Some three-fourths of individuals who kill themselves have seen a primary
care doctor during the previous month, research has shown. Thus primary care
physicians appear to be strategically situated to prevent a number of these
Yet primary care doctors inquire about gravely depressed patients' suicidal
thoughts or intent less than half the time, a new study has found.
The study was headed by Peter Franks, M.D., a professor of family and
community medicine at the University of California-Davis. Results appeared in
the September/October 2007 Annals of Family Medicine.
The study included 152 primary care physicians from four sites in either
northern California or Rochester, N.Y. The physicians were told the general
purpose of the study—that it had to do with learning more about
doctor-patient communication in primary care—but not the specific
purpose—that it concerned learning more about primary care doctors'
inquiries into depressed patients' suicidal thinking or intent. The physicians
were also told that, as a part of the study, several actors masking as
patients would visit their practices in the forthcoming months and
surreptitiously audiotape the sessions.
Thus, an actress portraying a middle-aged patient with major depression and
an actress portraying a middle-aged patient with adjustment disorder with
depressed mood visited each of the doctors sometime between May 2003 and May
2004. In addition to audiotaping their physician encounters, the pseudo
patients also filled out report forms about the encounters right after they
occurred. The report forms contained questions about the physicians'
depression-history taking, especially whether they had inquired about suicidal
thoughts or intent. Franks and his group then used the audiotapes and
report-form results to see how often physicians broached the subject of
suicide with the pseudo patients and which factors influenced their
willingness to do so.
The physicians raised the subject of suicide with major-depression pseudo
patients significantly more often than they did with adjustment-disorder
pseudo patients. And that's good, Franks and his group wrote, "because
patients with more depressive symptoms are more likely to attempt and complete
suicide." Even so, the physicians inquired about suicidal thoughts and
intent in less than half of their encounters with the major-depression pseudo
Two factors seemed to encourage primary care doctors to broach the subject
of suicide with acutely depressed patients. One was when depressed pseudo
patients asked for an antidepressant (sometimes they did, and sometimes they
didn't, according to study design). Another was when the doctor or the
doctor's family had experienced depression. However, other factors did not
seem to play a role in doctors' willingness to talk about suicide. They were
gender, communication style, specialty (family medicine or internal medicine),
and their confidence in their ability to treat depression.
Nonetheless, other factors were probably involved as well, study analysis
indicated, and Franks has a hunch what several might be. "I think the
main barrier is that docs think that exploring depression and suicidality will
antagonize the patient—that is, they either buy into societal prejudices
or worry that the patient does." Franks also suspects that some
physicians are reluctant to bring up the subject of suicide with acutely
depressed patients because it might actually encourage the patients to take
action—"a kind of magical thinking." Still others, he
conjectured, are afraid of bringing up the topic because they don't have the
time or resources to deal with a suicidal patient.
Some primary care doctors have responded positively to the study report."
They think it's great that we are drawing attention to the
problem," said Franks. Professional organizations might also be able to
reduce the number of suicides that occur in the wake of primary care visits,
Franks believes. For example, he proposed, APA might issue public-service
announcements encouraging depressed individuals to discuss any suicidal ideas
they have with their primary care doctors. APA, he suggested, might also
provide primary care doctors with guidelines on what to do if depressed
patients admit to having suicidal ideas.
The study was funded by the National Institute of Mental Health.
"Let's Not Talk About It: Suicide Inquiry in Primary
Care" is posted at<www.annfammed.org>
under the September/October issue. ▪