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Impact of screening for risk of suicide: randomised controlled trial

  • Mike J. Crawford (a1), Lavanya Thana (a1), Caroline Methuen (a2), Pradip Ghosh (a3), Sian V. Stanley (a1), Juliette Ross (a4), Fabiana Gordon (a1), Grant Blair (a1) and Priya Bajaj (a5)...
Abstract
Background

Concerns have been expressed about the impact that screening for risk of suicide may have on a person's mental health.

Aims

To examine whether screening for suicidal ideation among people who attend primary care services and have signs of depression increases the short-term incidence of feeling that life is not worth living.

Method

In a multicentre, single-blind, randomised controlled trial, 443 patients in four general practices were randomised to screening for suicidal ideation or control questions on health and lifestyle (trial registration: ISRCTN84692657). The primary outcome was thinking that life is not worth living measured 10–14 days after randomisation. Secondary outcome measures comprised other aspects of suicidal ideation and behaviour.

Results

A total of 443 participants were randomised to early (n = 230) or delayed screening (n = 213). Their mean age was 48.5 years (s.d. = 18.4, range 16–92) and 137 (30.9%) were male. The adjusted odds of experiencing thoughts that life was not worth living at follow-up among those randomised to early compared with delayed screening was 0.88 (95% CI 0.66–1.18). Differences in secondary outcomes between the two groups were not seen. Among those randomised to early screening, 37 people (22.3%) reported thinking about taking their life at baseline and 24 (14.6%) that they had this thought 2 weeks later.

Conclusions

Screening for suicidal ideation in primary care among people who have signs of depression does not appear to induce feelings that life is not worth living.

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Copyright
Corresponding author
Dr M. J. Crawford, Reader in Mental Health Services Research, Centre for Mental Health, Faculty of Medicine, Imperial College London, Claybrook Centre, 37 Claybrook Road, London W6 8LN, UK. Email:m.crawford@imperial.ac.uk
Footnotes
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The study was funded by an educational grant from Imperial College London and supported by St Mary's Paddington Charitable Trust.

Declaration of interest

None.

Footnotes
References
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Impact of screening for risk of suicide: randomised controlled trial

  • Mike J. Crawford (a1), Lavanya Thana (a1), Caroline Methuen (a2), Pradip Ghosh (a3), Sian V. Stanley (a1), Juliette Ross (a4), Fabiana Gordon (a1), Grant Blair (a1) and Priya Bajaj (a5)...
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eLetters

Is this a noninferiority trial?

Peter D O'Halloran, Lecturer
05 December 2012

Crawford et al (2011) have set out investigate whether screening for suicidal ideation among people who attend primary care services and have signs of depression increases the short-term incidence of feeling that life is not worth living. It seems to me that this is a non-inferiority trial i.e. the authors want to show that screening is no worse than not screening. This raises a number of design issues.

First, the trial is powered to detect an increase in the proportion who felt their life was not worth living from 30% to 45%. This seems a clinically large increase and suggests that anything short of a 50% increase in relative risk (RR) is acceptable. Secondly, having calculated the sample size based on RR, they analyse the main results using odds ratios (OR) rather than RR, so that it is difficult to see what sort of increase in RR was found and impossible to see the CI around the RR. Third, if this is seen as a non-inferiority trial, arguably screening would be regarded as non-inferior provided that the possibility of the suicidal ideation rate being 50% worse than non-screening could be ruled out (in the sense that the 95% confidence interval for the difference in ideation rates would not include 50% inferiority relative to the non-screened group) (Pocock, 2001). We only have the CI around the OR to go onbut given how wide they are, it is highly likely that the CI would includethe 50% increase in RR. For these reasons I think the results should be treated with caution.

Peter O'Halloran

Queen's University Belfast

References

Crawford, M.J., Thana, L., Methuen, C., Ghosh, P., Stanley, S.V., Ross, J., Gordon, F., Blair, G. & Bajaj, P. (2011) Impact of screeningfor risk of suicide: randomised controlled trial. The British Journal of Psychiatry 198(5), 379-384.

Pocock, S.J. (2003) The pros and cons of noninferiority trials. Fundamental & clinical pharmacology 17(4), 483-490.

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Conflict of interest: None declared

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Impact of sceening for risk of suicide

MANJEET SINGH BHATIA, Professor and Head
01 June 2011

This is a good study highlighting the impact of screening on suicide risk. However, the addition of following information may have added to theusefulness of the study. Firstly, screening for depression and suicide risk by using objective standardized scales. Secondly, screening the patients for suicidal ideation, planning or attempt. Screening may have different impact on all these groups. Thirdly, type of treatment given wasnot mentioned. Fourthly, whether all participants were new. Fifthly, the the correlation of impact of screening with type of psychiatric disorder not mentioned. In our experience, the sreening for risk of suicide helps in advocating cautious emergency treatment. Those reporting, suicidal ideation must be screened every time for it. The trainees must be made sensitized to screen for suicidal ideation. ... More

Conflict of interest: None Declared

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