Barriers to Effective Treatment and Intervention
The barriers to receiving effective mental health treatment are nothing short of daunting (US DHHS, 1999). This chapter describes the constellation of barriers deterring use of mental health treatment by people who are either suicidal or who have major risk factors for suicidality: a mental disorder1 or a past suicide attempt (Chapters 2, 3).
A close examination of barriers to treatment is warranted by several striking findings: (1) the vast majority (90–95 percent) of people in the United States who complete suicide have a diagnosable mental disorder, yet only about half of them are diagnosed and treated appropriately (Conwell et al., 1996; Fawcett et al., 1991; Harris and Barraclough, 1997; Isometsa et al., 1994b; Robins et al., 1959); (2) many are symptomatic for several years before suicide (Fawcett et al., 1991; Shaffer and Craft, 1999); (3) many have made a past suicide attempt (Harris and Barraclough, 1997); and (4) most who complete suicide make contact with health services in the days to months before their death. Nearly 20 percent make contact with primary care providers in the week before suicide, nearly 40 percent make contact within the month before suicide (Pirkis and Burgess, 1998), and nearly 75 percent see a medical professional within their last year (Miller and Druss, 2001). Among older people, the rates are higher, with about 70 percent making contact within the month before
suicide (Barraclough, 1971; Miller, 1976). However, suicide victims are three times more likely to have difficulties accessing health care than people who died from other causes (Miller and Druss, 2001).
These findings underscore the importance of sifting through reasons why people escape detection or fail to receive adequate diagnosis and treatment for risk factors and suicidality. They also underscore the importance of taking a broad view of barriers—focusing on suicidality, as well as on risk factors—because their treatment is so intertwined.
The barriers discussed in this chapter collectively weigh against treatment. Each barrier is unlikely to act in isolation, but likely interacts with and reinforces the others. The complex relationship of various precipitative, exacerbative, and maintenance effects of barriers is unique in each clinical case. Deeper and more nuanced understanding of the multiple barriers to treatment is essential for design, development, and implementation of preventive interventions. Prospective longitudinal studies can help to elucidate relationships among barriers as they change across the life-span and across the development of suicidality.
The chapter works its way from general to more specific barriers. It first looks broadly at barriers to treatment—such as stigma, cost, and the fragmented organization of mental health services. It then covers barriers raised within a range of therapeutic settings—by both clinician and patient. Finally, the chapter focuses on barriers for groups at greatest risk for suicide: older people, adolescents, certain ethnic populations, and incarcerated persons.
GENERAL BARRIERS TO TREATMENT
Stigma and Discrimination
The stigma of mental illness is one of the foremost barriers deterring people who need treatment from seeking it (US DHHS, 1999). About two-thirds of people with diagnosable mental disorders do not receive treatment (Kessler et al., 1996; Regier et al., 1993; US DHHS, 1999). Stigma toward mental illness is pervasive in the United States and many other nations (Bhugra, 1989; Brockington et al., 1993; Corrigan and Penn, 1998).
Stigma refers to stereotypes and prejudicial attitudes held by the public. These pejorative attitudes induce them to fear, reject, and distance themselves from people with mental illness (Corrigan and Penn, 1998; Hinshaw and Cicchetti, 2000; Penn and Martin, 1998). The stigma of mental illness is distinct from the stigma surrounding the act of suicide itself. The stigma of mental illness deters people from seeking treatment for mental illness, and thereby creates greater risk for suicide. The stigma surrounding suicide is thought to act in the opposite direction—to deter
people from completing suicide.2 A prominent nationally representative survey conducted in the early 1990s found that 44 percent of Americans are opposed to suicide under any circumstances; most of the remainder are opposed to suicide except in the case of terminal illness (Agnew, 1998). In some situations, however, the stigma of suicide acts to increase suicide risk because it may prevent people from disclosing to clinicians their suicidal thoughts or plans. Studies cited later in this chapter clearly indicate that patients often do not discuss their suicidal plans with their clinician. This, in turn, leads to their under-treatment and thus increases their likelihood of suicide.
The existence of stigma surrounding mental illness is best supported by nationally representative studies of public attitudes. Studies find that about 45–60 percent of Americans want to distance themselves from people with depression and schizophrenia. The figures are even greater for substance use disorders (Link et al., 1999). Stigma leads the public to discriminate against people with mental illness in housing and employment (Corrigan and Penn, 1998). It also discourages the public from paying for treatment through health insurance premiums (Hanson, 1998). Public attitudes toward mental health treatment are somewhat contradictory: while nationally representative surveys find that Americans generally support mental health treatment for people with disorders, the public is less willing to use formal services if they anticipate a mental health problem for themselves (Pescosolido et al., 2000; Swindle et al., 2000).
For people with mental illness, the consequences of societal stigma can be severe: diminished opportunities, lowered self-esteem, shame and concealment of symptoms, and lower help-seeking behavior (Hornblow et al., 1990; Link et al., 1997; Sussman et al., 1987; Wahl, 1999). The National Comorbidity Survey, one of the only nationally representative studies to investigate why individuals with mental illnesses do not seek treatment, found that almost 1 in 4 males and 1 in 5 females with Posttraumatic Stress Disorder cite stigma as their reason (Kessler, 2000). While the majority with mental illness do not seek treatment, there is wide demographic variability: women and younger adults (ages 18-44) are more likely to reach some kind of care, whereas ethnic minorities and older people are less likely (Bland et al., 1997; Gallo et al., 1995; Narrow et al., 2000; US DHHS, 1999; US DHHS, 2001). If they make contact with primary care providers, stigma inhibits them from bringing up their mental health concern. Patients may instead report more somatic symptoms of
mental illness, such as dizziness and stomach disturbances, because these are more culturally acceptable (US DHHS, 2001). Even if patients begin treatment for mental illness, stigma can deter them from staying in treatment. These problems are especially relevant for older people (Sirey et al., 2001), adolescents, and certain ethnic populations. These groups are discussed later in the chapter because they are at high risk for suicide.
Stigma also extends to family members. Family members of people with mental illness have lowered self-esteem and more troubled relationships with the affected family member (Wahl and Harman, 1989). Families of suicidal people tend to conceal the suicidal behavior to avoid the shame or embarrassment, or to avoid the societal perception that they are to blame (especially with a child or adolescent suicide). After suicide, family members suffer grief as well as pain and isolation from the community (PHS, 2001).
The cost of care is among the most frequently cited barriers to mental health treatment. About 60–70 percent of respondents in large, community-based surveys say they are worried about cost (Sturm and Sherbourne, 2001; Sussman et al., 1987). Economic analyses of patterns of use of mental health services clearly indicate that use is sensitive to price: use falls as costs rise, while use increases with better insurance coverage (Manning et al., 1986; Taube et al., 1986). Rises in co-payments of mental health services are associated with lower access (Simon et al., 1996a). The demand for mental health services is more responsive to price than is demand for other types of health services (Taube et al., 1986).
Having health insurance, through the private or public sector, is a major determinant of access to health services (Newhouse, 1993). People without health coverage experience greater barriers to care, delay seeking care, and have greater unmet needs (Ayanian et al., 2000). Overall, about 16 percent of Americans are uninsured, but rates are higher in racial and ethnic minorities (Brown et al., 2000). Having health insurance, however, does not guarantee receipt of mental health services because insurance typically carries greater restrictions for mental illness than for other health conditions (US DHHS, 1999).
Over the past decade, during the growth of managed care, disparities in coverage have led to a 50 percent decrease in the mental health portion of total health care costs paid by employer-based insurance (Hay Group, 1998). Not surprisingly, insured people with mental disorders in a large United States household survey in 1994 were twice as likely as those without disorders to have reported delays in seeking care and to have reported being unable to obtain needed care (Druss and Rosenheck, 1998).
A more recent household survey in 1998 found that people with a probable mental disorder are more likely than those without a disorder to have lost their health insurance and to report lower access to care (Sturm and Wells, 2000). The consequences of the disparities in insurance coverage for mental illness have led to legislative proposals at the state and federal level for parity—coverage for mental illness equivalent to that for other health conditions (US DHHS, 1999). While there do not appear to be any studies directly examining cost as a barrier to treatment for suicidal people, most researchers believe that cost does play a role.
Mental Health System Barriers
The fragmented organization of mental health services has been repeatedly recognized as a serious barrier to obtaining treatment (US DHHS, 1999). The vision, beginning in 1975, of the community support reform movement—an integrated, seamless service system that brings mental health services directly to the community—has not fully materialized. Mental health services continue to be so fragmented that they have been termed the “de facto” service system (Regier et al., 1993). People with mental illness frequently report their frustrations and waiting times as they navigate through a maze of disorganized services (Sturm and Sherbourne, 2001; Sussman et al., 1987). The disorganization is a product of historical reform movements, separate funding streams, varying eligibility rules, and disparate administrative sources—all of which have created artificial boundaries between treatment settings and sectors (Ridgely et al., 1990). Among the hardest hit are people with co-occurring substance abuse and mental health problems, a group at higher risk of suicidality. Co-occurring disorders are the rule rather than the exception in mental health and substance abuse treatment (US DHHS, 1999).
Linkages between different settings are critical for detection and treatment of mental disorders and suicidality (Mechanic, 1997). They include linkages between primary care and specialty mental health care; emergency department care and mental health care; substance abuse and mental health care; and, for adolescents, school-based programs with mental health or substance abuse care. The transition from inpatient care to community-based care is an especially critical period for suicidality in light of studies finding that a large proportion of completed suicides come after recent inpatient discharge, often before the first outpatient appointment (Appleby et al., 1999; Morgan and Stanton, 1997). In addition to improved linkages between different settings, many new programs strive to integrate mental health and primary care, through a variety of service configurations (e.g., a psychiatric nurse practicing with the primary care setting who treats some patients and is a referral source for others). Several
approaches to integrating care have been found successful in the treatment of depression (Katon et al., 1996; Katon et al., 1999; Smith et al., 2000). Its utility for suicidality is being studied through ongoing trials (Mulsant et al., 2001; Reynolds et al., 2001).
Services research has focused for the past decades in developing better models of care that bridge these different sectors of care to deliver more integrated mental health care. Several successful models have been developed, most notably wraparound services including multisystemic treatment, for children and adolescents with serious emotional problems and assertive community treatment, a form of intensive case management for people with serious mental illness, combined services for people with mental and substance abuse disorders, and management programs for late life depression in primary care settings (US DHHS, 1999). One major problem, however, is lack of availability to these state-of-the-art services. Many communities simply do not provide them, and, when they do, there are often waiting times for treatment (US DHHS, 1999). Low availability of mental health services (of any kind) is a major problem in rural areas (Beeson et al., 1998; Fortney et al., 1999) and communities with large minority populations (US DHHS, 1999; US DHHS, 2001). People in rural areas report significantly more suicide attempts than their urban counterparts, partly as a result of lower access to mental health services (Rost et al., 1998).
Another major problem is adapting model services to the unique needs of different communities or populations. Programs found successful for some populations may not translate into other settings. For example, a new primary care program for veterans designed to expand access to specialty mental health failed to do so (Rosenheck, 2000), despite the success of similarly designed gateway programs for other populations. Tailoring programs to the needs of distinct populations, including minority groups, is essential, given that they are less likely to access mental health treatment than are whites (US DHHS, 2001).
In the past two decades, managed care has grown from relative obscurity to cover almost 72 percent of Americans with health insurance in 1999 (OPEN MINDS, 1999). Driven by the goal of cost-containment, managed care refers to a variety of strategies for organizing, delivering, and/ or paying for health services. Its promise has been to improve access to health care by lowering its cost, reducing inappropriate utilization, relying on clinical practice guidelines to standardize care, promoting organizational linkages, and by emphasizing prevention and primary care. Managed care’s emphasis on treatment of mental health problems in primary
care is potentially advantageous for certain populations, such as older people and minorities, which are less inclined toward use of specialty mental health care (US DHHS, 1999). Managed care’s potential pitfalls are poorer quality of care, denial of needed care, under-treatment, and disruption in the continuity of clinician–patient relationships (IOM, 1997; Mechanic, 1997).
The impact of managed care on mental health services has been profound in terms of costs: there is strong evidence that managed care has lowered the cost of mental health services (US DHHS, 1999). The study cited above by the Hay Group (1998) indicated that during the growth of managed care, there was a 50 percent reduction in the mental health portion of total health care costs paid by employer-based insurance. Whether these cost reductions have lowered access to, and quality of, mental health services for people who need them is a critical topic for research, but one for which answers have been elusive. Research has been stymied by the dramatic pace of change in the health care marketplace, the difficulty of obtaining proprietary claims data, and the lack of information systems tracking mental health quality or outcome measures (Fraser, 1997; US DHHS, 1999). Most concerns center on potentially poorer quality and outcomes of care from limited access to mental health specialists, reduced length of inpatient care, and reductions in intensity of outpatient mental health services (Mechanic, 1997; Mechanic, 1998). There are also concerns that more impaired populations and children will be adversely affected (US DHHS, 1999). The 1999 Surgeon General’s Report on Mental Health concluded that, while research is sparse, existing incentives in managed care did not encourage an emphasis on quality of mental health care (US DHHS, 1999).
The impact of managed care expressly on detection or treatment of suicide has been largely unstudied. The limited body of relevant research has focused on depression treatment, spotlighting problems in quality of care and outcomes. The first major studies of prepaid managed care versus traditional fee-for-service care found generally no overall differences in outcome, but poorer outcomes for patients with the most severe mental illness (Lurie et al., 1992; Rogers et al., 1993). Later studies, focusing exclusively on primary care, found that less than 50 percent of depressed patients in staff-model health maintenance organizations received antidepressant medication that met practice guidelines (Katon et al., 1995; Simon et al., 1996b). One of few managed care studies to have addressed suicide, at least tangentially, was of 1204 outpatients with depression receiving care from seven managed care organizations of varying organizational structures (Wells et al., 1999). Using patient questionnaires, the study found that about 48–60 percent of patients with depressive disorder received some sort of mental health care. Only 35–42 percent of depressed
patients used medication at appropriate doses, leading the authors to conclude that overall quality of care was moderate to low. Two findings of the study are particularly relevant to suicide prevention: (1) patients with suicidal ideation did not receive higher rates of treatment than did patients without suicidal ideation (using measures of process and quality); (2) patients with both depression and alcohol abuse—which places them at higher risk of suicide—were not given more specialty referrals, as recommended by treatment guidelines (see later section on Substance Abuse). While the study did not assess outcomes of care, it did conclude that patients with suicidal ideation and other “silent,” yet serious, symptoms are at particular risk for not receiving appropriate treatment by managed care organizations. Another study, of serious suicide attempters in Florida, found that managed care’s criteria for approving admission to hospitals were not predictive of features seen in patients who made such attempts (Hall et al., 1999).
A largely unstudied question is whether reductions in intensity of outpatient services, or in length of stay in inpatient care, contribute to suicide risk. A case-control study of completed suicides in the UK found that “reduction in care” at the final service contact was associated with almost a 4-fold increase in risk of suicide (Appleby et al., 1999). Reduction in care was defined by the study as one or more of the following: reduced appointment frequency, lowered doses of medication, less supervised location (e.g., transfer from day hospital or outpatient), or discharge from follow-up. While this study was not of managed care per se, it raises questions about cost containment strategies used by managed care to reduce intensity or frequency of services for people at risk of suicide. In related findings, initial results from a study of all hospital discharges in Pennsylvania found a 25 percent reduction in length of stay during a 3-year period for inpatient treatment of depression. Preliminary results suggest that the reduction in length of stay was accompanied by an increase in readmission rates, a finding that the study investigators interpreted as suggesting that caution should be used when implementing practice guidelines for length of stay (personal communication, J. Harman, University of Pittsburgh School of Medicine, December 18, 2001).
Given the concerns about quality of care and lack of monitoring by managed care, the Surgeon General’s National Strategy for Suicide Prevention (PHS, 2001) explicitly recommends implementation of quality care/ utilization management guidelines by managed care organizations and health insurance plans for effective response to, and treatment of, individuals at risk for suicide. Quality improvement guidelines have been demonstrated to be successful at improving productivity and outcomes of depression in managed care, according to a randomized controlled trial (Wells et al., 2000).
CLINICIAN BARRIERS TO TREATMENT
The overwhelming majority of suicide victims have a diagnosable mental disorder—most commonly a mood or substance use disorder (Chapter 3). Yet, as indicated earlier, most suicide victims do not have their disorder diagnosed or adequately treated at the time of suicide. This section explores the multiple barriers to treatment posed by clinicians in primary care, emergency care, and specialty care.
Barriers in Primary Care
Primary care has become a critical setting for detection of depression and alcohol use disorders (US Preventive Services Task Force, 1996) because of their high prevalence (Murphy, 2000). Primary care refers to family physicians, obstetrician-gynecologists, nurse practitioners, general internists, or pediatricians.
The detection and treatment of depression by primary care physicians is of great relevance to suicidology. Depression evaluation presents the first opportunity for primary care physicians to ask about suicidal ideation, which is one of several symptoms of major depressive disorder (APA, 1994), and a major risk factor for completed suicide (Harris and Barraclough, 1997). Treatment of depression in primary care is associated with reduced rates of completed suicide, according to an uncontrolled ecological study on the Swedish island of Gotland (see discussion in Chapters 7 and 8, Rutz et al., 1989; 1992). The effects of depression treatment in primary care on suicidal behavior are being studied in a controlled clinical trial in the United States. Preliminary results indicate reduced rates of hopelessness, suicidal ideation, and related symptoms of depression in older primary care patients (personal communication, C. Reynolds, G. Alexopoulos, and I. Katz, University of Pittsburgh School of Medicine, 2001).
In primary care, routine screening for depression is not currently recommended for all asymptomatic adults; however, routine screening for depression is recommended if the physician suspects depression or if the patient carries depression risk factors (Beck et al., 1979; Preboth, 2000; U.S. Preventive Services Task Force, 1996).3 According the American
Medical Association council, considerable evidence indicates that a diagnostic interview for depression is comparable in sensitivity and specificity to many radiologic and laboratory tests commonly used in medicine (Preboth, 2000). During depression screening, guidelines explicitly recommend asking patients about suicidal intent and past suicide attempts. When a suicidal patient is identified, primary care physicians should refer them to specialty care and consider hospitalization (Beck et al., 1979; US Preventive Services Task Force, 1996). The role of primary care is likely to expand, however, as a result of recent health care trends and high level public health concern about suicide prevention. The Surgeon General’s National Strategy (PHS, 2001) sets as national objectives screening for depression in federally-supported primary care settings (e.g., Medicare and Medicaid) and the use of such screening as a performance measure for evaluating the quality of managed health care plans.
The expanding role of primary care in detection and treatment of depression stems from at least four major factors. The first is awareness of how frequently depression is encountered in primary care. Depression is one of the most common of all mental and somatic diagnoses (Von Korff et al., 1987). About 6–10 percent of people attending primary care settings have major depression (Katon and Schulberg, 1992). The second is that many people with depression prefer to be treated in primary care or resist referral to specialty care (Cooper-Patrick et al., 1999; Orleans et al., 1985; Williams et al., 1999). Seventy-five percent of those seeking help for depression do so through their primary care physician rather than through a mental health professional (Goldman et al., 1999). One reason may be that they perceive primary care as less stigmatizing than specialty mental health care. The third factor is the advent of new classes of antidepressant medications that are less toxic when taken in overdose, thus making medication management less complex for non-specialists (Hirschfeld and Russell, 1997; US DHHS, 1999). The fourth factor is the trend in cost containment. Managed care generally encourages the receipt of mental health services in primary, rather than specialty, care because of lower costs (Mechanic, 1998). It is thus not surprising that about half of all people with depression and other mental disorders—either by preference or by financing—receive their mental health treatment in primary care (US DHHS, 1999). Primary care physicians handle nearly half of all anti-depressant-related office visits (Pincus et al., 1998).
Only about 30–50 percent of adults with diagnosable depression are accurately diagnosed by primary care physicians (Higgins, 1994; Katon et al., 1992; Wells et al., 1994). Even more startling to suicide prevention are findings about the infrequency of suicide questioning during routine depression evaluation. Only 58 percent of a random sample of 3375 primary
care clinicians directly questioned patients about suicide (Williams et al., 1999), despite the fact that such questions are supposed to be asked during a depression evaluation (Beck et al., 1979; US Preventive Services Task Force, 1996). When broken down by specialty, the study found 65 percent of family physicians, 52 percent of general internists, and 48 percent of obstetrician-gynecologists assessed suicide by direct questions. Through regression analyses, the study found that family physicians and general internists were significantly more likely to make direct assessments for suicide than were obstetrician-gynecologists (Williams et al., 1999). Reasons for physician reticence in asking about suicide are discussed in a later section.
Even when patients’ depression is accurately diagnosed, only a minority of patients receive adequate treatment for depression (US DHHS, 1999; Young et al., 2001). Since the vast majority of primary care physicians prefer to treat depression with medication (Williams et al., 1999), studies often measure inadequate treatment by inadequate dosage or duration of medication, infrequent follow-up, lack of medication adjustment, and/or inadequate conformance to treatment guidelines. Although detection and treatment in primary care are improving, major professional efforts have been undertaken to highlight and respond to the problem (Beck et al., 1979; Hirschfeld et al., 1997).
What are the reasons for inadequate detection and treatment of depression by primary care physicians? The most frequently cited barriers relate to lack of knowledge and time. One recent survey of randomly selected primary care physicians found them to report widespread lack of knowledge about diagnostic criteria and treatment of depression. Overall, about one-third reported knowledge of formal diagnostic criteria and treatment, yet there was great variation between primary care specialties. Obstetrician–gynecologists reported the least knowledge, whereas family physicians reported the most knowledge (Williams et al., 1999). Inadequate time and competing demands created by other health problems— under the cost pressures of managed care—have been identified as barriers in several studies (Borowsky et al., 2000; Rost et al., 2000; Williams et al., 1999). The mean duration of a visit to a primary care physician is 16.3 minutes (Blumenthal et al., 1999), to which patients bring an average of six problems (cited in Williams et al., 1999). The time constraints on the primary care physician become immediately apparent, sparking concerns that primary care clinicians are ill-equipped for their enhanced role in detection of depression (Kane, 1996; Katon et al., 2001). Under-detection and under-treatment of depression are clearly associated with patient distress and disability (Hirschfeld et al., 1997).
Substance use disorders are second to mood disorders as the most common risk factor for suicide (Chapter 3). Substance abuse is an especially important risk factor for suicide in young adults (Chapter 3). Furthermore, substance abuse and mood disorders frequently co-occur, with 51 percent of suicide attempters having both (Suominen et al., 1996). Treatment of co-morbid alcoholism and depression with selective serotonin reuptake inhibitors (SSRI) reduces suicidality (Cornelius et al., 2000; Cornelius et al., 2001). Thus, detection and treatment of substance abuse and depression in primary care is important for suicide prevention (Murphy, 2000; PHS, 2001).
For the primary care setting, numerous professional groups recommend routine detection of problem drinking in all patients, as well as brief counseling for non-dependent problem drinkers (summarized in US Preventive Services Task Force, 1996). Nevertheless, problem drinking often goes undetected in primary care. In recent surveys, about 40 percent of primary care physicians do not perform routine screening for substance abuse (Bradley et al., 1995; Williams et al., 1999). The most commonly cited reasons are lack of time and fear of spoiling the relationship with the patient (Arborelius and Damstrom-Thakker, 1995).
For detection of drug abuse in primary care, professional guidelines diverge from those for problem drinking: they generally do not recommend screening all primary care patients for drug abuse. However, clinicians are recommended to be alert to signs and symptoms and to refer drug-abusing patients to specialized treatment (US Preventive Services Task Force, 1996). Standardized screening questionnaires are thought to be too insensitive to identify potential drug abusing patients. In a recent shift, arising from concern about suicide, the Surgeon General’s National Strategy (PHS, 2001) sets as national objectives screening for substance abuse, depression, and suicide risk in federally-supported primary care settings (e.g., via Medicare and Medicaid) and the use of such screening as performance measures for managed health care plans. A later section deals with the treatment of substance abuse, with or without a co-occurring mental disorder, because it is reserved for specialty care (US Preventive Services Task Force, 1996).
Primary Care Barriers to Detection of Suicidality
It is well established that a large proportion of suicide victims are not detected in primary care in the days before suicide. A systematic review of published studies found that, in the week before death, contact with primary care was made for 16–20 percent of completed suicides. Within
one month of death, the rate is 34–38 percent of completed suicides (Pirkis and Burgess, 1998). The frequency of contacts with primary care also increases in the month before death of young suicide victims (<35 years old) (Appleby et al., 1996). These findings are widely interpreted as suggesting that patients are motivated to seek help but are reluctant to bring up suicide as the reason during an office visit (Hirschfeld and Russell, 1997; Michel, 2000). Yet people with suicidal thoughts usually tell their physicians if they are asked (Delong and Robins, 1961).
Communication of suicidal intent is an interactive process. It depends on the patient’s willingness to communicate, as well as the clinician’s ability to listen, recognize, and ask questions about intentions. During the final contact with primary care, there is a striking breakdown in communication: physicians often do not ask about suicidal intent or ideation, and patients often do not spontaneously report it. A review of medical records of 61 completed suicides (<35 years) in Manchester, United Kingdom, found almost total absence of documentation of suicide risk by the general practitioner (Appleby et al., 1996). Suicide risk was commented upon in the medical record in only one case. Yet the physicians deemed that 64 percent of the patients had psychological concerns as the principal reason for the visit. A similar study of suicide deaths in Scottish adults (>16 years) found that only 3.3 percent of records indicated that patients expressed suicide ideation or communications at the time of the final consultation4 (Matthews et al., 1994). The figures are somewhat higher in a study from Finland in which 19 percent of suicide completers with depression communicated their intent to medical providers (Isometsa et al., 1994c). Despite limitations of using case notes to infer what occurred during the final visit, these studies—as well as clinical experience—point to a major barrier in communication: patients are reluctant to communicate their suicidal intent, and primary care physicians are reluctant to ask (Hirschfeld and Russell, 1997).
The failure of physicians to detect suicidality was described in a now classic paper as an “error of omission” (Murphy, 1975). Numerous interrelated reasons are proffered to explain physicians’ reticence to ask patients about suicide, yet there has been little systematic research.
One of the most common explanations for physicians’ reticence stems from their concern that asking patients about suicide will trigger suicidal behavior (Michel, 2000). Clinical experience, however, suggests this concern to be unwarranted: “There is universal agreement that asking questions about suicidal ideation does not trigger suicidal behavior…” (Michel, 2000:665). There is also indirect research support for this statement. The suicide
rate actually decreased on the Swedish island of Gotland after the introduction of a primary care educational program to improve depression identification and treatment. This reduction came in spite of investigators’ initial concerns that the suicide rate might increase (Rutz et al., 1989). Furthermore, the vast majority of patients in primary care—both suicidal and nonsuicidal—hold the view that physicians should inquire about emotional health issues on a regular basis or at yearly checkups (Zimmerman et al., 1995).
Another reason for physician reticence comes from the lack of acute predictors for suicide assessment. Most studies have found low sensitivity and specificity of suicide prediction (Goldney, 2000; see Chapter 7; Pokorny, 1993). In a prospective study, long-term risk factors for suicide were unable to provide the means for acute prediction of suicide (Fawcett et al., 1987). Considering the rarity of suicide in primary care—one suicide every 3–5 years—physicians have little incentive to take active steps to become skilled in suicide assessment or treatment (Michel, 2000). Nor do professional guidelines recommend routine screening of asymptomatic patients. Many professional organizations do not have guidelines on suicide assessment. After expressly evaluating the evidence, the US Preventive Services Task Force in 1996 found “insufficient evidence” to recommend routine suicide screening of asymptomatic adults. The Canadian Task Force on Periodic Health Examination came to a similar conclusion in 1994 (Feightner, 1994). But a change in policy may occur with the release in 2001 of the Surgeon General’s National Strategy for Suicide Prevention. This plan encourages development of guidelines for primary care settings. It also sets specific national objectives of screening for suicide risk in federally supported primary care settings (e.g., Medicare and Medicaid) and the use of such screening as a performance measure for managed health care plans.
A final reason cited for physician reticence is lack of clinical training (Bernstein and Feldberg, 1991; Ellis et al., 1998). A majority of primary care physicians are surprised by their patients’ attempted suicide and desire more training (cited in Michel, 2000). More generally, they report insufficient training in dealing with mental health problems (Kane, 1996; Williams et al., 1999). In short, it is generally believed that primary care physicians do not ask about suicide because they feel ill-equipped—in terms of training and skills in suicide assessment and treatment—to handle an affirmative answer.
The United States Surgeon General has been consistent in urging better training of primary care providers to deal with mental health problems (PHS, 2001). More to the point, the Surgeon General sets as a national objective that physicians and physician assistants “should be skilled in talking with patients about the risk for suicide, in providing crisis
intervention for those at imminent risk for the expression of suicidal behaviors … and in referring their patients for expert assessment and treatment” (PHS, 2001).
Barriers in Emergency Care
Suicidal patients are frequently encountered in the emergency department (ED). These patients present for care in four situations: (1) patients who mask their suicidal intent by complaining of other health problems; (2) overtly suicidal patients coming in on their own, or with the help of others; (3) patients who have already attempted suicide; and (4) patients pronounced dead in the ED from a suicide attempt and whose bereaved family must be consulted (Buzan and Weissberg, 1992).
Several barriers to care occur in the ED, all of which have been highlighted previously in the context of primary care. The first barrier is that patients with covert symptoms are not recognized. Another barrier is the lack of guidelines for suicide assessment by professional organizations. This prompted the Surgeon General to set as a national objective the development of guidelines expressly for the ED (PHS, 2001). Yet another barrier is the lack of training for ED staff. Seventy percent of emergency physician training programs in a 1990 survey reported not offering any training in the management of psychiatric emergencies (Weissberg, 1990).
Once diagnosed in the ED, suicide attempts are important to treat promptly, to admit to a psychiatric unit, and/or to arrange for effective care after discharge (Buzan and Weissberg, 1992). Suicide attempters are at risk of re-attempt or completed suicide (Chapter 3). However, they often do not receive follow-up care. For instance, up to half of all suicide attempts among adolescents did not receive subsequent care after an ED visit (Spirito et al., 1989). The need for effective linkages with follow-up care was set as a national objective by the Surgeon General (PHS, 2001). Yet barriers persist even with good linkage to care because many—more than 40 percent of adolescent attempters (Piacentini et al., 1995)—are nonadherent with treatment.
Barriers in Specialty Mental Health Care
A significant percentage of suicide completers make recent contact with specialty mental health care, either in the community or in the hospital. A review of the published literature found that about 41 percent of those who die by suicide have contact with inpatient care in the year before death. Up to 9 percent of them complete suicide within a day of discharge from inpatient care. The figures are slightly lower for commu-
nity-based psychiatric care, with 11 percent making contact in the year before death and 4 percent within a day of contact (Pirkis and Burgess, 1998). About 5 percent of suicides occur during hospitalization (Crammer, 1984; Robins et al., 1959).
These figures imply the existence of lost opportunities and numerous barriers to effective treatment in the specialty setting. Barriers extend throughout the process—from the very beginning of diagnosis to after discharge. The problems are similar to those discussed in other clinical settings: the failure to assess suicidal risk and to treat patients who are suicidal or at risk for suicide.
There is an additional barrier to mental health treatment for individuals of racial, ethnic or cultural minorities. There is substantial under-representation of minorities among mental health providers, and cultural differences between provider and consumer can greatly interfere with both diagnosis and treatment (US DHHS, 2001).
Barriers to Detection of Suicidality
One overarching barrier to detection of suicidality is the lack of professional guidelines for both assessment and treatment of the suicidal patient in the specialty mental health care setting. The Surgeon General’s National Strategy (PHS, 2001) calls for the development and implementation of professional guidelines for suicide assessment—as well as individualized policies, procedures, and evaluation programs for treatment in a full range of specialty mental health and substance abuse treatment centers. The lack of professional guidelines partly accounts for clinicians’ reporting that they do not receive adequate training in suicide detection and treatment, as discussed above.
One early barrier to detection of suicidality, and thus treatment, comes in the form of exclusion of suicidal patients by certain types of providers. While research is sparse, one study found that 59 percent of training clinics affiliated with clinical and professional psychology doctoral programs had a policy of excluding patients with suicidal risk (Bernstein and Feldberg, 1991). There are likely many reasons governing the policy, but one salient reason is fear of malpractice. Though suicide-related malpractice claims are still relatively rare, they have increased in the last decades (Jobes and Berman, 1993). The payouts in settlement or verdict are disproportionately high relative to the percentage of claims. For example, among lawsuits for malpractice filed against psychiatrists, 21 percent involve a patient’s suicide, yet 42 percent of the dollars paid out are in connection to these cases (Bongar et al., 1992). Clinicians’ fear of being sued in the wake of a patient’s suicide is considered widespread, even though court deci-
sions usually do not hold clinicians liable if they have practiced according to a loosely defined standard of care (Bongar et al., 1992; Bongar et al., 1998).
Clinicians who accept suicidal patients are legally and ethically obligated to assess suicidal risk through a clinical interview, mental status examination, direct and indirect questioning about suicide, and history taking (see Chapter 7). From a legal perspective, the assessment of suicide risk does not mean prediction of risk, because the latter is not yet possible. Rather, it means that the clinician used reasonable prudence that other professionals would exercise in similar circumstances (Maris et al., 2000). In one of the few surveys, researchers asked practicing psychologists, psychiatrists, and clinical social workers about their methods of suicide assessment. Respondents reported infrequent use of assessment instruments (e.g., Hopelessness Scale and Suicide Intent Scale) and reported that they did not find them to be very useful. Psychologists frequently use various psychological tests (e.g., MMPI, Rorschach Ink Blot). The overwhelming majority (>80 percent of clinicians) use clinical observations about patient affect and appearance, as well as direct interview questions about suicide plans, suicide thoughts, method availability, history of drug/alcohol use, and previous attempt, among others (Jobes and Eyman, 1995). Although these findings are not nationally representative and are limited by low response rate, they indicate the need for better assessment instruments.
Another barrier related to the assessment of suicide concerns appropriate diagnosis of the associated mental disorder. If a mental disorder is not properly diagnosed in specialty care, then patients receive either no treatment or inappropriate treatment, placing them at risk for suicide. One misdiagnosis that enhances suicide risk relates to bipolar disorder. Patient surveys (N=600) indicate that 69 percent are misdiagnosed, and they frequently consult four physicians before a correct diagnosis is made (Lewis, 2001). Through review of patient charts at first clinical contact, bipolar disorder is misdiagnosed as unipolar depression in more than one-third of patients with affective disorder (Ghaemi et al., 2000). When treated with antidepressants, but not with mood stabilizers, these patients are risk for rapid cycling (Ghaemi et al., 2000; Kilzieh and Akiskal, 1999), which carries a poorer prognosis and higher risk of suicide (Goodwin, 1999; Schweizer et al., 1988). Bipolar depression carries markedly higher rates of suicidality than do other phases of bipolar disorder (Dilsaver et al., 1997; Isometsa et al., 1994c). Many patients also do not receive adequate treatment even when bipolar disorder is accurately diagnosed, as discussed in later sections.
Communication of Suicidal Intent
In a large number of completed suicides, clinicians are caught unaware of patients’ suicidal intent. Across all treatment settings, about 22 percent of suicide victims communicate their intent to clinicians (Isometsa et al., 1995). The problem is worse in primary care, as discussed earlier, where the rate is lower. The situation is somewhat better in specialty care. A psychological autopsy study was conducted in Finland of all suicide victims over a 12-month period whose last appointment occurred 28 days before suicide (N=571). By interviewing health care professionals, investigators found that, during the last appointment, 39 percent and 30 percent of patients communicated their intent to outpatient and inpatient psychiatric care providers, respectively (Isometsa et al., 1995). In a related study, the same investigators found that 59 percent of suicide victims with depression communicated their intent to psychiatrists, as opposed to 19 percent to medical providers (Isometsa et al., 1994a). The communication of intent was determined by explicit notes in the medical records or from interviews of clinicians. The study confirmed an early psychological autopsy study that found an even greater disparity (87 percent of psychiatrists versus 17 percent of other physicians) in awareness of suicide communication or attempt (Murphy, 1975). None of these studies, however, indicated whether patients were explicitly asked about suicide by their clinician or whether they spontaneously reported their intent. While specialty care is associated with greater communication of intent, the fact remains that suicidal intent is not communicated in a sizable portion of all patients, regardless of treatment setting.
Barriers to Effective Treatment
The goal of suicide treatment in specialty care is to develop and implement a treatment plan, which includes monitoring of medication efficacy and safety, as well as discharge planning (Maris et al., 2000). The details of treatment, however, are not spelled out in clinical guidelines. Organizations of mental health specialists have developed no clinical guidelines for treatment of suicidality. Clinical guidelines for other areas of mental health treatment are typically developed on the basis of a strong body of evidence for efficacy (PHS, 2001; US DHHS, 2001). The clearest evidence to date suggests the efficacy of lithium, cognitive behavioral interventions, and the minimal contact-letter intervention (see Chapter 7). For suicide treatment, however the larger body of evidence for efficacy is beset by insufficient power and insufficient rigor in research design. It is thus difficult to conduct studies of suicide treatment
effectiveness in the absence of clear guidelines for what constitutes efficacious treatment. Consequently, the few available studies of suicidal patients focus on whether clinicians in the practice setting (“usual care”) administer appropriate treatment for the associated mental disorder, for which treatment guidelines are available (or for which there is more evidence of treatment efficacy). Studies also focus on process issues such as frequency of treatment.
Most of the available research on barriers to effective treatment pertains to treatment of the mental disorder(s) associated with suicide. The following section covers the relationship between suicide and under-treatment of depression and substance abuse.
Depression. Psychological autopsy studies have found that a large percentage of suicide victims with major depression were not receiving treatment or were receiving inadequate treatment. The majority of patients receiving antidepressants were prescribed inadequate doses (Isacsson et al., 1994; Isacsson et al., 1992; Isometsa et al., 1994b; Modestin and Schwarzenbach, 1992). Victims receiving psychotherapy rarely had visits as often as once a week (Isometsa et al., 1994b). These findings also apply to suicide attempters both before as well as after a suicide attempt (Suominen et al., 1998). Patients with depression and a history of past suicide attempts—a group at high risk for suicide—received inadequate pharmacological treatment in the 3 months before hospitalization (Oquendo et al., 1999).
Substance Abuse. Substance abuse is often under-treated in suicidal patients. Although not as well investigated as under-treatment for depression, studies indicate that alcohol dependence is under-treated in the vast majority of patients both before and after a suicide attempt (Suominen et al., 1999). As noted earlier, substance use and mental disorders frequently co-occur in completed (Henriksson et al., 1993) and attempted suicide (Suominen et al., 1996). Co-occurring disorders are best treated by programs that integrate mental health and substance abuse treatment (US DHHS, 1999). A major barrier to integrated treatment is the lack of such specialized programs (US DHHS, 1999).
PATIENT BARRIERS TO TREATMENT
The preceding sections have described the barriers deterring the majority of people with symptoms from seeking mental health care: stigma,
cost, and fragmentation of services. Additional patient barriers to care are fear of being hospitalized and thinking that they can handle their problems without formal treatment (Kessler, 2000; Sussman et al., 1987). If patients succeed in overcoming these general barriers to treatment, there are additional barriers confronting them within treatment itself.
Medication adherence is one key barrier. The term “adherence” is defined as the extent to which an individual’s use of medication adheres to medical advice. About 24–28 percent of suicide victims are non-adherent with medication treatment in the month before death (Appleby et al., 1999). More generally, about one-third of patients with mood disorders or psychosis (regardless of whether they are suicidal) are non-adherent (Cramer and Rosenheck, 1998), thereby placing them at risk for suicide. The reasons for non-adherence are complex. Certainly the barriers operating against reaching care—cost, fragmentation of services, and stigma— also apply for patients who are receiving care. Patients may be non-adherent to avoid the stigma attached to having a mental disorder, considering that most psychiatric medications need to be taken on a chronic basis (Kihlstrom, 1998). Medication side effects represent another major reason for less than optimal adherence (Fenton et al., 1997). Other reasons for patient non-adherence include: impaired cognition from the underlying disorder or co-occurring substance use; lack of social support; attitudes against medication or treatment; and dissatisfaction with treatment or poor therapeutic alliance, including lack of information from clinicians about dose and side effects (Fawcett, 1995; Fenton et al., 1997; Schou, 1997).
Another major barrier operating in the treatment setting is that the vast majority of patients who are suicidal often do not spontaneously report their suicidal intent to their clinician. A study, cited earlier, found that only 22 percent of suicide victims communicate their intent to their clinicians (Isometsa et al., 1995). The reasons for patient underreporting of suicidal intent are complex and difficult to discern upon psychological autopsy. The most commonly asserted reasons are the hopelessness of suicidality or the underlying symptoms of mental illness. Patients perceive their condition as hopeless and their clinician as unhelpful or unable to meet their needs for counseling, medication, and information (Hintikka et al., 1998; Michel, 2000; Pirkis et al., 2001). Fifty percent of adults who previously attempted suicide retrospectively reported that they could not have accepted help at the time of their attempt (Michel et al., 1994). Their cognition, judgment, or memory may be impaired, thus undermining their ability to appreciate the therapeutic value of treatment (Fawcett, 1995)
BARRIERS TO TREATMENT FOR HIGH-RISK GROUPS
Older men have the highest rates of suicide in the United States; the overall rate of suicide among men over 65 is about 30 per 100,000 population (Chapter 2). These figures underscore the urgency of examining the barriers to treatment for older people, especially men. The barriers range from general ones—cost of services and stigma—to more specific barriers posed by clinicians and patients.
For older people, the major financier of health services is Medicare. In comparison with private insurance, Medicare carries fewer benefits for mental health services via lower coverage of office visits and limits on hospitalization (US DHHS, 1999).5 Prescription drugs are not covered at all, although this may change under new policy initiatives. One-quarter of older people report that, because of Medicare restrictions, they would not seek mental health services if they needed them (Mickus et al., 2000). Other general barriers to treatment include limited transportation and stigma (Unutzer et al., 1999; US DHHS, 1999). Older people are less likely to accept a diagnosis of a mental disorder and they are less receptive to treatment than are other adults (Gallo et al., 1999; Leaf et al., 1988). They also perceive greater situational barriers to care (Leaf et al., 1988). If they enter treatment, they are more likely to discontinue prematurely because of stigma (Sirey et al., 2001). The significance of these barriers is borne out in overall patterns of utilization. Older persons are less likely to use mental health services than are other adults, and older males are less likely than older females (Burns et al., 2001; Leaf et al., 1987; Olfson and Pincus, 1996; Swartz et al., 1998). Thus, the demographic group most likely to complete suicide—older men—is the least likely to use services.
Several additional barriers, discussed below, relate specifically to suicidality: “ageism” in social attitudes; problems with detection and treatment of depression, the foremost risk factor for suicide in older people (Conwell et al., 1996); and problems in detection of suicidality.
Ageism refers to societal attitudes that devalue life as people age. It is manifest in stereotypes held by the public, older people, and clinicians. Members of the public, for example, perceive suicide in older people as less tragic than suicide in youth (Marks, 1988-1989). Clinicians, family members, and older adults report that suicidal ideation and depression
are part of the aging process (Duberstein et al., 1995; Seidlitz et al., 1995). The vast majority of surveyed primary care physicians think that, because of losses in late life, depression is understandable (Gallo et al., 1999). They are less alert to the complications of widowhood, which include depression, traumatic grief, and suicidality (Rosenzweig et al., 1997; Szanto et al., 1997; US DHHS, 1999). Depression and grief, in particular, are often misattributed to normal aging (Unutzer et al., 1999). Thus, stereotypes about aging thwart efforts to identify and diagnose depression and traumatic grief on the part of patients, families, and providers (US DHHS, 1999).
Under-detection and under-treatment of depression in older people is considered a major public health problem (Lebowitz et al., 1997; US DHHS, 1999). Most research focuses on primary care because this is where older patients present for, and prefer to receive, mental health care (Mickus et al., 2000; Unutzer et al., 1999). Most older people with depression in primary care remain undiagnosed (US DHHS, 1999). Detection of depression is worse in older than in younger patients, a well-recognized problem that does not appear to be improving (Harman et al., 2001c). Even with detection, up to 50 percent are given inadequate treatment (Katon et al., 1992; Unutzer et al., 2000; US DHHS, 1999), although a more recent study shows some improvement in treatment rates for depression (Harman et al., 2001b). More specifically, depressed older women are about two times more likely than depressed older men to receive antidepressants (Brown et al., 1995). Untreated or inadequately treated depression in primary care plays a role in suicide of older people (Lebowitz et al., 1997).
The reasons for lack of detection and treatment are a complex combination of clinician and patient factors (Pearson et al., 1997; Unutzer et al., 1999; US DHHS, 1999). Family physicians attribute their difficulty in detection to the atypical nature of depression’s symptoms in older people (Gallo et al., 1999).6 Further complicating the diagnosis is that older people commonly report somatic symptoms, as opposed to mental symptoms. Older men, in particular, are less likely than older women to be detected because they report fewer mood symptoms and crying spells (Unutzer et al., 1999). Greater reporting of somatic symptoms by older people might be an attempt to avoid the stigma of mental illness. It also might be that symptoms of physical disorders are amplified by depression (US DHHS, 1999), or that the depressive symptoms are relatively mild (Hotopf et al., 2001). Older persons are more likely to attribute their depression symp-
toms to a physical illness (Heithoff, 1995; Knauper and Wittchen, 1994). Further, older patients are often non-adherent with depression medications (NIH Consensus Development Panel on Depression in Late Life, 1992), taking only 50–70 percent of prescribed doses. Their low adherence to depression medications results partly from cost, from polypharmacy (i.e., reluctance to add another medication to the substantial number they have to take for other disorders), and from sensory and cognitive impairment (US DHHS, 1999).
One unexplored reason for lower treatment adherence or dropout may also be a mismatch between clinicians and patients in treatment preferences. Primary care physicians treating older people overwhelming prefer to prescribe medications rather than psychotherapy (Kaplan et al., 1999). Yet people with depression who attend primary care prefer counseling over medication—a finding based on a mixed age population (Dwight-Johnson et al., 2000). There are no studies that directly assess older people’s preferences for treatment and analyze findings by gender.
The detection of suicidality in older persons is a major opportunity considering that older people frequently make contact with their primary care physician before suicide. Some studies suggest that up to 70 percent of older people visit their clinician within 30 days of death (Barraclough, 1971; Caine et al., 1996; Conwell et al., 1991). Primary care clinicians are strongly in favor of suicidal assessment in depressed older patients (Harman et al., 2001a). Yet suicidality is complex to recognize in older persons for two main reasons: co-morbidities and infrequency of contacts with mental health specialists (Caine and Conwell, 2001). Co-morbid chronic illnesses are common in older people, they increase risk for depression and suicide, and they make symptom presentation more complicated to disentangle (US DHHS, 1999). To make accurate diagnoses, clinicians have to sort through symptoms of physical illness, depressive symptoms, and side effects of medications. When assessing for suicidality, only 44 percent of primary care providers ask about firearms access, despite the fact that firearms are the method of choice in older suicides (Kaplan et al., 1999). In this survey, general internal medicine physicians were the least likely primary care specialty to ask about firearms and reported the least confidence in assessing and treating suicidality. There is more recent evidence of improvement in physician attitudes about asking older patients about firearms access (Harman et al., 2001a).
There are no professional guidelines for screening older people for depression, substance abuse, or suicidality; however, the Surgeon General’s National Plan calls for screening as a minimum standard of care for hospice and nursing homes supported by Medicaid and Medicare.
Barriers to treatment for suicidal adolescents are generally the same as those discussed throughout this chapter: low access to care, low help seeking behavior, low utilization, problems with clinician detection of suicidality, and problems with referral or adherence to care. The empirical basis of these findings is primarily from studies of adolescent suicide attempters. Extrapolating from studies of suicide attempters to completers is problematic for adolescents because attempters are more likely to be female, whereas completed suicides are more likely to be male. Female adolescents are more likely than males to identify a need for mental health help (Saunders et al., 1994).
Access to mental health care is one of the foremost problems. Adolescents at the highest risk for suicide completion have dropped out of school and are unemployed. Their odds for suicide compared to controls are increased 44-fold (Gould et al., 1996). These adolescents, by definition, would not have access to school-based mental health services or employer supportive services.
Adolescent suicide attempters typically first access care in emergency departments, but up to half receive no formal treatment after their emergency department visit (Spirito et al., 1989). Of those receiving care after a visit, non-adherence is exceedingly common. In an inner city hospital where they had received emergency care, 77 percent of adolescent suicide attempters dropped out of treatment in the outpatient psychiatry clinic. Attempters kept significantly fewer appointments than did nonattempters (Trautman et al., 1993). In a separate study at the same clinic, age was inversely related to treatment adherence in male adolescents: younger males (ages 11–15) were more likely to keep appointments after emergency care than were older male suicide attempters (ages 16–19; Piacentini et al., 1995). The reasons for failure of adolescents to attend treatment are likely to include parent resistance to treatment, repetitive evaluations, long waiting periods, and poor communication in the emergency department (Rotheram-Borus et al., 2000; Rotheram-Borus et al., 1994).
Medication adherence is also low among adolescents, although there appear to be no direct data in suicide attempters or completers. In a study of adolescents discharged from inpatient psychiatric care, only 38 percent were adherent. Substance abuse was a major predictor of non-adherence (Lloyd et al., 1998).
Detection of suicidality is another barrier to treatment. Only 9 percent of teachers and only one-third of high school counselors thought that they could recognize a student at risk (King et al., 1999a; King et al., 1999b). Despite the fact that previous suicide attempt is the strongest predictor of
suicide, less than 20 percent of adolescent suicide attempters were actually asked about suicidal behavior by physicians at a medical clinic (Slap et al., 1992). A survey of pediatricians and family physicians in Maryland found that only 23 percent either frequently or always screened adolescents for suicide risk factors such as alcohol use or abuse, depression, physical or sexual abuse, or prior attempts (Frankenfield et al., 2000). The American Academy of Pediatrics recommends that pediatricians ask all adolescents about depression, suicidal thoughts, and other suicide risk factors during routine medical history (AAP, 2000). The American Medical Association also recommends annual screening of adolescents to identify those at risk for suicide (US Preventive Services Task Force, 1996).
The general barriers to mental health care for racial and ethnic minorities are similar to those operating for whites—cost, fragmentation and availability of services, and stigma. Added to these barriers are several that are more unique to the minority experience in the US: fear and mistrust of treatment, which stems from the legacy of racism and discrimination, as well as miscommunication for non-English speakers. All of these barriers can act alone or together to deter minorities from accessing and utilizing mental health care. Their access is also lower than whites because of lower socioeconomic status and lower rates of health insurance (Brown et al., 2000). When they utilize care, minorities are more likely than whites to be misdiagnosed or receive inferior quality of care. These disparities between minorities and whites—lower access, lower utilization, and poorer quality of care—are documented in recent reports of the US Surgeon General and the Institute of Medicine (IOM, 2002; US DHHS, 2001). The Surgeon General’s report also documents the similar overall prevalence of mental illness across distinct ethnic groups, including whites. Similar overall prevalence, combined with lower access, utilization, and quality, led to the conclusion that minorities suffer a greater burden of unmet mental health needs (US DHHS, 2001). Whether or not these general barriers expressly apply to detection and treatment of suicide in minority groups in community settings has not been empirically documented but can be assumed by extension.
Barriers to the detection and treatment of suicidality in American Indians and Alaska Natives require special focus because rates of suicide are 72 percent higher than those of the general United States population (see Chapter 2). The risk is greatest among young males under 40 years of age. The vast majority of suicides (69 percent) involve alcohol, although the rate varies depending on cultural group.
Of all ethnic groups in the United States, prevalence information is
most limited with respect to Native populations. Although evidence is sparse, there are indications that Native youth and adults have somewhat higher prevalence of mental illness compared to the United States population and different distributions of disorders (US DHHS, 2001). The availability of mental health services is a major problem because of the rural, isolated location of many Native communities and the paucity of providers with Native backgrounds. Native populations living on reservations have access to services of the Indian Health Service (IHS), yet its resources for mental health services—especially for secondary and tertiary care— are limited. Furthermore, the majority of American Indians and Alaska Natives live in urban areas and thus do not have access to IHS facilities, which are mainly located on or near reservations. About 23 percent of American Indians and Alaska Natives who report not having IHS coverage lack any other health insurance, compared with 14 percent of whites (Brown et al., 2000).
For suicide victims, however, access to service does not necessarily translate into utilization. A major problem, from a case control study conducted on a Plains Indian reservation, is that victims are less likely to seek health care than are matched controls drawn from the same reservation health facility (Mock et al., 1996). This is in marked contrast to studies of the general United States population, where victims are more likely than controls to seek health care. During health visits within 6 months of suicide, cases on the reservation reported fewer psychological and interpersonal problems than did controls, and almost all had no record of use of mental health services during this period. Given the low rates of health care utilization, the investigators concluded that the clinic shows little promise for detection of those at risk for suicide and recommended stronger community outreach especially to those at greatest risk (i.e., males under age 40).
There are multiple barriers to providing adequate mental health care in correctional facilities. These barriers emanate from society and correctional facility environments, leadership, officers, health care staff, and inmates themselves. Some of the barriers are similar to those of other populations, but the context is unique in prisons and jails.
Before the early 1970s, the courts and society allowed correctional facilities to have broad discretionary powers in the way they treated in-
mates (Anno, 1991). This changed with a series of court cases in the 1970s and 1980s (Newman v. Alabama 19727; O’Connor v. Donaldson 19758; 1980 Ruiz v. Estelle 19809; 1989 Langley v. Coughlin 198910) that held that inmates deserved professional treatment and evaluation of psychiatric problems in appropriate settings. From the Estelle decision, inmates were assured of three basic rights applicable to mental health services: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment.
In 1995 Madrid v. Gomez11 added several factors that determine the constitutionality of a correctional mental health system: (1) an inmate must have a means of making his or her needs known to the medical staff; (2) sufficient staffing must allow individualized treatment of each inmate with serious mental illness; (3) an inmate must have speedy access to services; (4) there must be a system of quality assurance, and staff must be competent and well trained; and (5) there must be a system of responding to emergencies and preventing suicides. Despite the protections afforded by these court cases, in 1996, Congress passed the Prison Litigation Reform Act (PLRA), which curtails the authority of the federal courts to intervene in class actions suits concerning prison conditions, including the delivery of medical care.
Correctional Facility Barriers
The environment in correction facilities is itself a deterrent to mental health. Inmates are often unsafe from random violence, rape, and exploitation (Kupers, 1999). To the extent that these factors increase the hopelessness of some inmates, they increase risk factors related to suicide and are hard for health professionals to mediate.
The growth in the number of individuals confined in prisons and jails has doubled in the past decade and tripled in the past 20 years (Bell, In press). This growth in population frequently outpaces correctional facility health care infrastructure preventing adequate mental health services delivery. Escalating costs of caring for individuals infected with HIV has eroded some progress in quality of care achieved with correctional health care reform that began in the 1970s. (Bell, In press).
The logistics of movement within corrections makes health care encounters much more difficult than in the free world. Thus, inmate access to mental health services becomes difficult (Schiff and Shansky, 1998). The mission of corrections is to house inmates in secure facilities that separate them from the rest of society. In correctional facilities, psychiatric needs may take a back seat to issues of security, order, and control (Wilmont, 1997). Accordingly, the roles and relationships among doctors, their inmate patients, and the correctional staff and authorities responsible for managing correctional facilities are often at odds.
Because of the high turnover of inmates in jails, it is difficult to provide complete health assessments that might uncover an inmate who is at high risk for suicide. Many facilities have addressed this problem by providing suicide-screening programs when the inmate first enters the institution. Screening is helped by directing attention to those inmates with a higher risk for suicide, such as young, white males. Other factors predisposing inmates to suicide include: legal complications such as denial of parole, bad news about “loved ones” at home, and victimization in sexual assault or other trauma. While 73 percent of jails report they have suicide prevention programs (Steadman and Veysey, 1997), the content of these programs remains unverified.
Health Care Staff
Even the most dedicated physicians find that jail and prison settings strain their ability to be compassionate (King, 1998) Thus, the attitudes and belief structures of the correctional staff and physicians also complicate the physician/inmate relationship. Within a correctional environment. medical staffs are often pressured to choose sides between correctional philosophy and attitudes and the ethical practice of medicine. “The prison medical community must resist the efforts that are made to tailor the quality and quantity of medical treatment to the exaggerated demands of institutional security, productivity, discipline, and administrative convenience. Every invitation or temptation to define the quality of professional care by the substandard criteria that may govern other facets of the prison’s operation must be eschewed” (Nathan, 1984 as cited in King, 1998).
Complicating things is the reality that the typical mental health care professional’s world is vastly different from the world from which the inmate comes. Class prejudices combined with ignorance about inmates’ background, culture, and environment creates barriers to high-quality interactions and communication (Adebimpe, 1981; Dehoyos and Dehoyos, 1965; Gross et al., 1969). In addition, most service providers are members of the white population while the majority of inmates are nonwhite. This
difference in origin and experiences frequently causes problems in interactions (US DHHS, 2001). Prejudices and imbalances of power and opportunity produce a climate of mutual fear and distrust that is antithetical to the trust needed for health care (Schiff and Shansky, 1998).
Ethical dilemmas unique to correctional facilities also create barriers to mental health treatment in correctional facilities. The issues of the doctor/patient relationship; the quality, extent and power of patient authority; the process of informed consent and refusal; physician beneficence; the use, misuse, and control and possible abuse of medical technology; and research on human participants, with particular emphasis on especially vulnerable populations including prisoners, are all issues of medical ethics strained in correctional environments (Bell, In press; Dubler and Anno, 1991), and which interfere with the provision of correctional mental health care.
A doctor is ethically required to provide a patient with enough information to make informed consent decisions regarding their treatment. Patients outside of prison are free to choose a medical approach or to deny treatment even if it results in death. In prison settings, inmates can consent to care but may not, in all circumstances, refuse care.
One example is that of an inmate who was denied the right to refuse dialysis (Commissioner of Correction v. Meyer, 199212) because the refusal was considered to be an attempt to manipulate the system to obtain a transfer.
Confidentiality is central to the doctor/patient relationship, but can be breached to protect injury to the patient or to others. In prison, confidentiality may not hold if the patient presents risks of escape or internal discord or riot. Patient concerns about confidentiality in a prison setting can seriously hinder appropriate care.
Some inmates visit a health care facility as a route to escape from boredom, a place to meet friends in more relaxed and less supervised setting, or as a way of escaping from the monotony of work and programs that continue unrelentingly and are unresponsive to individual daily choice. Some inmates only get out of their cell when they seek health care. Thus, there is some overuse of the system for purposes other than seeking health care. This knowledge develops a sense of cynicism from guards about reasons inmates want to be seen (King, 1998).
Some inmates may be extraordinarily demanding and manipulative.
Inmates may press health professionals for services or medications that they do not require. It is a rare prison physician (especially one new to corrections) who has not received repeated requests from inmates for medication for “nerves” or “sleeplessness” or “pain.” Health providers must ensure that their patients receive the care they need. Simultaneously, they must recognize that succumbing to inmate demands for unnecessary care can do harm.
Interventions in developing countries face many of the same barriers that are discussed above yet the obstacles are even greater. In developing countries, access to health care in general can be limited. Many countries have few primary care physicians, let alone specialists such as psychiatrists. For example, India has only 3 psychiatrists per million people (Murthy, 1998) and China has 10 per million (de Jong, 1996). In rural areas, the availability can be even less; there can be a physician patient ratio of 1:20,000—and worse for specialists (IOM, 2001).
In developing countries, medical care is often provided by community health centers and caregivers may have minimal education (IOM, 2001). Basic training for these providers—in interviewing and information recording, consultation, use of medication, and even increased awareness and management skills—may effectively improve mental health care (IOM, 2001). Limitations in the diagnostic and treatment capabilities of primary care physicians also have been noted (e.g., Al-Jaddou and Malkawi, 1997; Wright et al., 1989). Among physicians in Jordan, one study found that only 24 percent of the patients with mental disorders were identified (Al-Jaddou and Malkawi, 1997). In order for physicians to recognize the risk factors associated with suicide, they also require additional education. Yet in developing countries the financing of such training is a significant obstacle. A recent IOM report (2001) recommended that existing systems of primary care be extended and strengthened to deliver services for brain disorders, including mental illnesses. It suggested that the training be linked with secondary and tertiary care facilities and be integrated through national policies. Implementation of these recommendations would be likely to reduce the burden of suicides in these countries.
The stigma of mental illness is a major obstacle to treatment and increases the risk of suicide. In some countries, traditional beliefs increase the stigmatization of mental disorders (IOM, 2001). As in developed countries, stigma reduces the likelihood that an individual suffering with a mental disorder might seek out help. Without broad educational pro-
grams to reduce the discrimination faced by those with mental illness, many will forego potentially life-saving treatment.
Evaluating the problem of suicide globally is especially difficult because of the variability in the reporting of suicide and inadequate databases in developing countries. As described in Chapter 6, rates may be under-reported in countries where the predominant religion prohibits suicide, such as Catholicism in Ireland, because of the greater stigma (Kelleher et al., 1998; Myers and Farquhar, 1998). Furthermore, the reporting process can differ significantly and introduce additional artifacts. In developing countries, no registries may exist. The lack of accurate accounting for deaths by suicide makes assessment of risk factors and of effectiveness of interventions difficult if not impossible. Under-reporting and consequently underestimating the magnitude of the problem can reduce the effort and resources applied to finding solutions.
Stigma represents a major barrier to reducing suicide. The stigma against mental illness results in diminished opportunities and lower self-esteem. Stigma prevents people from seeking treatment for symptoms of mental illness. Untreated mental illness increases suicide risk.
Approaches to reduce the stigma associated with mental illnesses and their treatment must be sought.
Most people who complete suicide had contact with a health professional within a year of their death, 40 percent within a month of their death. Screening for depression or substance abuse is not routine in primary care. Even when depression is accurately diagnosed, only a minority of patients receives adequate treatment. Primary care physicians lack training and evidence-based screening, assessment, and referral practices for suicidality.
Professional evidence-based guidelines for suicide risk screening, assessment, and referral need to be developed and implemented into primary health care settings. Screening, treatment, and referral for the major suicide risk factors depression and alcohol abuse disorders should be conducted in primary health care settings.
Many individuals cannot access proper care for mental illness because of the fragmentation of services. This particularly affects those with co-occurring substance use.
Mental health services, including treatment for substance use disorders, should be delivered in an integrated fashion.
Certain populations face additional barriers to treatment that increase their vulnerability to suicide. For minors and aged adults, transportation and/or permission of family members present challenges to obtaining treatment. Barriers for incarcerated populations include lack of mental health care staff and, at times, either outright denial of care or forced treatment. Minority populations face discrimination and may refuse seeking professional care because of mistrust. Developing countries suffer severe lack of specialist care.
Efforts should be made to bridge the barriers to proper treatment in under-served, at-risk populations. Culturally appropriate strategies to increase access and utilization of mental health services should be employed.
Lack of adequate insurance coverage for mental health services represents a critical barrier to treatment for mental disorders, including substance use disorders, that increase suicide risk.
Insurance coverage equal to that of general health services should be extended to mental health services. Such action is projected to reduce suicide via increasing access to care for those at risk. Laws and policies mandating insurance coverage parity for mental health services are likely necessary before third-party payers will cover clinically adequate mental health services. Uninsured adults and children must be provided with effective treatment. Novel approaches to funding need to be explored, since current funding mechanisms are not adequate.
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“Hope” is the thing with feathers—
That perches in the soul—
And sings the tune without the words—
And never stops—at all—
And sweetest—in the Gale—is heard—
And sore must be the storm—
That could abash the little Bird
That kept so many warm—
I’ve heard it in the chillest land—
And on the strangest Sea—
Yet, never, in Extremity,
It asked a crumb—of Me
Reprinted by permission of the publishers and the Trustees of Amherst College from The Poems of Emily Dickinson, Thomas H. Johnson, editor, Cambridge, Massachusetts: The Belknap Press of Harvard University Press, Copyright © 1951, 1955, 1979 by the President and Fellows of Harvard College.