Helping depressed patients past a crisis

Most suicidal persons give their primary-care provider an opportunity to intervene, but clinicians often let it slip by. Here’s what you should be alert for.

As many as three out of four people who commit suicide have seen a primary-care provider within 30 days, statistics show. Yet, in a new study in which actresses portrayed depressed patients, clinicians screened for suicidality at a rate of only 36% (Ann Fam Med. 2007;5:412-418).

The co-author of that study, Mitchell D. Feldman, MD, MPhil, discussed the findings with Clinical Advisor senior editor Myra Dembrow. The study was conducted with physicians, but it could just as easily apply to any group of primary-care providers. Dr. Feldman is an internist and professor of medicine at the University of California, San Francisco School of Medicine. He is also co-editor of Behavioral Medicine: A Guide for Clinical Practice (New York, N.Y.: McGraw-Hill; 2007), now in its third edition.

Q: Why is this study important?
A: We trained actresses to play the role of either a depressed patient or one with an adjustment disorder, someone with depressed mood without quite meeting the full criteria for major depression. This methodology allowed us to make some findings that could only be implied before. In the past, we might ask clinicians how they assess patients with depression or do they screen for suicidality, but rarely could we observe what truly happens in the real world. This study provided a peek behind the curtain, so to speak, as to what’s really happening in the office when clinicians are assessing patients with depression.

Q: Did these patients come in specifically with a complaint of depression? Or were they coming in for some other ailment?
A: No, their chief complaint was related to depression, but they weren’t coming in saying they were depressed. They portrayed how depressed patients usually present in primary care —with complaints of insomnia or stress. Then it was, “By the way, my wrists hurt,” or “My back hurts.”

But the primary complaint was related more to a kind of psychosocial symptom. Rarely do patients come in and say, “I’m feeling depressed,” although when pushed, they might admit to it.

Q: So that was like real life.
A: Yes. The clinicians in this study knew they were going to be visited at some point, but they did not know when and they did not know what the presenting complaint was going to be. We found that most of the time, these patients went undetected. The clinicians were not aware that the patient they were treating was not a real patient, so we think our findings are fairly reflective of the real world.

Q: Did the clinicians perceive the depression?
A: Frequently they did. In fact, they often treated it reasonably by prescribing antidepressant medication or by referring the patient to a mental-health specialist. But even in that context, they were not screening for suicide. And that is very important.

We also trained these patients to ask specifically for a brand-name antidepressant, to ask generically for treatment, or to make no request. We found that patients who made a request were more likely to be screened for suicidality than those who made no request.

Q: We know that frequently, people who commit suicide have seen a primary-care provider within the past 30 days. Did these patients come in saying, “I have insomnia,” or “My mood is low?” Or did they come in with totally unrelated conditions like carpal tunnel syndrome?
A: I can’t answer that based on our study. But based on the literature on depression in patients in primary-care settings, I would say that, overwhelmingly, patients are presenting with physical or somatic complaints. They’re not complaining about depression—or certainly not voluntarily telling their clinicians that they’re feeling suicidal.

Q: So how reasonable is it to expect a primary-care clinician to pick up on it?
A: That is a good question. This is part of being a competent primary-care provider. Patients with psychosocial problems usually don’t present with psychosocial chief complaints.

Kurt Kroenke, MD, another general internist, has done considerable research on symptoms in primary care. Patients don’t present with complaints directly referable to specific diseases or problems. They present with symptoms, and part of the skill set of a good primary-care provider is to be able to go from the presentation of symptoms to a more explicit evaluation or differential diagnosis of what kinds of ailments may lie behind those symptoms. Frequently, depression is at least part of the picture there.

So, to answer your question, it’s very reasonable to expect primary-care providers to assess for depression and, if depression is present, to push further and assess for suicidality.

Q: Do clinicians actively avoid discussing suicide or does it just not occur to them?
A: Suicidality is one of a variety of issues that they may consciously or unconsciously avoid for a variety of reasons.

Primary-care providers are often rushed, and on the most pragmatic level, they may worry that bringing up suicide is going to lead to a long and detailed discussion that’s going to throw them off their schedule. But that’s only a small part of the answer.

A bigger part is that it’s difficult. It can be uncomfortable to ask patients about issues that feel very personal and that may engender emotions both on the patient’s part, and potentially, on the provider’s part. We avoid these issues because they’re uncomfortable. As we mention in the paper, some clinicians may avoid the topic in the mistaken belief that asking about suicide somehow may give the patient an idea that wasn’t in his or her mind before. There is absolutely no evidence for that. Or they may feel that if the patient is not thinking about suicide they’ll somehow offend the patient if they ask about it.

They don’t want to disrupt the relationship. And finally, providers mistakenly may feel that they will be able to figure it out without having to ask—that by looking at the patient and making certain assumptions, they would know that suicide or suicidal thoughts couldn’t possibly be on this patient’s mind.

I can tell you that I have overlooked suicidality by making those assumptions. And I have been surprised as I go through my routine algorithm—including screening for suicide in patients with depression—when patients have actually said, “Yes” when asked if they ever have suicidal thoughts. We make assumptions based on our prior knowledge of the patient or on superficial characteristics at our own peril.

Q: Are there triggers that a clinician should look for that might indicate suicidality?
A: Yes. One is the presence of psychosis. The more severe the depression and the more severe the mental illness, the higher the risk. And prior attempts, of course. There are also some classic demographic and risk factors described in the literature. Older Caucasian men, for example, are at the highest risk of completed suicide because they tend to use guns.

These are patients who need to be interviewed even more carefully. Ask very specifically about access to the means and the lethality of the means. Ask whether there is a loaded gun at home. These people are at much higher risk than patients who are vague about the means or their access to the means. That needs to be part of the conversation.

Q: Why did you use only female patients in the study, then?
A: Depression is much more prevalent in women. And women are going to have a higher rate of suicide attempts. It’s just that older white men will have more completed suicides.

Q: If a patient acknowledges suicidal thoughts, what should the clinician do?
A: First of all, thank the patient for sharing those thoughts and acknowledge that it was a hard thing to do. The next step is to ask more questions, specifically about his intent. Many patients may have vague thoughts about wanting to end it all, or “I don’t think life is worth living.” Frequently, it doesn’t go beyond that, and simply allowing the patient to express those thoughts and to acknowledge them is all they’re going to need during that visit. But obviously, you need to go beyond that. You need to screen for the risk factors that make suicide more likely or suggest that your patient is at higher risk of actually attempting and completing suicide.

One additional component that some experts recommend is a “no-harm contract.” This contract stipulates that should the patient’s thoughts escalate from vague contemplation of suicide to more specific plans, he or she will call you or a suicide hotline.

There has been no clear research that supports whether contracting with patients actually prevents suicide, and obviously a randomized clinical trial can’t be designed to test that. But it’s something that many clinicians integrate into practice and think is helpful.

Ms. Dembrow is a senior editor with The Clinical Advisor.

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