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Abstract
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In this issue of JAMA, the US Preventive Services Task Force (USPSTF) updates earlier recommendations, endorsing screening for depression in adults while finding insufficient evidence to recommend for or against screening for suicide risk.1 Our views regarding those recommendations are informed by our work in suicide prevention research and quality improvement (G.E.S., J.E.R., and U.W.), clinical practice (G.E.S. and U.W.), lived experience of suicidal ideation (U.W.), and experience of family suicide loss (J.E.R.).
The renewed recommendation for depression screening is expected and should prompt little controversy. As documented in the accompanying Evidence Review,2 evidence since 2016 only strengthens the arguments for the accuracy of commonly used screening questionnaires and the effectiveness of specific interventions, including antidepressant medications and specific psychotherapies, for people identified by screening.
In contrast, the finding that evidence is insufficient to recommend for or against screening for suicide risk will likely meet objections. Improved identification of suicide risk is recommended by the Surgeon General's office,3 advocacy organizations,4 and accreditation bodies.5 To reconcile disparate recommendations, developments since 2014 that affect context should be considered. First, use of standard depression questionnaires for screening and assessing treatment outcomes is now widespread. The USPSTF recommends depression screening for all adults. The Centers for Medicare & Medicaid Services (CMS) Quality Payment Program assesses and rewards use of standard depression questionnaires for both screening and monitoring outcomes for all adults receiving depression treatment. Specific measures reviewed by the USPSTF and CMS, including the 9-Item Patient Health Questionnaire (PHQ-9) or Edinburgh Postnatal Depression Scale, include specific questions regarding suicidal ideation. Rather than recommending whether clinicians should ask about suicidal ideation, we must recommend how they respond to the answers. Second, health systems are exploring, and sometimes implementing, prediction models using records data to identify people at high risk for suicidal behavior.6,7 Screening to identify suicide risk can now include more than questionnaires.
Considering these developments, the key questions addressed by the USPSTF evidence review could be reframed: Do either suicidal ideation reported on depression screening questionnaires or risk scores computed from health records data accurately predict subsequent suicidal behavior? Does clinical intervention for people identified either by screening questionnaires or by risk scores reduce risk of subsequent suicidal behaviors?
Language: en |