteran, he has expertise working with military personnel, veterans and first responders.

References

1. Xu J, Murphy SL, Kochanek KD, Arias E. Deaths: Final Data for 2019. Journal Issue. National Vital Statistics Reports. 2021;70(8):1-86. doi: https://dx.doi.org/10.15620/cdc:106058
2. 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(6):909-916. 
3. Boudreaux ED, Camargo Jr CA, Arias SA, et al. Improving suicide risk screening and detection in the emergency department. American Journal of Preventive Medicine. 2016;50(4):445-453.
4. Goldstein Grumet J, Boudreaux ED. Universal Suicide Screening Is Feasible and Necessary to Reduce Suicide. Psychiatr Serv. 2022:appi. ps. 202100625.
5. US Preventive Services Task Force. Screening for Depression and Suicide Risk in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;328(15):1534-1542. doi:10.1001/jama.2022.16946