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Letter to the Editor

Dr Green and Colleagues Reply

Kelly L. Green, PhD; Gregory K. Brown, PhD; and Shari Jager-Hyman, PhD

Published: August 24, 2016

See letter by Large and Ryan and article by Green et al

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Dr Green and Colleagues Reply

To the Editor: We appreciate the response from Large and Ryan to our article "The Predictive Validity of the Beck Depression Inventory Suicide Item."1 First, Large and Ryan assert that we suggest patients who score 0 on the suicide item "do not need ‘ a suicide risk assessment and corresponding risk management plan.’ " We did not intend to imply that a score of 0 should preclude risk assessment and management. Rather, we stated in our article that the item "should not be relied upon as the sole determination of risk in a suicide risk assessment or to make risk management decisions."1(p1684) Given the space limitations of our article, we did not unpack this statement further, so we will elaborate here. Although we suggest that a score of 1 or above should alert clinicians of the need to further assess suicide risk during the encounter, there are cases in which patients scoring a 0 warrant further assessment (such as assessing for a history of a suicide attempt). Thus, clinicians should take all available data into account when making clinical decisions.

Second, we strongly disagree with Large and Ryan’s assertion that it is not worthwhile to implement routine suicide risk screening. Identification of at-risk individuals is a necessary first step to preventing suicide. Indeed, recent research indicates that routine suicide risk screening improves detection of at-risk individuals2 and also changes clinician behavior for the better, resulting in increased rates of further risk assessment.3 Troubling data indicating that up to 40% of psychiatric patients who die by suicide are not assessed for suicide risk by mental health providers at their last visit prior to death4 suggest that inappropriate shortcuts occur during clinical practice. Screening is not a shortcut. Rather, it is a tool that provides guidance for conducting suicide risk assessments during each visit, which, in turn, prompts clinicians to use evidence-based interventions to reduce suicide risk. It is for this reason that suicide risk screening is included in the National Strategy for Suicide Prevention5 and is also a component of the Zero Suicide approach,6 which has been found to reduce suicide deaths within health systems by up to 80%.7,8

Finally, Large and Ryan’s claim that no efficacious interventions exist for the prevention of suicide and suicide attempts is incorrect. Follow-up interventions (eg, caring letters) have been found to prevent both suicide and suicide attempts following discharge for periods of up to 2 years.9 Several efficacious outpatient psychotherapy interventions have also been shown to prevent suicide attempts with follow-up periods of up to 2 years, including but not limited to dialectical behavior therapy,10 cognitive therapy for suicide prevention,11 and brief cognitive behavioral therapy.12 For a more thorough review and discussion of effective interventions for suicide prevention, we encourage readers to refer to our recent reviews.9,13


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. Boudreaux ED, Camargo CA Jr, Arias SA, et al. Improving suicide risk screening and detection in the emergency department. Am J Prev Med. 2016;50(4):445-453. PubMed doi:10.1016/j.amepre.2015.09.029

3. Betz ME, Arias SA, Miller M, et al. Change in emergency department providers’ beliefs and practices after use of new protocols for suicidal patients. Psychiatr Serv. 2015;66(6):625-631. PubMed doi:10.1176/

4. Smith EG, Kim HM, Ganoczy D, et al. Suicide risk assessment received prior to suicide death by Veterans Health Administration patients with a history of depression. J Clin Psychiatry. 2013;74(3):226-232. PubMed doi:10.4088/JCP.12m07853

5. The 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. US Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention Web site. Updated 2012.

6. About Zero Suicide. ZeroSuicide Web site. Accessed February 2, 2016.

7. Coffey CE. Pursuing perfect depression care. Psychiatr Serv. 2006;57(10):1524-1526. PubMed doi:10.1176/ps.2006.57.10.1524

8. Coffey CE, Coffey MJ, Ahmedani BK. An update on perfect depression care. Psychiatr Serv. 2013;64(4):396. PubMed doi:10.1176/appi.PS.640422

9. Brown GK, Green KL. A review of evidence-based follow-up care for suicide prevention: where do we go from here? Am J Prev Med. 2014;47(suppl 2):S209-S215. PubMed doi:10.1016/j.amepre.2014.06.006

10. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766. PubMed doi:10.1001/archpsyc.63.7.757

11. Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563-570. PubMed doi:10.1001/jama.294.5.563

12. Rudd MD, Bryan CJ, Wertenberger EG, et al. Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatry. 2015;172(5):441-449. PubMed doi:10.1176/appi.ajp.2014.14070843

13. Brown GK, Jager-Hyman S. Evidence-based psychotherapies for suicide prevention: future directions. Am J Prev Med. 2014;47(suppl 2):S186-S194. PubMed doi:10.1016/j.amepre.2014.06.008

Kelly L. Green, PhDa

Gregory K. Brown, PhDa

Shari Jager-Hyman, PhDa

aDepartment of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Potential conflicts of interest: None.

Funding/support: None.

J Clin Psychiatry 2016;77(8):1087-1088

© Copyright 2016 Physicians Postgraduate Press, Inc.

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