Written by Clay Smith
Depression screening (with varying forms of intervention) reduces depression symptoms in follow up, and the screening tools are fairly accurate. Suicide screening (with various interventions) does not reduce suicidal ideation or suicide attempts and may actually increase attempts, though the evidence is very limited.
Is screening helping patients – it’s a mixed review.
The US Preventive Task Services Task Force (USPSTF) recommended depression screening (and follow up interventions) in 2016. However, the USPSTF did not recommend suicide risk screening in 2014. Does this screening accomplish a reduction in completed suicide? This was a systematic review and meta-analysis (where possible). They found 32 RCTs on depression screening, 8 of which were meta-analyzed and found that screening reduced depressive symptoms at 6 or 12 months. Of note, many trials employed interventions far beyond just screening. A PHQ-9 semi-structured interview of ≥10 was 85% sensitive and specific. Only one RCT (N=443) screened for suicide risk in primary care patients and did not find any difference in suicidal ideation (SI) at 2 weeks in those screened vs not; there was one suicide attempt in the control group. Three studies screened for SI, with sensitivities/specificities in the 80% range; no studies have been replicated, and only one was ED-based. One of these studies had just 3 patients with SI; another had just 12. Depression and suicide screening did not seem to be associated with harm. Treatment of depression with behavioral or pharmacologic treatment seemed to reduce symptoms at around 8-weeks of follow up. They were not able to assess the impact on treatment after suicide screening on death, as there was only one death among 23 RCTs (N=22,632). There was no effect of 12 suicide screening studies (and various subsequent interventions) on suicide attempts: OR 0.94 (95%CI 0.73-1.22). Regarding treatment harms, second generation antidepressants (i.e. venlafaxine, trazodone, bupropion, and mirtazapine) were associated with an increased risk of suicide attempts: OR 1.53 (95%CI 1.09-2.15); n = 41,861); 0.7% 2nd gen. antidepressant vs 0.3% placebo.
This review focused on primary care. It did not include many ED or urgent care based studies, and did not include studies of the Columbia Suicide Severity Rating Scale (C-SSRS).
How will this change my practice?
Many hospital systems (including mine) are rushing to implement universal ambulatory screening, which may be beneficial for depression, but the evidence is less clear when considering suicide screening.
Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2023 Jun 20;329(23):2068-2085. doi: 10.1001/jama.2023.7787.