Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis

Abstract

ObjectiveTo characterise suicide-risk discussions in depressed primary-care patients.DesignSecondary analysis of recordings and self reports by physicians and patients. Descriptive statistics of depression and suicide-related discussion, with qualitative extraction of disclosure, enquiry and physician response.Setting12 primary-care clinics between July 2003 and March 2005.Participants48 primary-care physicians and 1776 adult patients.MeasuresPresence of depression or suicide-related discussions during the encounter; patient and physician demographics; depression symptom severity and suicide ideation as measured by the Patient Health Questionnaire (PHQ9); physician's decision-making style as measured by the Medical Outcomes Study Participatory Decision-Making Scale; support for autonomy as measured by the Health Care Climate Questionnaire; trust in their physician as measured by the Primary Care Assessment Survey; physician response to suicide-related enquiry or disclosure.ResultsOf the 1776 encounters, 128 involved patients scoring >14 on the PHQ9. These patients were seen by 43 of the 48 physicians. Suicide ideation was endorsed by 59% (n=75). Depression was discussed in 52% of the encounters (n=66). Suicide-related discussion occurred in only 11% (n=13) of encounters. 92% (n=12) of the suicide discussions occurred with patients scoring <2 on PHQ9 item 9. Suicide was discussed in only one encounter with a male. Variation in elicitation and response styles demonstrated preferred and discouraged interviewing strategies.ConclusionsSuicide ideation is present in a significant proportion of depressed primary care patients but rarely discussed. Men, who carry the highest risk for suicide, are unlikely to disclose their ideation or be asked about it. Patient-centred communication and positive healthcare climate do not appear to increase the likelihood of suicide related discussion. Physicians should be encouraged to ask about suicide ideation in their depressed patients and, when disclosure occurs, facilitate discussion and develop targeted treatment plans.

What Factors Determine Disclosure of Suicide Ideation in Adults 60 and Older to a Treatment Provider?

“…Finally, it is possible that confounding variables such as severity of depressive symptoms or intensity of suicide ideation may have influenced both disclosure and history of specialty mental health treatment. Prospective research is needed to enable causal inferences and mixed methods research could also yield insights into the nature of disclosures and provider response (Feldman et al., ; Vannoy & Robins, ).…”

“…Among patients who reported suicide ideation, but whose proxy did not report that they appeared to be suicidal, depressive symptom severity was lower. Vannoy and Robins () looked at primary care patients scoring greater than 14 on the Patient Healthcare Questionnaire (PHQ‐9 and found that only 7% of the patients who endorsed ideation on the PHQ‐9 disclosed these thoughts to their physician without being asked, and all of these patients were female.…”

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.…”

Suicide Risk Assessment and Risk Formulation Part I: A Focus on Suicide Ideation in Assessing Suicide Risk

“…The Suicide Ideation Questionnaire (SIQ; Reynolds, 1998) and, more recently, a briefer variation on the SIQ, the Ask Suicide-Screening Questions (ASQ;Horowitz et al, 2012), are two examples of such rapid screening tools, the former developed with the intent to measure the severity of suicide ideation and the latter suggesting that it has predictive value regarding risk of suicide. This claim, however, has been questioned, essentially on the limited available data on the relationship between suicide ideation and death by suicide (Wintersteen, Berman, & Silverman, 2013).…”