Clinicians Should Not Adopt a Single Self-Reported Item as a Screener for Suicide

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To the Editor: In their recent article, Green and associates state that item 9 of the Beck Depression Inventory, an item that pertains to suicide ideas and plans, should be used as "a brief, efficient screen for suicide risk in routine clinical care" and that "clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen." They imply that psychiatric outpatients and patients seen in the emergency department after a suicide attempt who do not self-report suicide ideas (with a score of 0 on item 9) do not need a "suicide risk assessment and corresponding risk management plan." While we acknowledge that item 9 might distinguish between high- and low-risk groups for suicide in a statistical sense, we believe the authors have overstated the case for its use as a routine screening tool in these populations.


See reply by Green et al and article by Green et al

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Clinicians Should Not Adopt a Single Self-Reported Item as a Screener for Suicide

To the Editor: In their recent article, Green and associates state that item 9 of the Beck Depression Inventory, an item that pertains to suicide ideas and plans, should be used as "a brief, efficient screen for suicide risk in routine clinical care"1(p1683) and that "clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen."1(p1683) They imply that psychiatric outpatients and patients seen in the emergency department after a suicide attempt who do not self-report suicide ideas (with a score of 0 on item 9) do not need a "suicide risk assessment and corresponding risk management plan." While we acknowledge that item 9 might distinguish between high- and low-risk groups for suicide in a statistical sense, we believe the authors have overstated the case for its use as a routine screening tool in these populations.

The World Health Organization (WHO) has very well-established guidelines outlining when screening is worthwhile.2,3 WHO suggests that a specific diagnostic test should be available to follow a sensitive but nonspecific screening procedure like item 9.2,3 However, there are no tests for future suicide that are specific enough to usefully divide patients into those at high or low likelihood of future suicide.4,5 Further, according to WHO, a useful intervention should be available to justify screening.2,3 However, there are no highly effective treatments that specifically prevent suicide or suicide attempts, and certainly none that have effectiveness over the very long period of follow-up described in the recent study. Finally, WHO recommends that screening should be shown to reduce overall morbidity or mortality.2,3 Despite over 50 years of suicide risk research, it has never been shown that allocating treatment resources on the basis of suicide risk assessment results in fewer suicides.

The thoroughness of a psychiatric assessment in these populations should never be determined by the simple presence or absence of self-reported suicidality. Every psychiatric outpatient and every patient seen in an emergency department after a suicide attempt should be thoroughly, sympathetically, and personally assessed by a mental health professional who should then be in a position to offer treatment in line with the patient’s needs and wishes.6 Unfortunately, there are no shortcuts in this realm of clinical practice.

References

1. Green KL, Brown GK, Jager-Hyman S, et al. The predictive validity of the Beck Depression Inventory suicide item. J Clin Psychiatry. 2015;76(12):1683-1686. PubMed doi:10.4088/JCP.14m09391

2. Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. Geneva, Switzerland: WHO; 1968.

3. Andermann A, Blancquaert I, Beauchamp S, et al. Revisiting Wilson and Jungner in the Genomic Age: A Review of Screening Criteria Over the Past 40 Years. Geneva, Switzerland: WHO; 2008.

4. Pisani AR, Murrie DC, Silverman MM. Reformulating suicide risk formulation: from prediction to prevention. Acad Psychiatry. 2015. PubMed doi:10.1007/s40596-015-0434-6

5. Large M, Ryan C. Suicide risk assessment: myth and reality. Int J Clin Pract. 2014;68(6):679-681. PubMed doi:10.1111/ijcp.12378

6. Ryan CJ, Large M, Gribble R, et al. Assessing and managing suicidal patients in the emergency department. Australas Psychiatry. 2015;23(5):513-516. PubMed doi:10.1177/1039856215597536

Matthew Large, BSc, MBBS, FRANZCP, DMedScia

mmbl@bigpond.com

Christopher J. Ryan, MBBS, MHL, FRANZCPb,c

aSchool of Psychiatry, University of New South Wales, Sydney, Australia

bCentre for Values, Ethics and the Law in Medicine, University of Sydney, Australia

cDiscipline of Psychiatry, Sydney Medical School, University of Sydney, Australia

Potential conflicts of interest: None.

Funding/support: None.

J Clin Psychiatry 2016;77(8):1087

dx.doi.org/10.4088/JCP.16lr10646

© Copyright 2016 Physicians Postgraduate Press, Inc.

J Clin Psychiatry 2016;77(8):1087

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