Clara B Soh

Screening for and treatment of suicide risk relevant to primary care: a systematic review for the U.S. Preventive Services Task Force.

BACKGROUND In 2009, suicide accounted for 36 897 deaths in the United States. PURPOSE To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care. DATA SOURCES Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012). STUDY SELECTION Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings. DATA EXTRACTION One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality. DATA SYNTHESIS Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths. LIMITATION Treatment evidence was derived from high-risk rather than screening-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited. CONCLUSION Primary care-feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

The Ankle–Brachial Index for Peripheral Artery Disease Screening and Cardiovascular Disease Prediction Among Asymptomatic Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force

BACKGROUND Screening for peripheral artery disease (PAD) may reduce morbidity and mortality. PURPOSE To review the evidence on the ability of the ankle-brachial index (ABI) to predict cardiovascular disease (CVD) morbidity and mortality independent of Framingham Risk Score (FRS) factors in asymptomatic adults and on the benefits and harms of treating screen-detected adults with PAD. DATA SOURCES MEDLINE and the Cochrane Central Register of Controlled Trials (1996 to September 2012), clinical trial registries, reference lists, and experts. STUDY SELECTION English-language, population-based prognostic studies evaluating the ABI in addition to the FRS and treatment trials or studies of treatment harms in screen-detected adults with PAD. DATA EXTRACTION Dual quality assessment and abstraction of relevant study details. DATA SYNTHESIS One large meta-analysis (n = 43 919) showed that the ABI could reclassify 10-year risk for coronary artery disease (CAD), but it did not report measures of appropriate reclassification (the net reclassification improvement [NRI]). Four heterogeneous risk prediction studies showed that the magnitude of the NRI was probably small when the ABI was added to the FRS to predict CAD or CVD events. Of 2 treatment trials meeting inclusion criteria, 1 large trial (n = 3350) showed that low-dose aspirin did not prevent CVD events in persons with a screen-detected low ABI but may have increased the risk for major bleeding events. LIMITATIONS Most prognostic studies did not allow for calculation of a bias-corrected NRI. Evidence on treatment benefits and harms was limited to aspirin and was scant. CONCLUSION Adding the ABI to the FRS probably has limited value for predicting CAD or CVD. Treatment benefits for asymptomatic individuals with screen-detected PAD are not established. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Primary Care Relevant Interventions for Tobacco Use Prevention and Cessation in Children and Adolescents: A Systematic Evidence Review for the U.S. Preventive Services Task Force

BACKGROUND Interventions to prevent smoking uptake or encourage cessation among young persons might help prevent tobacco-related illness. PURPOSE To review the evidence for the efficacy and harms of primary care-relevant interventions that aim to reduce tobacco use among children and adolescents. DATA SOURCES Three systematic reviews that collectively covered the relevant literature; MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects through 14 September 2012; and manual searches of reference lists and gray literature. STUDY SELECTION Two investigators independently reviewed 2453 abstracts and 111 full-text articles. English-language trials of behavior-based or medication interventions that were relevant to primary care and reported tobacco use, health outcomes, or harms were included. DATA EXTRACTION One investigator abstracted data from good- and fair-quality trials into an evidence table, and a second checked these data. DATA SYNTHESIS 19 trials (4 good-quality and 15 fair-quality) that were designed to prevent tobacco use initiation or promote cessation (or both) and reported self-reported smoking status or harms were included. Pooled analyses from a random-effects meta-analysis suggested a 19% relative reduction (risk ratio, 0.81 [95% CI, 0.70 to 0.93]; absolute risk difference, -0.02 [CI, -0.03 to 0.00]) in smoking initiation among participants in behavior-based prevention interventions compared with control participants. Neither behavior-based nor bupropion cessation interventions improved cessation rates. Findings about the harms related to bupropion use were mixed. LIMITATIONS No studies reported health outcomes. Interventions and measures were heterogeneous. Most trials examined only cigarette smoking. The body of evidence was largely published 5 to 15 years ago. CONCLUSION Primary care-relevant interventions may prevent smoking initiation over 12 months in children and adolescents.