Awareness helps primary doctors prevent patients' suicide

Although few of their patients commit suicide in a year, primary care physicians should use office visits to note possible risk factors for suicidal behavior, bolstered by candid discussions if needed, according to a review of recent research.

“Primary care physicians are urged to consider the complex, subtle and even convoluted ways in which depressed patients and others overtly or covertly seek and respond to help when experiencing death wishes,” says lead study author Herbert C. Schulberg, Ph.D., M.S.Hyg., of Weill Medical College, Cornell University in White Plains, N.Y.

The research appears in the journal General Hospital Psychiatry.

Suicide caused the death of 30,622 people in 2001, according to the U.S. Centers for Disease Control and Prevention. Some populations are at greater risk, however. The highest suicide rate is among white men age 65 years or older, and suicide is the third-leading cause of death among young people age 15 to 24.

Although patient suicide rates are under 1 percent per year for the average doctor, studies have shown that 45 percent of victims had visited their primary care physicians in the month before killing themselves, Schulberg reports. The role of primary care physicians is important because only 14 percent of patients who commit suicide were seeing a psychiatrist or mental health professional at the time.

Discerning potential suicides from other patients isn’t simple, Schulberg says: “Visit patterns per se are not thought to be sufficiently distinctive to alert physicians to their patients’ death wishes.”

Doctors should always note major risk factors like prior suicide attempts, depression, a history of severe mental illness or alcohol and drug abuse. As many as a third of people who commit suicide have some serious physical illness, but most of them do not.

Given that there are so few suicides among patients each year, screening all patients would be a waste of time for doctors, the U.S. Preventive Services Task Force says. However, questioning a patient with some of these risk factors may reveal suicidal thinking.

Many doctors fear that openly addressing the issue of suicide in depressed patients may trigger suicidal thoughts or action, Schulberg says. But directly asking them, “Are you feeling suicidal?” may often be as useful as a more formal clinical interview, he says.

With older patients, doctors may want to open discussions by addressing end-of-life issues.

“The physician can possibly uncover feelings of depression, fear of pain, unwillingness to suffer, and associated plans for self-initiated life-ending behaviors that would otherwise remain unnoted,” he says. They should also ask elderly patients about prescription medications which might be misused and about the availability of firearms.

Both psychotherapy and antidepressant medications can help depressed, potentially suicidal patients, he says. Suicide rates decline in populations using antidepressants, and many of these patients can be successfully managed by non-psychiatrists.

“Primary care physicians can successfully be trained to prescribe antidepressants within guideline standards and to achieve clinical outcomes matching those obtained by psychiatrists,” he says.

Schulberg also suggests that a nurse or social worker may take over some follow-up tasks for the physician, given the demands on the latter’s time. These “case managers” can maintain in-person or telephone contact with the patient and observe whether suicidal thinking has changed and if patients are taking medications properly.

Much more research is needed to confirm suicide prevention strategies and clinical interventions in primary care, Schulberg says. In the meantime, coupling the risk factors for suicide with an understanding of the patient’s specific life circumstances may help physicians decide on when and how to intervene with potentially suicidal patients.

This study was supported by a grant from the John D. and Catherine T. MacArthur Foundation, which also funds the Health Behavior News Service.