PURPOSE We wanted to describe the vocabulary and narrative context of primary care physicians' inquiries about suicide.METHODS One hundred fi fty-two primary care physicians (53% to 61% of those approached) were randomly recruited from 4 sites in Northern California and Rochester, New York, to participate in a study assessing the effect of a patient's request for antidepressant medication on a physician's prescribing behavior. Standardized patients portraying 2 conditions (carpal tunnel syndrome and major depression, or back pain and adjustment disorder with depressed mood) and 3 antidepressant request types (brand-specifi c, general, or none) made 298 unannounced visits to these physicians between May 2003 and May 2004. Standardized patients were instructed to deny suicidality if the physician asked. We identifi ed the subset of transcripts that contained a distinct suicide inquiry (n = 91) for inductive analysis and review. Our qualitative analysis focused on elucidating the narrative context in which inquiries are made, how physicians construct their inquiries, and how they respond to a patient's denial of suicidality.
RESULTSMost suicide inquiries used clear terminology related to self-harm, suicide, or killing oneself. Three types of inquiry were identifi ed: (1) straightforward (eg, "Are you feeling like hurting yourself?"); (2) supportive framing (eg, "Sometimes depression gets so bad that people feel that life is no longer worth living. Have you felt this way?"); and (3) no problem preferred (eg, "You're not feeling suicidal, are you?"). Four inquiries were glaringly awkward, potentially inhibiting a patient's disclosure. Most (79%) suicide inquiries were preceded by statements focusing on psychosocial concerns, and most (86%) physician responses to a standardized patient's denial of ideation were followed up with relevant statements (eg, "I hope you would tell me if you did.").CONCLUSION Although most suicide inquiries by primary care physicians are sensitive, clear, and supportive, some language is used that may inhibit suicide disclosure. Some physician responses may unintentionally reinforce patients for remaining silent about their risk. This study will inform future research in the development of quality improvement interventions to support primary care physicians in making clear, appropriate, and sensitive inquires about suicide. 2010;8:33-39. doi:10.1370/afm.1036.
Ann Fam Med
INTRODUCTION
Suicide is a stigmatized behavior accounting for more than 30,000 deaths per year in the United States.1 Although depression is highly prevalent among people who die by suicide, 2 relatively few have sought mental health specialty services in the weeks preceding their death. [3][4][5] In contrast, nearly one-half of the people who die by suicide have seen a primary care physician within a month of death. 4,6 From a public health perspective, primary care visits may represent an important opportunity for suicide prevention.An important aspect of case identifi cation for suicide risk is the frequency with ...
