Tuesday, July 12, 2022

Experts Debate Benefits, Drawbacks of Universal Suicide Screening

While most experts agree that suicide represents a worsening national epidemic in need of increased attention, there is less agreement on whether universal screening across health care settings is the best approach for identifying those at greatest risk. In a column published yesterday in Psychiatric Services, researchers offer two differing perspectives on the benefits and drawbacks of universal screening for suicide.

“Behavioral health providers across the country are both motivated to respond to the suicide epidemic in the United States and acutely aware of the unintended consequences of new requirements and regulations,” wrote editor Patrick Runnels, M.D., M.B.A., in a summary introducing the two columns in the journal’s “Controversies in Psychiatric Services” series.

Research shows that many people who die by suicide are seen in a primary care setting in the months leading up to their deaths. This has led some to advocate for expanding universal suicide risk screening in primary care.

Unlike indicated or selective suicide risk screening—which takes place after patients are identified through a positive depression screen or present with other mental health symptoms warranting further evaluation—universal screening involves all patients in both medical and mental health settings, regardless of the reason for their visit.

“Our position is that, relative to the known benefits of indicated or selected screening, the assumed benefits of universal screening in primary care are overestimated while it’s possible risks are underestimated,” explained Craig J. Bryan, Psy.D., of Ohio State University College of Medicine; Michael H. Allen, M.D., of the University of Colorado School of Medicine; and Charles W. Hoge, M.D., of Walter Reed Army Institute of Research, in the first of the two columns.

One such risk is an increase in false positives, the authors noted. “Some of these positive screening results would be perceived as medical emergencies in settings where further evaluation is not readily available, leading to problematic transfers to [emergency departments]. Such transfers will often be involuntary on the part of the patient, and some will result in unnecessary psychiatric hospitalization.”

They concluded, “Until confirmation of the hypothesis that universal screening can incrementally improve outcomes among primary care patients relative to indicated or selected screening, we believe it is best to follow existing evidence supporting the latter screening approach.”

In contrast, Julie Goldstein Grumet, Ph.D., of Zero Suicide Institute and Edwin D. Boudreaux, Ph.D., of the University of Massachusetts Medical School argued in the second of the two columns that targeted screening among only those with known behavioral health disorders “will miss many if not most adults and children at risk.” Another benefit of universal suicide risk screening might be improved training of health care professionals, according to the authors.

“Although adoption of universal screening is inherently associated with increased burdens in clinical settings, these burdens can be overcome,” Goldstein Grumet and Boudreaux wrote, pointing to the importance of involving leadership, frontline staff, information technology specialists, and others to design the protocol, workflow, and training and to oversee implementation of the screening.

They concluded, “The data are clear: Application of universal screening for suicide risk is feasible in health care, improves identification of risk, makes identification more equitable across racial groups, and, when combined with an intervention, reduces the probability of future suicidal behavior.”

For related information, see the Psychiatric News article “Half of Patients With Suicidal Thoughts Deny It.”

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