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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Is Detecting Suicidal Ideation Good?
A Platform For Progress
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Thomas L. Schwenk, Ann Arbor, USA University of Michigan
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Although Paul Nutting and colleagues acknowledge in their Discussion that "neither detection of suicidal ideation nor specialty referral is associated with improved outcomes", the entire thrust of their paper attempts to support such an association. There is an implication that detection of suicidal ideation should lead to specialty referral, but, fortunately, the study physicians were wiser than that. Suicidal ideation in primary care patients is as transient as depression often is, and it is a reflection of the wisdom of the study physicians that not only do they often use watchful waiting for many patients who are mildly depressed, they do the same with transient suicidal ideation. Despite the oft-quoted statement that patients who successfully suicide have seen their primary care physician within the prior month, they have also seen their physician many times in the past when they did not commit suicide, as did many other patients with similar suicidal ideation who saw the physician in the same time period. The false positive rate of assessment of suicidal ideation at a single point in time is so high as to be clinically unmanageable. I think this issue would be better served by studies that better characterize the psychiatric epidemiology of primary care populations, including the longitudinal fluctuation of suicidal ideation, in more detail, and over time, rather than well-intentioned, but mis-directed, interventions to detect something whose significance is murky at best. Competing interests: None declared |
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Herbert C. Schulberg, Ph.D, White Plains, NY, USA Professor of Psychology in Psychiatry, Weill Medical College of Cornell University, Patrick J. Raue, Ph.D
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Suicide constitutes a critical public health problem and family physicians can potentially play a key role in its resolution. In this vein, Nutting and his colleagues have significantly advanced our knowledge base by investigating the manner wherein primary care physicians identify and manage depressed patients exhibiting suicidal ideations and behaviors. Nevertheless, many questions remain to be studied. Among those stimulated by the Nutting report are the cues used by physicians to trigger the assessment and recognition of suicidality. The present study found one cue to be demographic, i.e.male gender, and the other clinical, i.e.severity of self-harm idation. Surprisingly, depressive severity which is an established suicdlity risk factor was found unrelated to physician recognition of the patient's distress. While physicians accurately identified 41% of the patients who acknowledged suicidal ideation, there clearly is room for improvement. As the authors note, their interventions focused on care management for depression but not specifically on suicide detection. We, therefore, agree with their recommendation regarding the value of incorporating suicide assessment components within existing depression interventions. Further research is similarly indicated with regard to the manner in which primary care physicians formulate a treatment plan for suicidal patients. What clinical and other factors induced physicians in the Nutting study to refer but 40% of their potentially suicidal patients to mental health specialists and to retain the majority in their own practices? Does this referral pattern betray the primary care physician's lack of confidence in the mental health specialty system, an appreciation that many medical patients resist a referral to mental health specialists, etc., or does the obtained referral pattern reflect the primary care physician's growing confidence in a personal ability to manage ever more complex psychiatric illnesses? In either case, enhanced depression and suicidal interventions are required given that those utilized in the study practices produced outcomes little better than usual care. We also would suggest that the six-month 40% rate of suicidal ideation among patients whose thoughts of self-harm had been recognized at baseline warrants further analysis. How were these patients treated duting the six-month study period and how did their baseline clinical characteristics compare with those of patients whose suicidal idation had remitted? In summary, Nutting and his colleagues have provided a meaningful platform upon which to pursue further research regarding the detection and managment of suicidality in primary care practice. They are to be thanked for it. Competing interests: None declared |
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