To characterise suicide-risk discussions in depressed primary-care patients.
Secondary 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.
12 primary-care clinics between July 2003 and March 2005.
48 primary-care physicians and 1776 adult patients.
Presence 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.
Of 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.
Suicide 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.
Determine frequency of suicide-related discussions in routine primary-care encounters with depressed patients along with demographic predictors.
Identify process variables that may or may not influence the likelihood that suicide will be discussed in primary care.
Analyse interview style related to enquiring about suicide and responding to patient responses to enquiry as well as unsolicited disclosure.
Suicide is addressed in a small minority of encounters with depressed patients in primary care.
Suicide is rarely discussed with depressed male patients who are at high risk for suicide.
Physician enquiries related to suicide are often made with patients who have the lowest levels of ideation, and the enquiries themselves are often biased to elicit a denial of ideation.
Strengths and limitations of this study
The study involved a large number of primary care physicians and patients representing real-world patient encounters.
It is unknown if the topic of suicide had been discussed in previous encounters and how such discussion influenced the present encounter.
We were unable to identify significant predictors of suicide-related discussion, yet we were able to demonstrate that some likely candidates such as participatory decision-making style and trust were not sufficient.