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Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care

¹ Center for Research Strategies, Denver, Colo
² Department of Family Medicine, University of Colorado Health Sciences Center, Denver, Colo
³ VA Greater Los Angeles Healthcare System and University of California, Los Angeles, Calif, and RAND Health Program, Santa Monica, Calif
⁴ Mental Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, Ark
⁵ Colorado Foundation for Medical Care, Englewood, Colo

CORRESPONDING AUTHOR: Paul A. Nutting, MD, MSPH, Center for Research Strategies, 225 E 6th Ave, Suite 1150, Denver, CO 80203, Paul.Nutting{at}CRSLLC.org

PURPOSE Primary care clinicians have difficulty detecting suicidal patients. This report evaluates the effect of 2 primary care interventions on the detection and subsequent referral or treatment of patients with depression and recent suicidal ideation.

METHODS Adult patients in 12 mixed-payer primary care practices and 9 not-for-profit staff model health maintenance organization (HMO) practices were screened for depression. Matched practices were randomized within plan type to intervention or usual care. The intervention for mixed-payer practices entailed brief training of physicians and office nurses to provide care management. The intervention for HMO practices consisted of guided development of quality improvement teams for depression care. A total of 880 enrolled patients met study criteria for depression, 232 of whom met criteria for recent suicidal ideation. Intervention effects on suicide detection and referral to mental health specialty care were evaluated with mixed-effects multilevel models in intent-to-treat analyses.

RESULTS Depressed patients with recent suicidal ideation were detected on 40.7% of index visits in intervention practices, compared with 20.5% in usual care practices (odds ratio = 2.64, 95% confidence interval, 1.45–5.07), with HMO plan type and male sex associated with detection. The interventions had no effect on referral of patients, starting an antidepressant, or suicidal ideation reported at a 6-month follow-up, although power was limited for all 3 analyses.

CONCLUSIONS Primary care interventions to improve depression care can improve detection of recent suicidal ideation. Further work is needed to improve physician response to detection, including referral to specialty care and more aggressive treatment, and to observe the effect on outcomes.

Key Words: Suicide • depression • primary care physicians • quality improvement

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