Suicide Inquiry in Primary Care: Creating Context, Inquiring, and Following Up

This original and innovative study by Vannoy et al. of verbal communication sought to observe and dissect the conversation between patient and physician, rarely included in the study of medical practices. This approach made it possible to identify the elements of the physician's discourse that may encourage or discourage patients' expression of suicidality (ideation or intention to act). These results may be extremely useful for training physicians to learn how to look for suicidality.

We note the relatively high participation rate by physicians (53- 61%), although the survey method used here (standardized patient, unannounced visit, recordings of the visit) might well have engendered reluctance on their part. In a French study (Verger et al. 2004) that asked physicians to complete a brief questionnaire each time they prescribed antidepressants treatment for the first time, the response rate was lower (26%). As the authors point out, it is possible that the participants in this study differ from nonparticipants.

The authors' discussion of the limitations of their survey method is very complete. We note three in particular. First, the method did not allow them to study appointments with regular patients, although long acquaintance with the patient may affect the content of the conversation. Second, how patients perceive the physician's verbal communication (especially according to their own characteristics) could not be studied, nor could its influence on the verbalization of suicidal ideation be examined. Finally, of course, this method cannot grasp the even more rarely studied nonverbal communication although it is undoubtedly important especially for creating an empathic atmosphere. It would also be interesting to study the extent to which the length of the visit and dynamics of the visit can affect the identification of suicidality. We observed a positive relation between the duration of the visit and the identification of suicidality in France (Verger 2004), but could not determine the direction of the relationship (did the observation of suicidal ideas result in a longer visit?). Other researchers have suggested that patients choose what they will reveal during an appointment in anticipating that physicians have time constraints: this may constitute a major obstacle to the expression of suicidal ideas (Pollock and Grime 2002).

Finally, the authors did not consider here the appointments during which the physician never raised the question of suicidality. The difference in the physicians' modes of communications in these two situations would make a stimulating follow-up.

References:

Verger P, Brabis P-A, Kovess V, Lovell A, Sebbah R, Villani P, Paraponaris A, Rouillon F. Determinants of early identification of suicidal ideation in patients treated with antidepressants or anxiolytics in general practice: a multilevel analysis. Journal of Affective Disorders, 2007;99:253-7.

Pollock K, Grime J. Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study. BMJ, 2002;325:687.

Competing interests:   None declared

Suicide prevention remains a challenge for everyone, including those in primary care. This study finds encouraging results that most of the primary care physicians in this study asked a question about self-harm in the context of psychosocial concerns (79%) and most negative patient responses (no suicidal thoughts) were followed by some statement that would encourage more exploration of this topic (86%) vs shutting it down with an awkward "good, I thought not" (4%). Whether by training or instinct, these physicians responded quite well to surrogate patients presenting with other complaints. With proper cautions about the nature of the surrogate patients' role and the possible selection bias of those physicians willing to participate in this study, I find this very encouraging.

Perhaps the attention on depression screening and diagnosis/treatment over years has improved our care. We now have some evidence for reasonable inquiry about one possible consequence of dispair and depression that can be buried under any presenting complaint. This is progress.

Competing interests:   None declared

This provocative analysis of standardized depressed patients who were asked about suicidal ideation highlights the vital importance of studying patient-physician communication.

I wonder how these qualitative findings might inform additional qualitative and quantitative studies of suicide prevention. More specifically, does high-quality communication help prevent suicide among those with current ideation? Can it head off future episodes? If so, how?

When the standardized patient denied suicidal thoughts in writing (apparently on a screen such as the Patient Health Questionnaire-9), audiotaped reviews demonstrated that the physicians did not necessarily ask about suicidal ideation. How valid and reliable is written denial? How valuable is human inquiry about suicidal ideation, particularly for those at increased risk, regardless of the current screening result?

One can be relatively confident that high quality communication has improved certain outcomes, e.g. treatment adherence, across populations (Zolnierek 2009). Like many clinicians, I believe that good communication is likely to benefit distressed primary care patients. What I don’t know, and what quantitative and ongoing qualitative analyses together might begin to illuminate, is for whom or under what circumstances aspects of communication are or are not beneficial.

Nowhere are the stakes higher than among those at risk for suicide. Given that about 40% or 12,000 of those persons committing suicide last year are reported to have visited a primary care clinic in the months before the event, the answers to questions raised by this study are pertinent.

Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009 Aug;47(8):826-34.

Competing interests:   None declared

Thank you to Vannoy et al. for this important study that furthers the field's understanding of the importance of the physician interview and assessment. In the context of this study with its noted limitations, Vannoy et al. correctly looked at the inquiry itself and the context to show that differences in approach do occur and include confusing or negating types of inquiries. It was reassuring to see that most inquired and sought to confirm their inquiry as direct statements using a word or phrase that connotes fatality to the patient is necessary to ensure the patient senses the physicians understanding of the depth of their pain. Given these were 1st visits, I questioned if the patients completed an intake questionnaire that the physician read prior to the interview? Did their nursing staff inquire about depression or suicide and if so was that noted for the physician prior to the patient interview? What, if any, impact did or would this have had on the physician? Further study of physician’s inquiry of youth would be interesting given that youth tend not to disclose to adults as they do to peers. The methodology, however, used by Vannoy et al. provides a strong basis for this type of study and resulting educational programs.

Physicians have the unique role of saving lives. This is increasingly significant when it comes to assessing and treating those suffering with a mental illness. When a patient presents demonstrating or voicing any mental health thoughts, feelings or behaviors it should be standard practice for all treating professionals, physicians and their nursing staff, to inquire about suicide. One suicide is too many and when nearly 50% or more see their physician within the month of their suicide and over 33,000 suicides (CDC 2006), this study clearly demonstrates the need for mandated physician education and continuing education training on suicide risk assessment and inquiry.

Competing interests:   None declared