Predictors of primary care physicians' self-reported intention to conduct suicide risk assessments

Recognising and Responding to Suicide-Risk Factors in Primary Care: A Scoping Review

The cost of one suicide is estimated to be £1.67 million (2 million euros) to the UK economy. Most people who die by suicide have seen a primary care practitioner (PCP) in the year prior to death. PCPs could aim to intervene before suicidal behaviours arise by addressing suicide-risk factors noted in primary care consultations, thereby preventing suicide and promoting health and wellbeing. This study aimed to conduct a rapid, systematic scoping review to explore how PCPs can effectively recognise and respond to suicide-risk factors. MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: suicide prevention, mental health and primary care. Two reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analysing study characteristics and findings. Forty-two studies met the eligibility criteria and were cited in this scoping review. Studies were published between 1990 and 2020 and were of good methodological quality. Six themes regarding suicide risk assessment in primary care were identified: Primary care consultations prior to suicide; Reasons for non-disclosure of suicidal behaviour; Screening for suicide risk; Training for primary care staff; Use of language by primary care staff; and, Difference in referral pathways from general practitioners or primary care practitioners. This review focused on better recognition and response to specific suicide-risk factors more widely such as poor mental health, substance misuse and long-term physical health conditions. Primary care is well placed to address the range of suicide-risk factors including biological, physical-health, psychological and socio-economic factors and therefore these findings could inform the development of person-centred approaches to be used in primary care.

Examination of medical student and physician attitudes towards suicide reveals need for required training

The attitudes of healthcare providers towards suicidal patients are known to influence their motivation to treat patients during a suicidal crisis. Patients who attempted suicide are more likely to have recently visited a primary care provider who is not necessarily sufficiently trained in managing a suicidal patient rather than a mental health provider who is trained to do so. For those reasons, documenting medical students and physicians' attitudes towards suicide can help in the development of effective intervention training to prepare them to manage these types of patients. In this mini review, attitudes towards suicidal patients, the effectiveness of training on changing their attitudes are discussed. In summary, primary care providers are recognized as a top area where improvements can prevent suicides; providing proper suicide prevention training can effectively improve attitudes and quality of care for suicidal patients.

Raising Suicide in Medical Appointments-Barriers and Facilitators Experienced by Young Adults and GPs: A Mixed-Methods Systematic Review

The aim of this review was to understand the barriers and facilitators facing GPs and young adults in raising and addressing suicide in medical appointments. A mixed-methods systematic review was conducted of qualitative and quantitative studies. The focus was papers that explored barriers and facilitators experienced by young adults aged 18 to 26, and GPs working in primary care environments. Nine studies met the inclusion criteria. Four studies provided information on young adults' views, four on GPs, and one considered both GP and young adults' viewpoints. Nine barrier and seven facilitator themes were identified. Unique to this review was the recognition that young adults want GPs to initiate the conversation about suicide. They see this as a GP's responsibility. This review further confirmed that GPs lack the confidence and skills to assess suicide risk in young adults. Both findings combined could explain previous results for reduced identification of suicide risk in this cohort. GP training needs considerable focus on addressing skill deficiencies and improving GP confidence to assess suicide risk. However, introducing suicide risk screening in primary care for young adults should be a priority as this will overcome the need for young adults to voluntarily disclose thoughts of suicide.

Suicide risk assessment fears, attitudes and behaviours of lifeline crisis supporters

Lifeline Australia operates crisis support services through Lifeline Crisis Supporters. An integral part of their role is to conduct online suicide risk assessments with help-seekers. However, there is limited literature regarding suicide risk assessment practices for this population. This study aimed to examine how suicide prevention training, vicarious trauma and fears impacted suicide risk assessment behaviours of Lifeline Crisis Supporters. A cross-sectional survey design was used to recruit a volunteer convenience sample of 125 Lifeline Australia Crisis Supporters (75.2% females; M_age  = 54.9) in 2018 to participate in an online survey. Findings revealed that those with more suicide-specific training had less risk assessment-related fears, and that fears were not related to attitudes towards suicide prevention. There was no significant relationship between vicarious trauma and amount of training or years of experience in the role. Further, participants with higher levels of vicarious trauma demonstrated significantly more negative attitudes towards suicide prevention. Overall, training appears to be a significant factor in suicide risk assessment practice behaviours of Lifeline Crisis Supporters, highlighting a need for ongoing training and support for them. This research also suggests that whilst fears exist, they do not significantly impair Lifeline Crisis Supporters' ability to undertake suicide risk assessment.

Suicide-Related Knowledge and Attitudes among a Sample of Mental Health Professionals

Inadequate knowledge of the potential signs and risk factors of suicide negatively affects the ability of healthcare professionals to recognize patients at risk of suicide. The principal aim of the present study is to assess the attitudes and knowledge about suicide in a large sample of mental health professionals. We examined the relationship between Suicide Knowledge and Skills Questionnaire items and the experience of a patient dying by suicide. We also examined whether various healthcare professionals respond differently to the items of the Impact of a Patient’s Suicide on Professional and Personal Lives Scale. Results demonstrated that healthcare professionals who had experienced a patient suicide reported greater skills than professionals who had not experienced a patient suicide. However, 44% of professionals who had experienced a patient suicide felt that they did not have adequate training on this particular issue. Among those who had experienced a patient suicide, there was an increased tendency to hospitalize patients with suicide risk and an increased use of collegial consultation. Concerning personal emotions, healthcare professionals reported troubled relationships with family members and friends and the loss of self-esteem. In conclusion, better knowledge and attitudes about suicide are necessary for suicide-prevention strategies.

Épidémiologie descriptive du risque suicidaire dans le système médical français de médecine générale

OBJECTIVE

Suicide prevention certainly includes a better knowledge of suicide risk in primary care. A number of international publications have shown interest in assessing this risk, but mostly through specific consultant populations: young patients, old patients, anhedonic, depressive, etc. Our study analyses suicide risk prevalence in patients consulting in general medicine for any somatic or psychiatric reason, their pathology or their age.

METHOD

This cross-sectional study was conducted with adult patients (827 subjects included) who were consulting a French generalist doctor panel randomly selected. They filled a validated self-questionnaire (aRSD) assessing their suicide risk in the 15 preceding days and providing professional and personal data.

RESULTS

The totally operable 757 files (483 female; 274 male) show that close to a quarter of consultants (24.3%) presents with a positive suicide risk in the 15 days preceding their consultation and 6.3%, reveal a severe risk (aRSD ≥ 7) with ideas and impulses to commit the act. When the reason to consult is psychiatric, 64.6% of these consultants have aRSD positive. One time out of two, the risk is even severe.

CONCLUSIONS

This data shows how important the suicide risk prevalence is in general medicine. It confirms the main role played by primary care patricians in acting to prevent suicide risk. This data also shows the contribution represented by a self-questionnaire that would rapidly assess the suicide intent while screening, it.

Universal suicide screening in college primary care

Implementation of a universal primary care (PC) suicide-screening program in a college student health center to heighten awareness, provide support and enhance education of staff and students served. Program feasibility, data collection, electronic medical record (EMR) adaptations and staff learning outcomes were examined. Participants: 1,607 students with PC visits during Spring 2018 semester. Methods: Annual Suicide Behaviors Questionnaire (SBQ-R), EMR template, safety alert, referral tracking and simulated staff training were employed. Chi-square tests assessed documentation, safety alerts and mental health referral changes. Paired t-tests evaluated staff learning outcomes. Results: 12.8% of students screened positively for suicide risk during implementation. Documentation consistency, EMR safety alert utilization, mental health referrals and subsequent appointments increased significantly. Staff learning outcomes yielded growth in knowledge and comfort with suicide screening and brief intervention. Conclusion: A comprehensive suicide-screening program is feasible for identifying students at-risk and promoting positive clinical changes in college PC practice settings.

PCP Opinions of Universal Suicide Risk Screening in Rural Primary Care: Current Challenges and Strategies for Successful Implementation

PURPOSE

Universal suicide risk screening has the potential to address the disproportionately high rates of suicide in the rural United States, as 83% of people who have died by suicide have visited a health care provider in the year prior to their deaths, and rural patients are more likely to visit medical professionals than behavioral health professionals for mental health concerns. This study describes the opinions of primary care providers (PCPs) practicing in a primarily rural state regarding universal suicide risk screening, barriers to implementation, and strategies to increase the feasibility of screening in their practices.

METHODS

In-depth, individual semistructured qualitative interviews were conducted with a sample of PCPs practicing in West Virginia (N = 15). Applied thematic analysis of the data was completed by a team of 3 coders using a consensus-coding methodology.

FINDINGS

The majority of PCPs supported the practice of screening, but they identified multiple barriers, including a lack of access to mental health and crisis support services, concerns about clinic flow and follow-up with suicidal patients, cultural beliefs specific to rural Appalachia, and provider discomfort with screening. Strategies suggested to address these barriers included the use of technology for screening, a multidisciplinary team approach, streamlined methods for screening and risk assessment, co-located behavioral health, and additional trainings for PCPs on the topic of suicide.

CONCLUSION

Future research should examine the efficacy of universal suicide risk screening programs in rural adult primary care that utilize these strategies in diverse samples with longitudinal data.

Health Risk Assessments in Michigan's Medicaid Expansion: Early Experiences in Primary Care

INTRODUCTION

Michigan is one of 3 states that have implemented health risk assessments for enrollees as a feature of its Medicaid expansion, the Healthy Michigan Plan. This study describes primary care providers' early experiences with completing health risk assessments with enrollees and examines provider- and practice-level factors that affect health risk assessment completion.

METHODS

All primary care providers caring for ≥12 Healthy Michigan Plan enrollees (n=4,322) were surveyed from June to November 2015, with 2,104 respondents (55.5%). Analyses in 2016-2017 described provider knowledge, attitudes, and experiences with the health risk assessment early in Healthy Michigan Plan implementation; multivariable analyses examined relationships of provider- and practice-level characteristics with health risk assessment completion, as recorded in state data.

RESULTS

Of the primary care provider respondents, 73% found health risk assessments very or somewhat useful for identifying and discussing health risks, although less than half (47.2%) found them very or somewhat useful for getting patients to change health behaviors. Most primary care provider respondents (65.3%) were unaware of financial incentives for their practices to complete health risk assessments. Nearly all primary care providers had completed at least 1 health risk assessment. The mean health risk assessment completion rate (completed health risk assessments/number of Healthy Michigan Plan enrollees assigned to that primary care provider) was 19.6%; those who lacked familiarity with the health risk assessment had lower completion rates.

CONCLUSIONS

Early in program implementation, health risk assessment completion rates by primary care providers were low and awareness of financial incentives limited. Most primary care provider respondents perceived health risk assessments to be very or somewhat useful in identifying health risks, and about half of primary care providers viewed health risk assessments as very or somewhat useful in helping patients to change health behaviors.

Suicide exposures and bereavement among American adults: Evidence from the 2016 General Social Survey

BACKGROUND

We investigated lifetime suicide exposures and bereavement among a representative sample of American adults from the 2016 General Social Survey.

METHODS

Questions on lifetime suicide exposures, bereavement and mental health status were administered to 1432 respondents. Suicide exposed and bereaved respondents were compared to non-exposed respondents on three different measures of mental health functioning with cross tabulations and means comparison tests.

RESULTS

51% of respondents had exposures to one suicide or more during their lifetimes, and 35% were deemed bereaved by suicide, having experienced moderate to severe emotional distress from their losses. Findings suggested more exposures and bereavements were associated with greater numbers of bad mental health days and more expectations of "having nervous breakdowns" but with no clear associations with CES-D scores.

CONCLUSIONS

These findings suggest suicide exposures and bereavement are far more pervasive than commonly thought, with more than half of the population exposed and a third bereaved. Health professionals need to more actively assess for suicide exposures and bereavements, and be vigilant for significant impacts of suicide even when the suicide decedent is not a first degree family relative, helping to reduce the mental health distress presently associated with these experiences.

A novel approach to suicide prevention - Educating when it matters

BACKGROUND

Looking at the burden of suicide, there is a dire need for medical schools to incorporate suicide prevention training. Effective communication helps in early detection and management of suicidal behavior. Medical students can act as a GATEKEEPER if they receive adequate training.

METHODOLOGY

This was an educational intervention study done at tertiary care teaching hospital to assess the knowledge and attitude of medical students toward depression and suicide and to impart and assess communication skills for suicide prevention in one of the four batches of students in 4^th semester. Pretest was conducted to assess knowledge and attitude toward depression and suicide, followed by training using interactive lectures, demonstration of interview, and hands-on training with patients and role-plays. The posttest and objective structured clinical examination (OSCE) were administered for skill assessment. Feedback was taken regarding this intervention.

RESULTS

The mean marks of the pre- and post-test were 8.96 (8.3-9.6) and 14.58 (13.8-15.3), respectively, out of 25. The difference was statistically significant (t = 13.24, P ≤ 0.0001) which suggests improvement in knowledge. We found mixed responses in attitude statements showing limited change. Mean obtained marks on OSCE examination out of 66 was 42.7. Among various components of OSCE, students scored high on rapport building. The most useful components of trainings were role-play, OSCE, and interaction with patients as per their feedback.

CONCLUSION

The intervention was found effective in increasing knowledge, changing attitude, and enhancing communication skills of medical students toward suicide prevention. Training of communication skills for suicide prevention in depressed person should be given to every medical student as suggested by feedback.

Do Primary Care Physicians Help the Bereaved With Their Suicide Losses: Loss Survivor Perceptions of Helpfulness From Physicians

Several previous studies suggested that primary care physicians can provide important bereavement assistance to survivors of suicide, yet no study has investigated whether suicide-bereaved patients perceive their physicians as helpful. Contacting bereavement communities on social media, we collected online survey data from 146 bereaved respondents reporting suicides causing them severe emotional distress. Data analysis suggested that nearly half (48%) of the respondents encountered positive, help-offering responses from physicians, compared to 10% whose responses were deemed as negative. Analysis of our data suggested that loss survivors' perceptions of a physician's helping or reproachful responses were associated with differences in grief difficulties and mental health distress.

A Comparison of Psychiatric and Nonpsychiatric Nurse Practitioner Knowledge and Management Recommendations Regarding Adolescent Mild Traumatic Brain Injury

BACKGROUND

Nurse practitioners (NPs) are statutorily authorized to provide assessment and cognitive recommendations for concussion in most states. Their scope of practice includes assessment and management of concussion sequalae including anxiety, insomnia, and depression, as well as return to school and activity guidance.

OBJECTIVES

Analysis of symptom-based diagnosis of mild traumatic brain injury (TBI) in adolescents, including return to school and school workload recommendations comparing psychiatric and nonpsychiatric NPs.

DESIGN

Cross-sectional Web-based survey with embedded videos using standardized actors and scripts randomized for patient sex and sport. A total of 4,849 NPs licensed in Oregon or Washington were invited by e-mail to view and respond to this study, with a response rate of 23%.

RESULTS

Psychiatric mental health nurse practitioners (PMHNPs) were 44% less likely than family NPs to report using standardized concussion tools. 17% had completed continuing education on mild TBI compared to 54.5% of family NPs. Seven PMHNPs provided additional feedback related to discomfort in completing the survey due to lack of comfort or experience. Return to school recommendations and reduced workload advice did not significantly differ by NP type.

CONCLUSION

PMHNPs may support individualized assessment through concussion evaluation, use of standardized tools, and differential consideration of TBI for mental health symptoms. More research is required related to the role and contribution of cognitive rest to full recovery.

Primary care assessment of patients at risk for suicide

Primary care providers (PCPs) play a crucial role caring for patients with depression, managing antidepressant therapy, and assessing patients for suicide risk. Ten percent of the more than 20 million primary care visits for depression each year involve mental health issues, and account for 62% of the antidepressants prescribed in the United States. Psychiatric disorders appear to be underrecognized and undertreated in primary care. Suicidal ideation is present in a significant percentage of depressed primary care patients but rarely discussed. This article describes the warning signs and risk factors associated with suicide and recommends screening tools that can help PCPs identify patients at risk.

Predictors of Comfort and Confidence Among Medical Students in Providing Care to Patients at Risk of Suicide

OBJECTIVE

The aim of this study was to identify factors associated with comfort and confidence in providing care to patients at risk of suicide, in a sample of Australian medical students.

METHODS

An online cross-sectional survey was completed by 116 current medical students (42 % male) aged between 20 and 41 years (M = 25, SD = 3.8).

RESULTS

Greater personal experience of suicide and previous contact with patients with psychiatric problems were significantly associated with both increased perceived comfort and increased confidence in providing care for individuals with suicidal thoughts or behaviors, based on self-report. However, these effects may not reflect objective measures of competency and additional research is needed to assess generalizability of the findings due to the sampling method.

CONCLUSIONS

Increasing medical student contact with patients at risk of suicide through the implementation of psychiatry placements, gateway programs, and early year exposure to patients with psychiatric problems may increase perceived confidence and comfort in providing care to individuals at risk of suicide. Further research should evaluate the impact of such programs on behavioral indices of clinical competency.

Health Care Resources and Mental Health Service Use Among Suicidal Adolescents

Developing policies and interventions that increase rates of mental health service use for suicidal adolescents is crucial for suicide prevention. Data from a sample of suicidal youth (n = 1356) from the National Longitudinal Study of Adolescent Health (Add Health) were analyzed to examine whether type of insurance, receipt of routine medical care, and access to school-based mental health treatment predicted mental health service use cross-sectionally and longitudinally. Rates of mental health service use were low in cross-sectional analyses at all three waves (∼11%-30%), despite the fact that respondents were at high risk for suicide attempts and depression. With demographic factors and symptom severity controlled, only receipt of a routine physical predicted an increased likelihood of mental health service use at wave I and in longitudinal analyses. Implications discussed include the utility of universal suicide screenings and integrated behavioral health care as potential intervention strategies for this population.

The Impact of Knowledge of Suicide Prevention and Work Experience among Clinical Staff on Attitudes towards Working with Suicidal Patients and Suicide Prevention

Suicide-preventive training has shown to influence attitudes. This study aimed at investigating what impact other factors than knowledge might have on attitudes towards work with suicidal patients and suicide prevention. In 2007, 500 health-care staff working in a psychiatric clinic in Stockholm received a questionnaire with items concerning work with suicidal patients to which 358 (71.6%) responded. A set of attitude items were tested using structural equation modelling (LISREL). Three models were found to be satisfactory valid and reliable: Job clarity, Job confidence and Attitudes towards prevention. These were then used in regression analyses as dependent variables with predictors such as experience of work with suicidal patients, perceived sufficient training,age and gender. Perceived sufficient training was consistently the most important predictor for all three attitude concepts (p < 0.01, β = 0.559 for Job clarity; p < 0.01, β = 0.53 for Job confidence; p < 0.01, β = 0.191 for Attitudes towards prevention). Age was another significant predictor for Job clarity (p < 0.05, β = 0.134), as was experience of patient suicide for Job confidence (p < 0.05, β = 0.137). It is concluded that providing suicide preventive education is likely to improve attitudes towards the prevention of suicide, clarity and confidence regarding their role in the care for suicidal patients. These improvements may contribute to the prevention of suicide in health care settings.

The Use of Simulation to Teach Suicide Risk Assessment to Health Profession Trainees-Rationale, Methodology, and a Proof of Concept Demonstration with a Virtual Patient

OBJECTIVE

There is increasing use of educational technologies in medical and surgical specialties. Described herein is the development and application of an interactive virtual patient (VP) to teach suicide risk assessment to health profession trainees. We studied the effect of the following: (1) an interaction with a bipolar VP who attempts suicide or (2) completion of a video-teaching module on interviewing a bipolar patient, on medical students' proficiency in assessing suicide risk in standardized patients. We hypothesized that students who interact with a bipolar VP will be at least as likely to assess suicide risk, as their peers who completed a video module.

METHODS

In a randomized, controlled study, we compared the frequency with which second-year students at the Medical College of Georgia asked suicide risk and bipolar symptoms questions by VP/video group.

RESULTS

We recruited 67 students. The VP group inquired more frequently than the video group in 4 of 5 suicide risk areas and 11 of 14 other bipolar symptomatology areas. There were minimal to small effect sizes in favor of the VP technology. The students preferred the video over the VP as an educational tool (p = 0.007).

CONCLUSIONS

Our study provides proof of concept that both VP and video module approaches are feasible for teaching students to assess suicide risk, and we present evidence about the role of active learning to improve communication skills. Depending on the learning context, interviewing a VP or observation of a videotaped interview can enhance the students' suicide risk assessment proficiency in an interview with a standardized patient. An interactive VP is a plausible modality to deliver basic concepts of suicide risk assessment to medical students, can facilitate individual preferences by providing easy access and portability, and has potential generalizability to other aspects of psychiatric training.

Medical care expenditure in suicides from non-illness-related causes

OBJECTIVES

Several epidemiological studies on medical care utilization prior to suicide have considered the motivation of suicide, but focused on the influence of physical illnesses. Medical care expenditure in suicide completers with non-illness-related causes has not been investigated.

METHODS

Suicides motivated by non-illness-related factors were identified using the investigator's note from the National Police Agency, which was then linked to the Health Insurance Review and Assessment data. We investigated the medical care expenditures of cases one year prior to committing suicide and conducted a case-control study using conditional logistic regression analysis after adjusting for age, gender, area of residence, and socioeconomic status.

RESULTS

Among the 4515 suicides motivated by non-illness-related causes, medical care expenditures increased in only the last 3 months prior to suicide in the adolescent group. In the younger group, the proportion of total medical expenditure for external injuries was higher than that in the older groups. Conditional logistic regression analysis showed significant associations with being a suicide completer and having a rural residence, low socioeconomic status, and high medical care expenditure. After stratification into the four age groups, a significant positive association with medical care expenditures and being a suicide completer was found in the adolescent and young adult groups, but no significant results were found in the elderly groups for both men and women.

CONCLUSIONS

Younger adults who committed suicide motivated by non-illness-related causes had a higher proportion of external injuries and more medical care expenditures than their controls did. This reinforces the notion that suicide prevention strategies for young people with suicidal risk factors are needed.

National pathways for suicide prevention and health services research

CONTEXT

In 2012, the National Action Alliance for Suicide Prevention's Research Prioritization Task Force (RPTF) released a series of Aspirational Goals (AGs) to decrease suicide deaths and attempts. The RPTF asked experts to summarize what was known about particular AGs and to propose research pathways that would help reach them. This manuscript describes what is known about the benefits of access to health care (AG8) and continuity of care (AG9) for individuals at risk for suicide. Research pathways are proposed to address limitations in current knowledge, particularly in U.S. healthcare-based research.

EVIDENCE ACQUISITION

Using a three-step process, the expert panel reviewed available literature from electronic databases. For two AGs, the experts summarized the current state of knowledge, determined breakthroughs needed to advance the field, and developed a series of research pathways to achieve prevention goals.

EVIDENCE SYNTHESIS

Several components of healthcare provision have been found to be associated with reduced suicide ideation, and in some cases they mitigated suicide deaths. Randomized trials are needed to provide more definitive evidence. Breakthroughs that support more comprehensive patient data collection (e.g., real-time surveillance, death record linkage, and patient registries) would facilitate the steps needed to establish research infrastructure so that various interventions could be tested efficiently within various systems of care. Short-term research should examine strategies within the current healthcare systems, and long-term research should investigate models that redesign the health system to prioritize suicide prevention.

CONCLUSIONS

Evidence exists to support optimism regarding future suicide prevention, but knowledge is limited. Future research is needed on U.S. healthcare services and system enhancements to determine which of these approaches can provide empirical evidence for reducing suicide.

Suicide risk assessment and risk formulation part I: a focus on suicide ideation in assessing suicide risk

The main procedure used by clinicians to determine whether an individual may be at risk of suicidal behaviors is the suicide risk assessment (SRA). The purpose of the SRA is to identify risk and protective factors that then provide the data for the formulation of suicide risk. The suicide risk formulation (SRF) assigns a level of suicide risk that ideally leads to triage and treatment deemed appropriate for that level of risk. Some of the problems with the SRA are explored here, with an emphasis on addressing the over reliance on communicated suicide ideation, and recommendations are made for improvements. Part II of this article (Berman & Silverman, 2013, also appears in this issue of STLB) examines the process of an SRF and, similarly, makes recommendations to improve clinical practice toward the desired end of saving lives.

Health care contacts in the year before suicide death

BACKGROUND

Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples.

OBJECTIVE

To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed.

DESIGN

Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states.

PARTICIPANTS

In all, 5,894 individuals who died by suicide, and were health plan members in the year before death.

MAIN MEASURES

Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site.

KEY RESULTS

Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means.

CONCLUSIONS

This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.

Ethnic variations in suicidal ideation and behaviors: a prominent subtype marked by nonpsychiatric factors among asian americans

OBJECTIVE

Main objectives were to utilize multivariate rather than traditional regression approaches to capture the heterogeneity of subtypes of suicidal ideation and behaviors within ethnic minority groups. Mental illness is associated with suicidal ideation and behaviors in a vast majority of the general population, making psychopathology a common identifier of suicide risk. Yet recent studies suggest a need to better characterize suicidal ideation and behaviors among ethnic minorities and Asian Americans who do not exhibit the most commonly assessed risk factors.

METHOD

The present study examined adults 18 years of age or older from the National Latino and Asian American Study and utilized latent class analysis to classify 191 Asian Americans with a history of serious suicidal ideation or attempts from a community sample into subtypes.

RESULTS

Two main subtypes resulted, including 48% in a "psychiatric" and 52% in a "nonpsychiatric" subtype of suicidal ideation and behaviors. The nonpsychiatric subtype was predominantly characterized by sociocultural factors (discrimination, family conflict, and low acculturation), medical problems, and limited functioning. The nonpsychiatric was less likely than the psychiatric subtype to seek help for mental health but was no different in access to a medical doctor, highlighting possible points of outreach.

CONCLUSIONS

Findings advance the culture and suicide literature by highlighting how current research and practice that characterize suicidal ideation and behaviors as a mental health phenomenon may not comprehensively identify suicidality among an ethnic minority group.

Physicians' characteristics associated with exploring suicide risk among patients with depression: a French panel survey of general practitioners

Background

General practitioners (GPs) have a key role to play in suicide prevention, but the rates at which they question patients with depression about suicidal thoughts and plans are rather low. Little is known about GPs' characteristics associated with such inquiries. Our objectives were to describe GPs' attitudes, perceived barriers, and self-reported practices in this questioning of these patients and to analyze factors associated with these practices.

Methodology

This cross-sectional survey was conducted among participants in a panel of randomly selected French GPs (1249/1431 participated: 87.3%). GPs were interviewed with a standardized questionnaire covering their professional and personal characteristics, attitudes, and practices in exploring the suicide risk of their patients with depression. We built a suicide inquiry score by summing the responses to 5 items and used a multiple linear regression analysis to explore the characteristics associated with this score.

Principal Findings

Most GPs reported inquiring about the presence of suicidal ideation often or very often; less than 30% reported that they frequently explored signs of a specific suicide plan. The mean suicide inquiry score was 12.4 (SD, 2.9; range, 5–20). False ideas, such as thinking that patients who report suicidal ideas do not often commit suicide, were frequent (42.3%). Previous continuing medical education on suicide, participation in a formal mental health network, and patients who committed suicide in the past 5 years were associated with a higher score. Reluctance to question patients about suicide and perception of insufficient skill were associated with a lower score.

Conclusions/Significance

This study showed great variability in French GPs' practices in exploring suicide risk in patients with depression. Interventions aiming at improving GPs' initial training and continuing medical education in suicide and/or depression, and their collaboration with mental health specialists should be developed, and their impacts assessed.

Particular difficulties faced by GPs with young adults who will attempt suicide: a cross-sectional study

Background

Suicide is a major public health problem in young people. General Practitioners (GPs) play a central role in suicide prevention. However data about how physicians deal with suicidal youths are lacking. This study aims to compare young adult suicide attempters (from 18 to 39 years old) with older adults in a primary care setting.

Methods

A cross-sectional study was carried. All suicide attempts (N=270) reported to the French Sentinel surveillance System from 2009 to 2011 were considered. We conducted comparison of data on the last GP’s consultation and GPs’ management in the last three months between young adults and older adults.

Results

In comparison with older adults, young adults consulted their GP less frequently in the month preceding the suicidal attempt (40.9 vs. 64.6%, p=.01). During the last consultation prior to the suicidal attempt, they expressed suicidal ideas less frequently (11.3 vs. 21.9%, p=.03). In the year preceding the suicidal attempt, GPs identified depression significantly less often (42.0 vs. 63.4%, p=.001). In the preceding three months, GPs realized significantly less interventions: less psychological support (37.5 vs. 53.0%, p=.02), prescribed less antidepressants (28.6 vs. 54.8%, p<.0001) or psychotropic drugs (39.1 vs. 52.9%, p=.03) and made fewer attempts to refer to a mental health specialist (33.3 vs. 45.5%, p=.05).

Conclusion

With young adults who subsequently attempt suicide, GPs face particular difficulties compared to older adults, as a significant proportion of young adults were not seen in the previous six months, as GPs identified less depressions in the preceding year and were less active in managing in the preceding three months. Medical training and continuing medical education should include better instruction on challenges relative to addressing suicide risk in this particular population.

Comorbidity-independent risk for suicidality increases with bulimia nervosa but not with anorexia nervosa

BACKGROUND

Eating disorders are serious psychiatric illnesses with high levels of suicidality and high comorbidity. However, no study has established the extent to which suicidality is uniquely associated with eating disorders rather than attributable to comorbid mood, anxiety, or substance use disorders. The current study examined whether unique associations between eating disorders and suicidality exist and whether potential associations differ by eating disorder diagnosis.

METHODS

Participants were women (n = 364) from the second stage of a large epidemiological study examining eating and health related attitudes and behaviors. The Structured Clinical Interview for Axis I diagnoses (SCID-I) was used to determine lifetime psychiatric diagnoses and lifetime suicidality.

RESULTS

A multiple regression model including eating and comorbid disorders indicated that bulimia nervosa (BN) was significantly associated with suicidality above and beyond risk predicted by comorbid disorders. No unique association was found for anorexia nervosa (AN) or eating disorder not otherwise specified while controlling for comorbidity.

CONCLUSIONS

BN is independently associated with suicidality, and findings emphasize the need to incorporate suicide risk assessment in standardized assessments of eating disorders.

Addressing suicidality in primary care settings

By design or by default, primary care providers (PCPs)are frequently the vanguard in the fight against suicide. Recent studies have highlighted programs to improve screening and prevention of suicidality in the medical home, particularly among high-risk patients, such as adolescents, the elderly, and veterans. Increasing efforts are also being paid to improving the PCP's skill in assessing for suicidality. However, it is becoming increasingly apparent that screening alone will not significantly lower suicide rates until it occurs within a well-integrated system that facilitates timely referral to more intensive mental health services for those patients who need them. Unfortunately, such systems are sorely lacking in many, if not most, areas of the USA.