Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care

Abstract

PURPOSE Primary care clinicians have diffi culty detecting suicidal patients. This report evaluates the effect of 2 primary care interventions on the detection and subsequent referral or treatment of patients with depression and recent suicidal ideation.METHODS Adult patients in 12 mixed-payer primary care practices and 9 not-forprofi t staff model health maintenance organization (HMO) practices were screened for depression. Matched practices were randomized within plan type to intervention or usual care. The intervention for mixed-payer practices entailed brief training of physicians and offi ce nurses to provide care management. The intervention for HMO practices consisted of guided development of quality improvement teams for depression care. A total of 880 enrolled patients met study criteria for depression, 232 of whom met criteria for recent suicidal ideation. Intervention effects on suicide detection and referral to mental health specialty care were evaluated with mixed-effects multilevel models in intent-to-treat analyses.RESULTS Depressed patients with recent suicidal ideation were detected on 40.7% of index visits in intervention practices, compared with 20.5% in usual care practices (odds ratio = 2.64, 95% confi dence interval, 1.45-5.07), with HMO plan type and male sex associated with detection. The interventions had no effect on referral of patients, starting an antidepressant, or suicidal ideation reported at a 6-month follow-up, although power was limited for all 3 analyses.CONCLUSIONS Primary care interventions to improve depression care can improve detection of recent suicidal ideation. Further work is needed to improve physician response to detection, including referral to specialty care and more aggressive treatment, and to observe the effect on outcomes. INTRODUCTION Suicide represents a major social 1 and economic 2,3 burden on the health of the American people and ranks among the top 10 causes of death for Americans aged 10 years and older. 4 Suicide attempts are even more common, 5-7 increase morbidity and health care costs, 3 and further elevate the risk of individuals for a subsequent completed suicide. 8 Suicide prevention has been identifi ed as a national priority 9,10 and is now the target of a comprehensive national strategy. 4 Primary care physicians have an important role in detecting patients at higher risk for suicide, and for prevention. Many [11][12][13][14] but not all 15 studies report that individuals make primary care visits before completing suicide. Improving primary care for suicidal patients poses several critical challenges. Completed suicide is relatively infrequent in primary care practice. Although suicidal ideation is more frequent than suicidal behavior or completed suicide, 16-21 the relationships among ideation, suicide attempts, and completed suicide are uncertain. 5,6,8,[22][23][24][25][26][27] Patients rarely volunteer suicidal ideation, although many will acknowledge ideation if asked directly 13 Rather than increasing primary care physician vigi...

Suicide Inquiry in Primary Care: Creating Context, Inquiring, and Following Up

“…Detecting and assessing risk for suicide relies on patient disclosure of factors related to potential self-harm, particularly suicidal ideation. 13 Few patients spontaneously disclose suicidal thoughts, however, 14,15 and few primary care physicians ask about suicide ideation. 8,14 Suicide risk assessment challenges normative patient-physician communication by forcing the physician to probe for an often unstated concern.…”

Prevention of depression and suicide in Primary Health Care settings: a systematic review of the evidence

“…In the programme by Nutting et al (2005), the effect was greatest amongst men, whilst Hegerl et al (2006) found significant effects for both men and women. The remaining three interventions did not make a gender distinction in their data collection or analyses.…”

“…It should be noted, however, that at this point in time half of the GPs that participated in the intervention were no longer working on the island. Nutting et al (2005) also report on a decrease of the effects after a six-month period. The remaining interventions included here had either very short follow-up periods (e.g.…”

“…However when compared to a control region the changes were significant amongst females only. Nutting et al (2005) rerport on two additional programmes that involved education of physicians regarding care of depressed patients (Nutting et al, 2005). One of them, QuEST, included 24 primary care physicians who participated in four conference session regarding guidelines for detection and treatment of depression.…”

“…Still, in three studies these effects were limited to females and in one to patients with major depression. Two further articles (Pfaff et al, 2001 andNutting et al, 2005) succeeded in improving the identification of suicidal ideation. Results on interventions aiming solely to improve the detection of depression are somewhat more inconsistent.…”