How do suicide risk or depression screenings compare to identify patients at risk?

Editor’s Note: September is National Suicide Prevention Month.  

COLUMBUS, Ohio – Research led by The Ohio State University Wexner Medical Center and Wesleyan University found that depression screening tools outperformed suicide risk screenings under most conditions. 

“We compared the effectiveness of multiple depression and suicide risk screening methods for the purpose of identifying primary care patients who subsequently attempted suicide. Our findings may generate a lot of discussion within the suicide prevention community, as it contradicts long-held assumptions about suicide risk screening,” said principal investigator Craig J. Bryan, PsyD, clinical psychologist, professor and director of the Division of Recovery and Resilience at Ohio State’s Department of Psychiatry and Behavioral Health. 

Study findings are published online in the Joint Commission Journal on Quality and Patient Safety.

From 1999 to 2021, the suicide rate in the United States increased by more than 35%, according to the National Vital Statistics Reports. Other researchers have found that approximately half of suicide decedents visit a primary care or general medical provider in the month before their deaths. Suicide decedents are more than twice as likely to visit primary care than a mental health clinic.

This study compared the performance of multiple depression screening methods (Patient Health Questionnaire [PHQ]-2, PHQ-8, and PHQ-9) and multiple suicide risk screening methods (PHQ-9 item 9 and suicide-focused screening of “thoughts of killing yourself”during the entire lifespan, within the past month, and within the past week) in a convenience sample of primary care patients.

During the study, 2,475 patients (military personnel, family members, and retirees) from six military primary care clinics completed the PHQ-9 and screening for suicidal ideation during routine clinic visits.

Follow-up phone interviews were conducted for one year to assess the incidence of suicide attempts. Sensitivity, specificity and accuracy were calculated for each screening method for identifying patients who attempted suicide.

More than 65% of patients who screened positive for suicidal ideation also screened positive for depression on the PHQ-9. Depression screening with the PHQ-9 correctly identified more patients who attempted suicide during follow-up than the PHQ-2. 

Five (0.2%) patients attempted suicide within 1 month, 16 (0.6%) attempted suicide within 3 months, 39 (1.4%) attempted suicide within 6 months, and 57 (2.1%) attempted suicide within 12 months of baseline. There were no known suicide deaths.

“Conclusions based on our findings should be made cautiously considering several limitations. Our study examined depression as the only clinical indication for suicide risk screening. These findings may not extrapolate to other potential indications of screening in primary care such as substance use disorders, postpartum depression and other psychiatric conditions,” said co-author Alexis M. May, PhD, assistant professor of psychology at Wesleyan University in Middletown, CT.

Additional research is needed to examine the incremental (or lack of) benefit of depression and suicide risk screening among primary care patients with these indications and other patient subgroups, May said.

Since this study was conducted within the military medical system with adult patients only, this may limit generalizability to other healthcare systems and populations, said Bryan, who is the Trott Gebhardt Philips Endowed Professor of Psychiatry and Behavioral Health and a senior researcher in The Suicide and Trauma Reduction Initiative for Veterans (STRIVE) at Ohio State. STRIVE is one of the nation’s leading research sites for clinical trials on suicide treatment, prevention and intervention. 

This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs, through the Defense Medical Research and Development Program.

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