Let's Not Talk About It: Suicide Inquiry in Primary Care

Abstract

PURPOSE The purpose of this study was to ascertain physician characteristics associated with exploring suicidality in patients with depressive symptoms and the infl uence of patient antidepressant requests.METHODS Primary care physicians were randomly recruited from 4 sites in northern California and Rochester, NY; 152 physicians participated (53%-61% of those approached). Standardized patients portraying 2 conditions (major depression and adjustment disorder) and 3 antidepressant request types (brand specifi c, general, or none) made unannounced visits to these physicians between May 2003 and May 2004. We examined factors associated with physician exploration of suicidality.RESULTS Suicide was explored in 36% of 298 encounters. Exploration was more common when the patient portrayed major depression (vs adjustment disorder) (P = .03), with an antidepressant request (vs no request) (P = .02), in academic settings (P <.01), and among physicians with personal experience with depression (P <.01). The random effects logistic model revealed a signifi cant physician variance component with ρ = 0.57 (95% confi dence interval, 0.45-0.68) indicating that there were additional, unspecifi ed physician factors determining the tendency to explore suicide risk. These factors are unrelated to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confi dence in treating depression.CONCLUSIONS When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality. Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help. Research is needed to further elucidate physician characteristics associated with the assessment of suicidality. INTRODUCTIONSuicide is a leading cause of death and potential life-years lost worldwide. 1 Most people who die by suicide have a treatable mental disorder, usually depression, but few have seen a mental health specialist. 2,3 Although many patients are reluctant to seek and actively engage in mental health treatment, up to 75% of those who complete suicide have seen a primary care clinician in the previous 30 days. [4][5][6][7] The primary care setting thus presents an excellent venue for detection of and early intervention for suicide risk. 8,9 Suicide ideation, defi ned as the presence of passive or active thoughts about a premature end of life, is present in 2% to 7% of all primary care patients.10,11 Suicide ideation confers risk for suicide as well as morbidity and all-cause mortality. [12][13][14][15][16][17][18] In spite of ample opportunity for detection and intervention, presuicidal patients seldom alert physicians to their plans, and studies have found low rates of inquiry and detection of patients' suicidal thoughts by primary care practitioners. 8,15,19 Remarkably little is known about the factors that infl uence whether primary care physicians broach the topic of suicide. [20][21][22][23] To d...

Characteristics, Management, and Depression Outcomes of Primary Care Patients Who Endorse Thoughts of Death or Suicide on the PHQ-9

“…Although suicide risk should always be assessed as a routine component of depression evaluation, patients often do not disclose their suicidal thoughts and evidence suggests that primary care providers infrequently ask about suicidality when evaluating depression. 21,22 Using Item 9 from the PHQ-9 does not replace clinical evaluation of suicide risk; however, its use may help primary care providers become more comfortable initiating such discussions. The need for careful suicide risk assessment of all individuals with mental health concerns is underscored by the fact that a small number of individuals reporting SI on Item 9 scored below the threshold on the PHQ-2 and on the PHQ-8.…”

Practical Suicide-Risk Management for the Busy Primary Care Physician

“…In patients with current suicidal ideation and/or documentation in the medical record of having made a suicide plan or attempt, only one third were referred for consultation. Don'T ASk, Don'T TEll, Don'T knoW Further reinforcing these findings, a 2007 study 30 found only 36% of simulated patients requesting antidepressant medication were even asked about suicide. Patients with simulated major depressive disorder were slightly more likely to be asked, 30 although more than half of these patients were not asked.…”

“…Don'T ASk, Don'T TEll, Don'T knoW Further reinforcing these findings, a 2007 study 30 found only 36% of simulated patients requesting antidepressant medication were even asked about suicide. Patients with simulated major depressive disorder were slightly more likely to be asked, 30 although more than half of these patients were not asked. Physician-specific factors that were related to training (eg, time since training) or that could have had a bearing on individual beliefs (eg, sex) did not explain the results.…”

“…Physician-specific factors that were related to training (eg, time since training) or that could have had a bearing on individual beliefs (eg, sex) did not explain the results. 30 Notably, physicians who had personally experienced depression, those who had family or friends with depression, and those who worked in academic settings were more likely to ask about suicide. 30 Although this study found no association with level of physician training, residency training for depression and suicide-related behavior is perceived as inadequate.…”

“…30 Notably, physicians who had personally experienced depression, those who had family or friends with depression, and those who worked in academic settings were more likely to ask about suicide. 30 Although this study found no association with level of physician training, residency training for depression and suicide-related behavior is perceived as inadequate. 31 Residency training directors surveyed in family medicine, pediatrics, and internal medicine reported substantial dissatisfaction in the adequacy of their program's depression and suicide training.…”