Prevention Research Priorities. Dr. Comtois outlined seven priorities for suicide prevention research. (1) Increased rigor for future research designs. (2) Replication of the effective prevention and interventions. (3) Dissemination of what is known. There is a tremendous need throughout the health services and community systems for operationalization of data-based approaches; there is great need for treatment manuals. (4) Universal nomenclature and assessment methods to allow comparisons across studies. (5) Focus on suicidal behaviors specifically. (6) Reassessment of ethical ways to include people with high risk in treatment studies. (7) Extension of studies beyond those suicide attempts that reach medical attention.
THE ROLE OF THE PRIMARY CARE PHYSICIAN IN PREVENTING SUICIDE
Dr. Herbert C.Schulberg covered three main topics in his talk: (1) Prevalence of suicidality in the primary care setting (2) assessment and intervention for suicidality in primary care practice, and (3) the current state of research in this field. Dr. Schulberg stated that treatment of suicidality in primary care brings two clinical areas together, suicide prevention and management of mental disorders in primary care.
We cannot extrapolate from studies of psychiatric patients as to what the preva lence or what the suicide rate is among primary care patients.
Prevalence of Suicidality in the Primary Care Setting. According to Dr. Schulberg it is difficult to engage primary care physicians in suicide screening and prevention because of the low prevalence in their patient populations. “4.2 percent of all the definite or possible suicides were attributed to primary care patients,” according to research described by Dr. Schulberg. Approximately one patient commits suicide every 3 years according to another study, with patient loads of 2,000–4,000 per practitioner. Time demands of medical practice are a disincentive for attending to low-base rate disorders, even when fatal. Therefore, it may be preferable for primary care physicians to monitor for the major risk factors for suicide. A history of psychiatric hospitalization, depressive disorders, alcohol and/or substance abuse, marital life events, and physical illness comorbid with depression all increase risk of suicide, according to Dr. Schulberg, and could serve as flags for intervention. Drs. Bell and Schulberg discussed the successful adoption of general practitioner practice guidelines for hypertension as a possible model for suicide risk factor screening.
Assessment and Intervention for Suicidality in Primary Care Practice. Dr. Schulberg reports “that the primary care physicians do not do a good job of assessing whether or not there is a psychiatric episode” in general. Research he and his colleagues did found that only 27 percent of those reaching diagnostic criteria for depressive disorders were identified by the primary care physician. False positives are very rare. Suicidal ideation is rarely assessed in the primary care
setting, according to Dr. Schulberg. He described a case vignette analysis which found that 91 percent of the physicians presented with case histories considered depression, but suicidal ideation was only considered two percent of the time in relation to the consequences of the depressive disorder. The group discussed how reinforcing the associated medical risks of depression, such as a 6-fold increased rate of myocardial infarctions in a study Dr. Fawcett described, may be a way of engaging general practitioners in mental health screening.
Physicians find it very difficult to ask direct questions about suicide, according to Dr. Schulberg. One study he described found that in only 2 of over 60 completed suicides was there “any indication in the medical records of concern about suicide, and in both of those instances, the physician did not consider the patient to be at significant risk.” Physicians’ inquiry about suicidality varies across specialties, and by the patient’s age and psychiatric history according to Dr. Schulberg. Family physicians consistently make more inquiries about psychosocial wellbeing than do internists and obstetrician/gynecologists, according to Dr. Schulberg. Primary care physicians are more apt to ask patients with a psychiatric history, or who are middle-aged. Once patients have been identified as suicidal, one study Dr. Schulberg described found that “physicians asked about misuse of medications 77 percent of the time, but in only half the instances would they inquire as to whether or not the patient had access to a gun or any other way of taking his life.” Physicians are reticent and non-optimistic in treating older, suicidal patients, as compared to treating older patients for other maladies, according to Dr. Schulberg. Yet once patients of all ages are identified as suicidal, primary care physicians are very likely to refer the patient to mental health services.
When patients were asked about what it was like to talk to your primary care physician, they responded that the primary care physicians were harried and su perficial and really not very interested in what the nature of the problem was that led them to the suicide attempt
Patient behavior impacts assessment and intervention opportunities. Frequency of visits to general practitioners does not distinguish suicidal patients according to a study described by Dr. Schulberg. When examining those with acute mental health needs, therefore at increased risk of suicide, research found that over half “turned to a health provider other than a mental health specialist,” a finding that has been replicated a number of time over the last 20 years. Yet, approximately “less than half [of the patients] informed the primary care physician of their thoughts and plans [for suicide],” according to research Dr. Schulberg described. Other research found that in general, people prefer to talk to a mental health practitioner, rather than a general practitioner about mental health needs.
Patients report feeling “extruded” upon the typical quick referral after disclosing suicidality to their general practitioners, according to Dr. Schulberg. This is important, because experience of rejection may significantly impact on compliance with the mental health services. This is a