This week’s Research Corner newsletter touches on the topic of suicide. If you are having thoughts of suicide, please call or text 988 to reach the 988 Suicide and Crisis Lifeline, which provides 24/7, free, confidential support for people in distress. And if you are curious about how the new 988 crisis line has performed since launching last year, check out our most recent podcast episode.

Why an Influential Task Force Doesn’t Recommend Screening for Suicide Risk

During my recent hospital shift as a new resident in internal medicine, a nurse briefed me about a young woman who had been admitted days earlier for a skin infection. The day prior to my shift, the nurse told me, the woman had expressed a desire to end her own life. The nurse also said the patient seemed less desperate now, but as I walked to her hospital room to meet her, I wondered whether I should ask again about those suicidal thoughts.

For about seven years, doctors have been encouraged to routinely ask patients during medical visits about symptoms of depression. There’s good evidence that such routine screenings can help people who are depressed get treated earlier. What’s less clear is whether it’s also helpful to routinely screen patients for suicide risk.

Last month, the U.S. Preventive Services Task Force (USPSTF) — an organization that issues influential guidance to clinicians about all sorts of medical screenings — reinforced their recommendation in favor of screening for depression. But they declined – at least for now – to endorse the same type of screening for suicide risk.

Screening tools for suicide risk are accurate, but it’s unclear whether they change health outcomes for most patients

Members of the USPSTF published a systematic review, or combined analysis, of 27 studies of suicide screenings justifying their recommendation. While the review focused on the primary care setting — not on the type of higher-risk hospital patient I saw the other day — I still found its insights useful in reflecting on how I’ll handle these delicate questions going forward.

The authors found that overall, the commonly used suicide risk screening tools they checked were fairly accurate. Using questions like “have you been considering suicide in the last month?” and “have you ever attempted suicide?” the tools accurately identified patients having suicidal thoughts at least 80% of the time.

But what happens after high-risk patients are identified?

That’s where the researchers found a paucity of evidence. None of the studies of suicide prevention interventions such as therapy or medications they reviewed were large enough to determine whether the interventions have any statistically significant impact on suicide deaths or attempts.

Possible unintended harms of suicide screenings

Fortunately, the USPSTF team found that being asked about suicide doesn’t seem to increase people’s frequency of suicidal thoughts or suicidal behavior in the weeks after screening. 

But the researchers did highlight some other potential harms. For example, they noted the risk that health insurance companies could use screening as a basis for denying coverage for medical care related to suicide attempts. They also raised the concern that life insurance companies might reduce payouts for patients with a history of suicide attempt in their medical records.

What are clinicians to do while we wait for the evidence to roll in?

While the USPSTF concluded that there’s not enough evidence at this point to recommend that primary care providers routinely conduct suicide screenings with all adult patients, other organizations like the Surgeon General’s office and advocacy groups have endorsed the practice. 

Personally I’m conflicted as well. I’d love to have clearer guidelines for how to handle situations like the one I faced the other morning. But I also know that a screening tool is only as good as the next steps it can offer a patient — and in this case, those best next steps aren’t yet as obvious as we’d like.

That morning in the hospital, I entered my patient’s room to find her lying uncomfortably in her bed, staring at the TV screen. 

“Hey, I’m Dr. Shah, and I just wanted to check in and see how you’re doing this morning,” I began. 

“Not good. I’m in pain and nauseous,” she replied. As I began to examine her left foot, to check the healing of the skin infection that originally brought her into the hospital, I decided to ask the question again: Was she having suicidal thoughts?

She paused before answering, and then broke into tears. 

“No,” she said. “But I am so, so anxious. The social worker told me I still may not have a place to stay after I leave the hospital. And I’ve been having pain from migraines — but I haven’t been on medication since before COVID.” 

I quickly reached out to the social worker to see if there might be options for housing services we hadn’t yet considered, and we restarted her old medications to stop those debilitating headaches.

Broaching the subject of suicide seemed to open a door with this patient, and helped us connect iin a genuinely meaningful way. While I can’t be sure that my question will reduce her risk of suicide down the road, it did create a space for me to meet some of her other immediate needs. And at that moment, I was glad I’d asked.

Tradeoffs’ coverage of diagnostic excellence is funded in part by the Gordon and Betty Moore Foundation.