Primary Care Screenings Cut Suicide Risk, Study Shows

In the winter of 2023, Cynthia Smith, MD, an internal medicine physician in Philadelphia and the chief membership and engagement officer for the American College of Physicians, treated a high-achieving, middle-aged man who said he felt completely alone and isolated.

Smith used depression and suicide screeners and found the man was actively thinking of harming himself. She and the man created a safety plan. Then, she connected her patient to a clinical social worker within her health system who helped him enter an intensive outpatient treatment program for depression.

“I am not sure if screening this patient for depression saved his life, but I do think he left the office feeling less alone and more supported than when he arrived. Screening him helped us achieve that outcome,” said Smith. “Our patient needed to know that we cared about him.”

Smith ‘s experience is part of a broader movement to screen patients for depression and suicide with the goal of getting people into treatment.

Prior research has shown more than 40% people who die by suicide visit a primary care clinician in the month before death, and more than 75% see a primary care physician in the year before a suicide death.

New research published in Annals of Internal Medicine showed these screening processes reduced suicide attempts and deaths by suicide by 25% in one health system.

Clinicians using screening questions to engage patients in safety planning “can know that this work is valuable, and that it will save lives,” said Julie Angerhofer, PhD, MPH, a collaborative scientist at Kaiser Permanente Washington Health Research Institute in Seattle, and a co-author of the study. “For those who are considering investing in doing this work, it is good news because it is going to have an effect. We did not know that until we did this trial.”

Suicide is the 11th leading cause of death in the United States, accounting for 49,000 fatalities in 2022, according to the US Centers for Disease Control and Prevention.

The new study findings “are significant when it comes to working with people who are at risk for suicide in primary care practice and shows that it is both feasible and effective,” said Julie Goldstein Grumet, PhD, vice president for suicide prevention strategy and director of the Zero Suicide Institute at the nonprofit Education Development Center.

Moving the Needle

Grumet said the use of standardized screening tools, like those used in the study protocol, is key.

When patients screened positive for depression with the Patient Health Questionnaire 2 (PHQ-2), they were asked to complete the additional questions of the PHQ-9. If patients reported frequent suicidal thoughts, they received a brief, self-administered version of the Columbia-Suicide Severity Rating Scale. The analysis included 333,593 patients who had 1.56 million visits for any reason to their primary care clinician.

Patients who reported some level of intent or planning for a suicide attempt in the prior month were connected to a clinical social worker for same day safety planning.

The study showed that the rate of documented fatal or nonfatal suicide attempts within 90 days of a primary care visit was 25% lower in the suicide care than in the usual care period and 24% lower in the 60 days after a visit, both statistically significant findings.

These tools help clinicians “to determine the type of care needed and to provide the right level of intervention,” Grumet said.

Both Smith and the study utilized social workers to help with safety planning. But because many clinicians do not work in integrated health systems with access to these professionals, other workflows can also support the screening and safety planning process, Angerhofer said. For instance, nurses can be trained to conduct a safety plan.

“Some systems also use centralized groups of providers trained in safety planning to support primary care teams virtually,” she said. Clinicians can also refer to free trainings on safety planning available online — including the one on the Zero Suicide website.

Smith said one of the biggest barriers to suicide care is the lack of resources needed to follow-up on a positive screen.

The study findings are “a call to action, but it can’t be the straw breaking the backs of primary care doctors; it has to be supported,” Smith said.

The study was supported by a grant from the National Institute of Mental Health. Various study authors reported receiving consulting fees, honoraria, and grants from the University of Washington, Advocate Aurora Health, the Donaghue Medical Research Foundation’s Greater Value Portfolio program, and the Patient-Centered Outcomes Research Institute, among others.

Debra Wallace is an award-winning journalist who specializes in writing on health, special needs parenting, and entertainment.