Primary Care Docs Often Miss Suicide Clues

Some three-fourths of individuals who kill themselves have seen a primary care doctor during the previous month, research has shown. Thus primary care physicians appear to be strategically situated to prevent a number of these tragedies.

Yet primary care doctors inquire about gravely depressed patients' suicidal thoughts or intent less than half the time, a new study has found.

The study was headed by Peter Franks, M.D., a professor of family and community medicine at the University of California-Davis. Results appeared in the September/October 2007 Annals of Family Medicine.

The study included 152 primary care physicians from four sites in either northern California or Rochester, N.Y. The physicians were told the general purpose of the study—that it had to do with learning more about doctor-patient communication in primary care—but not the specific purpose—that it concerned learning more about primary care doctors' inquiries into depressed patients' suicidal thinking or intent. The physicians were also told that, as a part of the study, several actors masking as patients would visit their practices in the forthcoming months and surreptitiously audiotape the sessions.

Thus, an actress portraying a middle-aged patient with major depression and an actress portraying a middle-aged patient with adjustment disorder with depressed mood visited each of the doctors sometime between May 2003 and May 2004. In addition to audiotaping their physician encounters, the pseudo patients also filled out report forms about the encounters right after they occurred. The report forms contained questions about the physicians' depression-history taking, especially whether they had inquired about suicidal thoughts or intent. Franks and his group then used the audiotapes and report-form results to see how often physicians broached the subject of suicide with the pseudo patients and which factors influenced their willingness to do so.

The physicians raised the subject of suicide with major-depression pseudo patients significantly more often than they did with adjustment-disorder pseudo patients. And that's good, Franks and his group wrote, “because patients with more depressive symptoms are more likely to attempt and complete suicide.” Even so, the physicians inquired about suicidal thoughts and intent in less than half of their encounters with the major-depression pseudo patients.

Two factors seemed to encourage primary care doctors to broach the subject of suicide with acutely depressed patients. One was when depressed pseudo patients asked for an antidepressant (sometimes they did, and sometimes they didn't, according to study design). Another was when the doctor or the doctor's family had experienced depression. However, other factors did not seem to play a role in doctors' willingness to talk about suicide. They were gender, communication style, specialty (family medicine or internal medicine), and their confidence in their ability to treat depression.

Nonetheless, other factors were probably involved as well, study analysis indicated, and Franks has a hunch what several might be. “I think the main barrier is that docs think that exploring depression and suicidality will antagonize the patient—that is, they either buy into societal prejudices or worry that the patient does.” Franks also suspects that some physicians are reluctant to bring up the subject of suicide with acutely depressed patients because it might actually encourage the patients to take action—“a kind of magical thinking.” Still others, he conjectured, are afraid of bringing up the topic because they don't have the time or resources to deal with a suicidal patient.

Some primary care doctors have responded positively to the study report.“ They think it's great that we are drawing attention to the problem,” said Franks. Professional organizations might also be able to reduce the number of suicides that occur in the wake of primary care visits, Franks believes. For example, he proposed, APA might issue public-service announcements encouraging depressed individuals to discuss any suicidal ideas they have with their primary care doctors. APA, he suggested, might also provide primary care doctors with guidelines on what to do if depressed patients admit to having suicidal ideas.

The study was funded by the National Institute of Mental Health.

“Let's Not Talk About It: Suicide Inquiry in Primary Care” is posted at<www.annfammed.org> under the September/October issue. ▪