Guide to Clinical Preventive Services, Second Edition
Mental Disorders and Substance Abuse
Screening for Suicide Risk 
RECOMMENDATION
There is insufficient evidence to recommend for or against routine screening by 
primary care clinicians to detect suicide risk in asymptomatic persons (see 
Clinical Intervention). Clinicians should be alert to signs of suicidal ideation 
in persons with established risk factors. The training of primary care 
clinicians in recognizing and treating affective disorders is recommended. 
Clinicians should be alert to signs and symptoms of depression (see Chapter 49) 
and should routinely ask patients about their use of alcohol and other drugs 
(Chapters 52 and 53). 
Burden of Suffering
In 1993, the age-adjusted rate of suicide in the U.S. was approximately 
11.2/100,000 persons; 31,230 suicide deaths were reported.1 The actual incidence 
is uncertain because suicidal intent is often difficult to prove after the fact; 
uniform criteria for declaring a death due to suicide have only recently been 
developed.2 An estimated 210,000 persons attempt suicide each year, resulting in 
over 10,000 permanent disabilities, 155,500 physician visits, 259,200 hospital 
days, over 630,000 lost work days, and over $115 million in direct medical 
expenses.3 The highest rate of completed suicide is among men aged 65 years and 
older, but suicide attempts are more commonly reported among women and among men 
and women aged 20-24 years.4 The suicide rate in American teenagers has 
increased substantially in recent years.5 Suicide is the third leading cause of 
death in persons 15-24 years old1 as well as a leading cause of years of 
potential life lost.6 Suicides among young persons may also lead to suicide 
clusters, in which a number of other adolescents in the same community commit 
suicide.7 
The most important risk factor for suicide is psychiatric illness. The majority 
of suicide victims have affective, substance abuse, personality or other mental 
disorders.8-9a Persons with a history of one or more psychiatric hospital 
admissions carry a particularly high risk of suicide.10 Other risk factors for 
suicide and attempted suicide, particularly in persons with underlying mental or 
substance abuse disorders, include social adjustment problems, serious medical 
illness, living alone, recent bereavement, personal or family history of suicide 
attempt, family history of completed suicide, divorce, separation, and 
unemployment.4,8,11,12 
Firearms are used in about 60% of all suicides.1,4,8,9,13 Firearm-related deaths 
accounted for nearly all the increase in suicide rates during the 1980s.14 
Case-control studies have demonstrated that the risk of suicide is almost five 
times higher for persons who live in a household where at least one firearm is 
kept, when compared with persons who live in a household free of guns.14a-16 The 
second most common means of suicide among males is hanging, whereas among 
females it is poisoning (drug overdose).4 Alcohol intoxication is associated 
with at least 25-50% of all suicides9 and is especially common in suicides 
involving firearms.4 
Accuracy of Screening Tests
About one half to two thirds of persons who commit suicide visit physicians less 
than 1 month before the incident, and 10-40% visit in the preceding week.9,17 It 
is often difficult, however, for physicians to identify suicidal patients 
accurately. Direct questions about suicidal intent may have low yield; only 3-5% 
of persons threatening suicide express unequivocal certainty that they want to 
die.18 Nearly 30% of American high school students report having seriously 
thought about committing suicide,19,20 making it unlikely that suicidal thoughts 
alone would be a useful index of suspicion in this population. Although the 
clinician can identify established risk factors in the medical history (e.g., 
psychiatric illness, prior suicide attempt, access to firearms, substance abuse, 
recent life event such as death or divorce), the majority of patients with these 
characteristics do not intend to kill themselves.21,22 Asking general medical 
patients about sleep disturbance, depressed mood, guilt, and hopelessness 
correctly identified 84% of those who had experienced suicidal thoughts within 
the previous year.22a The study was not designed to assess actual suicide risk, 
however, and has not been replicated in the clinical setting. If validated, 
these questions may identify patients who may benefit from in-depth evaluation 
for suicide risk. 
Researchers have attempted to identify specific risk factors that are the 
strongest predictors of suicidal behavior. Many studies have shown, however, 
that structured instruments to assess these risk factors misclassified many 
persons as high risk who did not subsequently attempt suicide and (with some 
instruments) identified many as low risk who did commit suicide.23-28 For 
example, one scoring system,25 based on 4-6 years of longitudinal data from 
4,800 psychiatric patients, was able to identify correctly 35 of 63 (56%) 
subsequent suicides, but it generated 1,206 false positives (positive predictive 
value less than 3%). 
Also, physicians may not effectively assess risk factors for suicide, such as 
previous suicide attempts or psychiatric illness. In one study of completed 
suicides,29 over two thirds of victims had made previous attempts or threats, 
but only 39% of their physicians were aware of this history. Although 
psychological autopsy studies (retrospective psychiatric evaluation based on 
interviews with survivors) reveal that nearly all victims have evidence of 
previous psychiatric diagnoses (e.g., depression, bipolar disorder, alcohol and 
other drug abuse, schizophrenia) and previous psychiatric treatment,17,21,30 
many primary care clinicians fail to recognize the presence of mental illness. 
Several studies have shown that depression is frequently overlooked (see Chapter 
49), as is substance abuse (see Chapters 52 and 53). Improved early detection of 
these conditions might help persons at risk for suicide, but further research is 
needed to evaluate its effectiveness in reducing suicide rates. 
Recent studies have identified evidence of altered serotonin activity in 
patients who complete suicide, particularly those with depression and 
schizophrenia.31-33 No studies have evaluated these biochemical markers as 
screening tools in the general population. 
Effectiveness of Early Detection
Suicide is a relatively rare event, and large samples and lengthy follow-up 
would be needed for studies to demonstrate significant reduction in suicide 
rates as a result of a specific intervention such as mental health counseling 
and hospitalization, limitation of access to potential instruments of suicide, 
and treatment of underlying conditions.18 Although these measures seem to be 
clinically prudent, no direct evidence that they reduce suicide rates was found. 
Effects on less specific outcome measures, such as feelings of hopelessness,34 
have been reported. Even in the setting of attempted suicide, there is limited 
and conflicting evidence that intervention is beneficial; but there is also no 
conclusive evidence that it is not. Surveys indicate that patients receiving 
psychiatric consultation for attempted suicide find the therapy to be of limited 
benefit,35 and 35-40% choose not to remain in treatment.36,37 One study of 
hospitalized patients admitted for poisoning or self-inflicted injury reported 
fewer subsequent suicide attempts in persons who received psychiatric counseling 
than in controls who were discharged prematurely before seeing a psychiatrist.38 
Another cohort study of patients hospitalized for self-poisoning found no 
difference in subsequent suicide attempts among patients who attended 
psychiatric outpatient follow-up and those who did not.39 Among suicide 
attempters without immediate psychiatric or medical needs randomized to receive 
hospital admission or discharge home, there were no differences in psychological 
testing or further suicide attempts between the two groups at 1 week; long-term 
follow-up was not evaluated, however.40 Some selection biases were apparent in 
all of these studies, thereby limiting the generalizability of their results to 
all suicide attempters. Findings from these studies may not be applicable to 
successful suicide because people who attempt and those who complete suicide may 
differ. Involuntary hospitalization can be of immediate benefit to persons 
planning suicide and s often required for medicolegal reasons in persons with 
suspected suicidal ideation,41,42 but no reliable data on the long-term 
effectiveness of this measure were found. 
Another potential intervention is limiting access to the most common instruments 
of suicide, such as firearms and drugs. Although there is no direct evidence 
that removal of firearms can prevent suicide, studies have shown that geographic 
locations with reduced availability of these weapons have lower suicide rates 
among adolescents and young adults.8,43 Studies of deaths by drug overdose have 
found that, in over half of cases, the ingested drugs were either prescribed by 
a physician within the preceding week or were provided in a refillable 
prescription.44 There is little information, however, on how the physician can 
best identify persons who require nonlethal quantities of prescription drugs, or 
whether these measures will prevent subsequent suicide. Legislation in one 
country restricting the prescription of sedatives may have been associated with 
a reduced rate of suicide, but the evidence was not conclusive.45 
Since it has been estimated that as many as 90% of persons who commit suicide 
suffer from psychiatric disorders, it is possible that treatment of these 
underlying illnesses may prevent suicide.34 Indirect evidence suggests that 
patients with affective disorders who receive comprehensive psychiatric care 
have lower suicide rates than most persons with psychiatric illnesses,46,47 but 
studies with control groups are needed to exclude the possibility of selection 
bias in these results. A Swedish population-based time series study evaluated 
suicide rates before and 1 year after all postgraduate physicians in a community 
were trained to recognize and manage affective disorders appropriately.48 The 
suicide rate in the community decreased 50% in the year following the program, 
which was significant compared to previous trends in that community and to 
national rates in Sweden. Repetition of these results in a controlled trial with 
longer follow-up is needed. As many as 50% of persons who kill themselves are 
intoxicated with alcohol or other drugs,9 and a significant proportion also 
suffer from a substance abuse disorder.8 Early detection and treatment of 
alcohol and other drug abuse has the potential to prevent suicide, but firm 
evidence of this effect is lacking. 
Recommendations of Other Groups
The American Academy of Pediatrics recommends asking all adolescents about 
suicidal thoughts during the routine medical history.49 The American Medical 
Association50 and Bright Futures51 recommend that providers screen adolescents 
annually to identify those at risk for suicide. 
The Canadian Task Force on the Periodic Health Examination found insufficient 
evidence to recommend for or against the inclusion of suicide risk evaluation in 
the periodic health examination. Based on the high burden of suffering, however, 
they recommend that clinicians routinely evaluate the risk of suicide among 
persons in high-risk groups, particularly if there is evidence of psychiatric 
disorder (especially psychosis), depression, or substance abuse, or if the 
patient has recently attempted suicide or has a family member who committed 
suicide.52 The recommendations of the American Academy of Family Physicians are 
currently under review. 
Discussion
Suicide is a leading cause of death in the U.S., but there is no evidence that 
screening the general population for suicide risk is effective in reducing 
suicide rates. Routine medical history is often not sufficient to recognize 
suicide risk or suicidal intent. Several screening instruments have been 
developed to identify risk factors, but these do not accurately predict the 
likelihood of suicide. Even when a risk factor or suicidal intent is detected, 
there is weak evidence that interventions effectively reduce suicide rates. 
Several studies have evaluated treatment of those who attempt suicide, but 
results were conflicting, and these studies may not be generalizable to the 
population of those who complete suicide. Training primary care clinicians to 
recognize and treat appropriately underlying mental health problems such as 
depression and substance abuse may be effective, but long-term controlled 
studies have yet to be performed. 
CLINICAL INTERVENTION
There is insufficient evidence to recommend for or against routine screening by 
primary care clinicians to detect suicide risk in asymptomatic persons ("C" 
recommendation). Clinicians should be alert to evidence of suicidal ideation 
when the history reveals risk factors for suicide, such as depression, alcohol 
or other drug abuse, other psychiatric disorder, prior attempted suicide, recent 
divorce, separation, unemployment, and recent bereavement. Patients with 
evidence of suicidal ideation should be questioned regarding the extent of 
preparatory actions (e.g., obtaining a weapon, making a plan, putting affairs in 
order, giving away prized possessions, preparing a suicide note). It may also be 
prudent to question the person's family members regarding such actions. Persons 
with evidence of suicidal intent should be offered mental health counseling and 
possibly hospitalization. 
The training of primary care clinicians in recognizing and treating affective 
disorders in order to prevent suicide is recommended ("B" recommendation). 
Clinicians should be alert to signs of depression (see Chapter 49) and other 
psychiatric illnesses, and they should routinely ask patients about their use of 
alcohol and other drugs (see Chapters 52 and 53). Patients who are judged to be 
at risk should receive evaluation for possible psychiatric illness, including 
substance abuse, and counseling and referral as needed. 
Patients who are recognized as having suicidal ideation, or patients who suspect 
suicidal thoughts in their relatives or friends, should be made aware of 
available community resources such as local mental health agencies and crisis 
intervention centers. Parents and homeowners should also be counseled to 
restrict unauthorized access to potentially lethal prescription drugs and to 
firearms within the home (also see Chapters 58 and 59). 
The draft update of this chapter was prepared for the U.S. Preventive Services 
Task Force by S. Patrick Kachur, MD, MPH, and Carolyn DiGuiseppi, MD, MPH. 
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