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Systematic Review
"To review the benefits and harms of screening and treatment for depression, anxiety, and suicide risk, and the accuracy of instruments to detect these conditions among primary care patients."
"KQ4. Does Treatment of High Suicide Risk (Psychotherapy or Pharmacotherapy) Result in Improved Health Outcomes in Adults, Including Pregnant and Postpartum Persons?
We included 23 RCTs (reported in 36 articles, N=22,632) of suicide prevention among people at increased risk of suicide (Table 46). The impact of psychological interventions for suicide prevention on suicide deaths could not be determined due to the small number of events, however enough events were available to address suicide attempts. One large (n=18,882) good-quality multi-site trial conducted in US integrated care settings tested two suicide prevention interventions among adults with an elevated risk for suicide based on item 9 of the PHQ-9.This study found that, compared to usual care, a care management intervention had no impact on the rate of suicide attempts (HR, 1.07 [97.5% CI, 0.84 to 1.37]; p=.52) and a low-intensity online skills training intervention was associated with an increased risk of suicide attempts (HR, 1.29 [97.5% CI, 1.02 to 1.64]; p=.015) Most other studies reported five or fewer suicide attempts per study group and the pooled effect was not statistically significant (OR, 0.94 [95% CI, 0.73 to 1.22]; 12 RCTs [n=14,573]; I2=11.2%, including only the care management arm of the large trial; Figure 40, Table 47). Although there was a small statistically significant benefit for depression symptom severity, there was no clear improvement over usual care for suicidal ideation, self-harm, other mental outcomes, or emergency or inpatient healthcare utilization. (Table 47). Usual mental health care was the most common control group, and was in some cases enhanced or optimized, so most of the included studies could be considered comparative effectiveness studies. The study with the most favorable findings (n=598) used individually tailored depression care management for older adults who had screened positive for depression. This study reported improvements in depression outcomes for up to one year and suicidal ideation for up to eight months, but only five suicide attempts and one suicide death over two years. One study examined the impact of a pharmacologic intervention and found no differences between those taking placebo or 600 mg/day of lithium for up to one year in any suicide-related outcome, although medication adherence was low in this study."
"Both direct and indirect evidence support depression screening in primary care settings, including during pregnancy and postpartum. While evidence is insufficient to draw conclusions about the benefits or harms of anxiety screening interventions, there is clear evidence that treatment for anxiety is beneficial, and more limited evidence indicating acceptable accuracy of some anxiety screening instruments to detect generalized anxiety disorder. There are numerous important gaps in the evidence for suicide risk screening in primary care settings."