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Research Article
Suicidal Behavior and Difficulty of Patients, as Perceived
by Community Mental Health Nurses
Background: Mental health professionals who
work in community mental health services
play an important role in treating patients
after attempted suicide or deliberate self-
injury. When such behaviors are interpreted
negatively, patients may be seen as difficult,
which may lead to ineffective treatment and
mutual misunderstanding.
Objective: The goal of this study was to assess
the association between the grading of suici-
dality and perceived difficulty. We hypothe-
sized that a higher grading of suicidality is
associated with increased perceived difficulty.
Methods: We analyzed cross-sectional data
from 176 patients who participated in 2 cohort
studies: 92 patients in the MATCH-cohort study
and 84 patients in the Interpersonal Commun-
ity Psychiatric Treatment (ICPT) study. The
dependent variable was perceived difficulty, as
measured by the Difficult Doctor-Patient
Relationship Questionnaire (DDPRQ) and the
Difficulty Single-item (DSI), a single item
measuring the difficulty of the patient as
perceived by the professional. Grading of sui-
cidality was considered as the independent
variable. Multiple linear and logistic regres-
sion was performed.
Results: We found a significant association
between perceived difficulty (DDPRQ) and high
gradings of suicidality (B: 3.96; SE: 1.44; β: 0.21;
P=0.006), increasing age (B: 0.09; SE: 0.03; β: 0.22;
P<0.003), sex (female) (B: 2.33; SE: 0.83; β: 0.20;
P=0.006), and marital status (being unmarried)
(B: 1.92; SE: 0.85; β: 0.17; P=0.025). A significant
association was also found between the DSI and
moderate (odds ratio: 3.04; 95% CI: 1.355-6.854;
P=0.007) and high (odds ratio: 7.11; 95% CI:
1.8.43-24.435; P=0.005) gradings of suicidality.
Conclusion: In this study, we found that per-
ceived difficulty was significantly associated
with moderate and high gradings of suici-
dality, increasing age, female sex, and being
unmarried.
(Journal of Psychiatric Practice 2023;29;113–
121)
KEY WORDS: suicidality, suicide risk, suicidal
behavior, self-injury, mental health professional,
perceived difficulty
Suicide is a major public health issue worldwide,
with ∼800,000 people dying by suicide every year,
accounting for 1.5% of all deaths.1For each death
from suicide, there are 20 suicide attempts (the
intention to die by self-injurious behavior), for a
total of ∼16 million attempts. Furthermore, it is
estimated that 160 million persons have suicidal
thoughts annually worldwide.2Mental health pro-
fessionals working in community mental health
MARK VAN VEEN, MSc
BAUKE KOEKKOEK, PhD
MARGOT KLOOS, MSc
ARJAN W. BRAAM, MD, PhD
VAN VEEN: Institute for Nursing Studies, University of
Applied Sciences, Utrecht, The Netherlands; KOEKKOEK:
Research Group for Social Psychiatry and Mental Health
Nursing, University of Applied Science, Nijmegen, The
Netherlands; and Pro Persona Mental Health Services,
Wolfheze, The Netherlands; KLOOS: deceased; at the time
the article was written Pro Persona Research, Wolfheze, The
Netherlands; BRAAM: Department of Humanist Chaplaincy
Studies for a Plural Society, University of Humanistic
Studies, Utrecht, The Netherlands; and Department of
Emergency Psychiatry and Department of Residency Train-
ing, Altrecht Mental Health Care, Utrecht, The Netherlands
Copyright © 2023 Wolters Kluwer Health, Inc. All rights
reserved.
The MATCH study was funded by a SIA RAAK PRO-grant
(number PRO-3-05) and additional funding was received from
the University of Applied Sciences, Nijmegen. The ICPT
study was funded by Stichting tot steun VCVGZ. The funding
bodies played no role in the design of the study, in the
collection, analysis, and interpretation of data, and in writing
the manuscript.
The authors declare no conflicts of interest.
Please send correspondence to: Mark van Veen, MSc,
University of Applied Sciences, Institute for Nursing Studies,
Heidelberglaan 7, Utrecht 3584 CS, The Netherlands (e-mail:
markvanveen1973@gmail.com).
DOI: 10.1097/PRA.0000000000000697
Journal of Psychiatric Practice Vol. 29, No. 2 March 2023 113
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services frequently deal with patients who have just
attempted suicide, show nonsuicidal self-injury, or
have suicidal thoughts,3and they play an important
role in treating these patients.4,5 Although treating
these patients is part of their daily work, mental
health professionals often find them challenging to
manage and a source of distress.3,6 Several factors,
such as cultural, religious, and professional back-
ground and knowledge of and experience dealing
with suicidality, influence the behaviors of these
professionals,7who may feel incompetent and avoid
direct communication with suicidal patients.8
Furthermore, an eventual suicide of a patient may
evoke feelings of guilt, sadness, and incompetence that
are sometimes difficult to handle.7This is more likely to
occur when the patient is younger, or the professional
has just started working, is still in training, has never
experienced a suicide before, or has little support from
colleagues.7,9 A lack of knowledge and understanding of
why people show suicidal or self-injurious behavior may
contribute to professionals possibly developing the belief
that patients are attention-seeking and manipulative.10
Such a belief could lead to a negative attitude and neg-
ative prejudices toward these patients.11 Thus, patients
maycometobeseenbymentalhealthprofessionalsas
“difficult,”a term referring to patients with severe
mental illnesses and challenging and ambivalent
behaviors who have received insufficient adequate
treatment.12 This perceived “difficulty”can result in
mutual misunderstanding and ineffective treatment,
when treatment lacks an empirical and theoretical base
and clear treatment goals are absent.13 As a result the
quality of care often becomes low, resulting in more
symptoms and long-term and intensive care use and
dependency.12 To our knowledge, the direct association
between perceived difficulty and suicidality has not
received clear attention in the literature to date.
Therefore, the goal of this study was to assess the
association between the grading of suicidality and per-
ceived difficulty. We hypothesized that a higher grading
of suicidality is associated with increased perceived
difficulty.
METHODS
Setting and Sample
To test our hypothesis, we combined data from 2
existing samples of patients who had participated in
studies in secondary mental health services
(specialist treatment and support provided by vari-
ous health professionals for patients who were
referred to them for specific expert care), in which
identical instruments and questionnaires were used.
Sample 1: MATCH-cohort Study
The first sample was drawn from the MATCH-
cohort study, a longitudinal study designed to
examine the determinants and consequences of
long-term use of health services and complex care
situations in people with common mental disorders,
described in more detail elsewhere.14 The original
study enrolled 283 patients and their professionals
from 3 large Dutch mental health services at base-
line. The patients were between 18 and 65 years of
age with a common mental disorder (eg, depression
or anxiety disorder) and/or a personality disorder
according to DSM-IV criteria [the Dutch version of
DSM-5 was not available at the time the assess-
ments were done in this study (2012-2016) and in
the study described below (2014-2016)]. Patients
with psychotic, bipolar I, or cognitive disorders as a
primary diagnosis and patients who were unable to
read and understand Dutch were excluded. Because
the patients in the second sample (see below)
received secondary mental health care, we only
used data from the 92 MATCH patients who also
received secondary mental health care at baseline
for the present analysis. The other patients in the
MATCH sample received other forms of mental
health care and were therefore excluded from our
analysis.
Sample 2: Interpersonal Community Psychi-
atric Treatment (ICPT) Cluster Randomized
Trial
The second sample came from a multicenter, clus-
ter, randomized controlled trial15 that studied the
effects of ICPT versus care as usual. The inclusion
criteria for patients in the ICPT study were iden-
tical to those in the MATCH-cohort study (18 to 65 y
of age, common mental disorder, and/or a person-
ality disorder). As in the MATCH-cohort study,
patients with psychotic, bipolar I, or cognitive dis-
orders as a primary diagnosis and patients who
were unable to read and understand Dutch were
excluded. The ICPT study included 93 patients, 84
of whom had completed the assessment of the out-
come variable at baseline that was needed for
our study.
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SUICIDAL BEHAVIOR AND PERCEPTION OF PATIENT DIFFICULTY
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Measures
All instruments and their psychometric properties
used in this study were described in the 2015 pub-
lication describing the ICPT study protocol.16 These
were the Mini Neuropsychiatric Interview (MINI
Plus), the Difficult Doctor-Patient Relationship
Questionnaire (DDPRQ), and a single item meas-
uring the difficulty of the patient as perceived by
the professional.
Sociodemographic Variables (Assessed by
Researcher)
At baseline, questions concerning age, sex, marital
status, ethnicity, working situation, education, and
income were assessed.
Diagnoses and Grading of Suicidality (Assessed
by Researcher)
DSM-IV Axis I disorders were assessed, with the
Dutch Mini Neuropsychiatric Interview (MINI
Plus), a structured diagnostic interview, adminis-
tered at baseline. The MINI Plus is the briefest full
psychiatric interview available and, depending on
the number of disorders, takes between 15 and
45 minutes to administer.17 Overall, the validity
and reliability of the MINI Plus are considered
good.18
Included in the MINI Plus are 6 questions about
suicidality, including: Q1 “Think that you would be
better off dead or wish you were dead?”(1 point), Q2
“Want to harm yourself or to hurt or to injure
yourself?”(2 points), Q3 “Think about suicide?”(3
points), Q4 “Plan or intend to hurt yourself, either
passively or actively?”(4 points), Q5 “Take any
active steps to prepare to injure yourself or to pre-
pare for a suicide attempt in which you expected or
intended to die?”(5 points), Q6 “Make a suicide
attempt?”(6 points). The grading of the suicidality
ranges from low (1 to 5 points in total), to moderate
(6 to 9 points in total), to high ( >9 points in total).
DSM-IV Axis II disorders were assessed with the
Structured Interview for DSM-IV Personality
(SIDP-IV), a structured clinical interview,19 if the
patient screened positive on the 10-item Standard-
ized Assessment of Personality—Abbreviated Scale-
Self Report (SAPAS-SR).20 The SIDP-IV is a widely
used semistructured interview with good psycho-
metric properties.21 The SAPAS-SR has been found
to be one of the briefest, most sensitive, and specific
screening instruments for personality disorders and
is very useful in clinical populations.22
Perceived Difficulty Outcome Variable (Assessed
by Community Mental Health Nurse)
The dependent variable was measured using the
DDPRQ, a 10-item instrument that assesses
problems in the relationship between patient and
professional and perceived difficulty (eg, “How
‘frustrating’do you find this patient?”or “How at
ease did you feel when you were with this patient
today?”). The DDPRQ consists of a 6-point Likert
response scale from “not at all”to “a great deal.”
The sum score is based on 10 items, with a score of
30 or above a cutoff for a patient who is considered
difficult and a possible total score of 60 points.23
Overall, the DDPRQ has good to very good psycho-
metric properties, with Cronbach αof 0.88.24
The dependent variable was also measured using
a“Difficulty Single-item”(DSI) question measuring
the difficulty of the patient as perceived by the
professional. This question was “To what extent do
you rate this patient as difficult?”scored on a 7-
point Likert scale ranging from “not at all difficult”
to “very difficult,”with 7 the highest possible
score.25 This single question has not yet been
validated.
Statistical Analysis
The sociodemographic variables working status and
source of income were dichotomized before further
analysis. On preliminary inspection, the outcomes
of the DSI proved to be bimodally distributed.
Therefore, for further analysis in logistic regression,
we used a dichotomized variable with 2 values (“no
perceived difficulty”for scores of 1 to 3 and “per-
ceived difficulty”for scores of 4 to 7). Scores on the
DDPRQ had a normal distribution and could be
analyzed with linear regression.
Univariate linear regression analysis was per-
formed to determine predictors of perceived
difficulty based on the DDPRQ sum score and uni-
variate logistic regression was used for the dicho-
tomized single-item DSI score. A significant value of
P≤0.20 was used to select variables (demographic
and clinical variables and level of suicide risk) to be
included in further analysis. Then, multivariate
linear regression for the DDPRQ sum score and
Journal of Psychiatric Practice Vol. 29, No. 2 March 2023 115
SUICIDAL BEHAVIOR AND PERCEPTION OF PATIENT DIFFICULTY
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multivariate logistic regression for the DSI outcome
variable were used to identify demographic and
clinical variables (diagnoses and grading of suici-
dality) that were independently related to perceived
difficulty as assessed by the DDPRQ and the DSI.
All variables were entered in a backward stepwise
manner, only retaining the variables that were
statistically significant in the model. Significance
was set at Pvalue ≤0.05. All statistical analyses
were performed using SPSS, version 26.
Ethical Approval
All procedures complied with the ethical standards
of the relevant national and institutional commit-
tees on human experimentation and with the Hel-
sinki Declaration of 1975, as revised in 2008. The
MATCH study was approved by a certified Medical
Ethics Review Committee, The Clinical Research
Centre Nijmegen (CRCN), in The Netherlands
(Ref: NL41139.091.12), as was the ICPT study
(Ref: NL44744.091.13 with NTR: 3988).
RESULTS
We analyzed cross-sectional data from 176 patients
who participated in the 2 cohort studies: 92 patients
from the MATCH-cohort study and 84 patients from
the ICPT study. Perceived difficulty was measured by
the DDPRQ and the DSI. The sociodemographic and
clinical variables of the patients are shown in Table 1.
The sociodemographic and clinical variables were
screened for their association with the outcome
variable, as shown in Table 2 (DDPRQ sum score,
univariate linear regression, and DSI, univariate
logistic regression). The variables with a Pvalue
≤0.20 for their association with the dependent
variables were included in the multivariate analy-
ses for DDPRQ sum score and DSI (Table 3). We
found a significant association between perceived
difficulty (DDPRQ) and high gradings of suicidality
(B: 3.96; SE: 1.44; β: 0.21; P=0.006), increasing age
(B: 0.09; SE: 0.03; β:0.22; P<0.003), sex (female) (B:
2.33; SE: 0.83; β: 0.20; P=0.006), and marital sta-
tus (being unmarried) (B: 1.92; SE: 0.85; β: 0.17;
P=0.025). We also found a significant association
between the DSI and moderate (odds ratio: 3.04;
95% CI: 1.355-6.854; P=0.007) and high (odds
ratio: 7.11; 95% CI: 1.843-27.435; P=0.005) grad-
ings of suicidality.
DISCUSSION
In this study, we assessed the association between
perceived difficulty of patients by mental health
professionals and the grading of suicidality. We
hypothesized that a higher grading of suicidality
would be associated with more perceived difficulty.
Perceived difficulty indeed was significantly asso-
ciated with moderate and higher grades of suici-
dality, meaning that perceived difficulty increased
with increased grading of suicidality.
Not much empirical research has been done on
perceived difficulty, but the existing literature
reports that contributing factors involve a combi-
nation of professional factors (eg, poor communica-
tion skills, stress management), patient factors (eg,
a personality disorder, self-destructive behavior),
and organizational factors (eg, conflicts within a
team).9,26 A cross-sectional survey found that per-
ceived difficulty cannot be explained by individual
patient characteristics but rather by treatment
characteristics perceived by the mental health pro-
fessional, such as ‘’feeling powerless.”27 Our find-
ings are in part consistent with these conclusions.
However, we did find some patient characteristics
that appeared to contribute to perceived difficulty.
As far as we know, no other research has suggested
or found that marital status, age, and sex contribute
to perceived difficulty.
Previous studies have stressed the complexity of
working with suicidal patients.28–30 More than half of
the patients in our sample had some degree
of suicidality (57.4%). A diligent clinical assessment of
suicide risk by mental health professionals is impor-
tant when a patient has suicidal thoughts or plans.31 In
addition to assessment, decisions also need to be made
about necessary care, with potentially important con-
sequences for the patient.32 The results of our study
showed that patients with a moderate or high level of
suicideriskwerelikelytobeperceivedasdifficult in
the interpersonal relationship by their mental health
professional. Several other studies have found similar
results,28,30,33 but they did not differentiate among
levels of suicidality. Difficulties in clinical work with
suicidal patients may occur duetoalackofknowledge
about suicidality or the use of ineffective interventions
(eg, nonsuicide contracts),34 but they may also result
116 March 2023 Journal of Psychiatric Practice Vol. 29, No. 2
SUICIDAL BEHAVIOR AND PERCEPTION OF PATIENT DIFFICULTY
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from negative prejudices and attitudes toward suicidal
patients.11 The feeling of not being taken seriously by
their mental health professional is harming to patients’
feelings and may strengthen their feelings of incom-
petence or hopelessness. Systematic research has
shown an association between a strong therapeutic
alliance and fewer suicidal thoughts; this finding was
reported in longitudinal studies in which the alliance
with a mental health professional was evaluated.35 The
therapeutic alliance, therefore, requires special atten-
tion when treating patients with some level of
suicidality.36
Strengths and Limitations
To our knowledge, this study is the firstattemptto
describe the direct association between perceived diffi-
culty and suicidality. Our analysis has a few limitations.
First, the cross-sectional nature of our data precludes
predictive,causalconclusions.Futureresearchcould
further clarify the relationships among perceived diffi-
culty and level of suicide risk by, for example, utilizing
longitudinal and experimental methodologies.
Second, we realize that the suicide grading
measure used in the current study was relatively
limited in scope. The items used in this research
were taken from the MINI Plus,17 as part of the
assessment of Axis I diagnoses, which is not a
structured assessment of suicide risk. Future
research should carefully examine the replicability
of the current results using more sophisticated
suicide risk measures.37
Relevance for Clinical Practice
In this study, moderate and high gradings of suici-
dality were significantly associated with perceived
difficulty by community mental health nurses.
Training to improve practices in dealing with suicidal
patients is recommended; however, resources for such
training are scarce. In The Netherlands, the Dutch
Multidisciplinary Guideline for the Assessment and
Treatment of Suicidal Behavior38 recommends the
use of the Chronological Assessment of Suicide Events
(CASE) approach. This approach, which was origi-
nally developed by Shea,39 includes (1) gathering
information related to risk factors, protective factors,
and warning signs of suicide; (2) collecting informa-
tion related to the patient’s suicidal ideation,
TABLE 1. Sociodemographic Variables,
Clinical Variables, and Perceived Difficulty
ICPT and MATCH
(N =176) [n (%)]
Sociodemographic variables
Age (mean ±SD) (y) 38.7 ±12.6
Sex
Female 117 (66.5)
Male 59 (33.5)
Ethnicity
Dutch 164 (93.2)
Other 12 (6.8)
Marital status
Married 50 (28.4)
Unmarried 126 (71.6)
Working status
Employed 39 (22.2)
Incapacitated 70 (39.8)
Volunteer 28 (15.9)
Looking for job 8 (4.6)
Other 31 (17.6)
Education
Primary education 8 (4.6)
Secondary education 52 (29.6)
Tertiary education 116 (65.9)
Source of income
Salary 37 (21.0)
Social benefit 114 (64.8)
Student grant 8 (4.6)
Other 17 (9.7)
Clinical variables on the basis of the MINI Plus
Axis I disorders
Depressive disorder 51 (29.0)
Anxiety disorder 33 (18.8)
Alcohol abuse 16 (9.1)
Substance abuse 12 (6.8)
Axis II disorders
Paranoid PD 7 (4)
Schizoid PD 3 (1.7)
Schizotypal PD 3 (1.7)
Antisocial PD 2 (1.1)
Borderline PD 26 (14.8)
Histrionic PD 1 (0.6)
Narcissistic PD 1 (0.6)
Avoidant PD 28 (15.9)
Dependent PD 12 (6.8)
Obsessive-compulsive PD 20 (11.4)
Grading of suicidality
No suicidality 75 (42.6)
Low 48 (27.3)
Moderate 38 (21.6)
High 15 (8.5)
Perceived difficulty
DDPRQ (mean ±SD) 27.3 ±5.1
DSI (mean ±SD) 3.4 ±1.4
DDPRQ indicates Difficult Doctor-Patient Relationship
Questionnaire23,24;DSI,Difficulty Single-item, a single
item measuring the difficulty of the patient as perceived by the
professional; ICPT, Interpersonal Community Psychiatric
Treatment Study15,16; MATCH, MATCH-cohort study14;
MINI, Mini Neuropsychiatric Interview; PD, personality
disorder.
Journal of Psychiatric Practice Vol. 29, No. 2 March 2023 117
SUICIDAL BEHAVIOR AND PERCEPTION OF PATIENT DIFFICULTY
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TABLE 2. Univariate Associations Between Sociodemographic and Clinical Variables and Grading of Suicidality and
Perceived Difficulty (DDPRQ and DSI)
Perceived difficulty (DDPRQ)
ICPT and MATCH (N =176)
Perceived difficulty (DSI)
ICPT and MATCH (N =176)
Variables B βSE P B Wald 95% CI P
Sociodemographic variables
Age <0.01 0.13 <0.01 0.077 0.00 0.00 0.977-1.024 0.980
Sex (male vs. female) 1.67 0.15 0.86 0.053 −0.05 0.02 0.487-1.847 0.877
Ethnicity (Dutch vs. other) −1.28 −0.06 1.53 0.402 −0.52 0.68 0.172-2.048 0.409
Marital status (married vs.
unmarried)
1.87 0.17 0.84 0.028 0.16 0.24 0.608-2.283 0.628
Working status (job vs. other) 0.22 0.02 0.79 0.782 0.13 0.10 0.527-2.439 0.749
Education
Primary education REF REF REF REF REF REF REF REF
Secondary education −1.00 −0.09 0.86 0.259 0.18 0.26 0.603-2.383 0.606
Tertiary education −1.45 −0.12 1.00 0.152 0.30 0.59 0.622-2.965 0.442
Income 0.79 0.06 0.94 0.399 −0.18 0.23 0.404-1.730 0.630
Clinical variables MINI Plus
Axis I disorders −0.11 −0.01 0.77 0.887 0.26 0.73 0.713-2.356 0.394
Axis II disorders 0.91 0.08 0.83 0.275 −0.29 0.77 0.392-1.429 0.380
Grading of suicidality
No suicidality REF REF REF REF REF REF REF REF
Low 1.69 0.15 0.93 0.070 −0.12 0.09 0.414-1.907 0.762
Moderate 1.60 0.13 1.00 0.111 1.15 7.37 1.375-7.195 0.007
High 3.64 0.20 1.42 0.011 1.74 7.99 1.713-19.488 0.005
DDPRQ indicates Difficult Doctor-Patient Relationship Questionnaire23,24;DSI,Difficulty Single-item, a single item measuring the difficulty of the
patient as perceived by the professional; ICPT, Interpersonal Community Psychiatric Treatment Study15,16; MATCH, MATCH-cohort study14;
MINI, Mini Neuropsychiatric Interview; REF, reference.
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planning, behaviors, desire, and intent; and (3) mak-
ing a clinical formulation of risk based on all of the
information. A recent Dutch study by Jongkind et al40
found that the CASE approach is used in a simplified
form in The Netherlands, and the authors recom-
mended that practitioners be educated to utilize the
CASE approach more thoroughly. The Collaborative
Assessment and Management of Suicidality (CAMS)
approach, which was developed by Jobes,41 is a
treatment framework in which a patient and a mental
health professional work together to keep the patient
stable, ideally in outpatient therapy. Its specificgoals
are the evaluation, treatment, and management of
chronic suicidal behavior.
A recent meta-analysis comparing the effective-
ness of CAMS with other approaches showed
promising results in terms of significantly lower
suicidal ideation and general distress, significantly
higher treatment acceptability, and significantly
lower hopelessness.42 The CAMS approach has
been fully implemented in Danish and Norwegian
mental health care, but not yet in other countries as
far as we know. Another well-known model used in
the United States is the Assess, Intervene, and
Monitor for Suicide Prevention (AIM-SP) model,
which has been proposed as a framework for
implementing zero suicides in clinical care. “Assess”
refers to the use of screening and risk assessment to
identify patients at risk. “Intervene”consists of
conducting suicide-specific brief and psychosocial
interventions. “Monitor”provides strategies for
ongoing monitoring and increased contact during
known high-risk periods. AIM-SP provides guide-
lines for clinical training and best practice in sui-
cide prevention that can be applied in a wide range
of care settings.43 The framework can be used in
long-term outpatient care.44
Besides evidence-based programs or frameworks,
clinical supervision and support and feedback from
colleagues remain an embedded resource for prac-
tice quality in community mental health institu-
tions to increase competence and decrease stress,
and they have been associated with decreased
depressive symptoms in mental health care
professionals.45 Since patient “difficulty”as per-
ceived by mental health professionals often results
in ineffective treatment, higher levels of care use,
and persistence of symptoms,45–47 further research
is needed concerning the factors underlying the
perceived difficulty to enhance outcomes for
patients and improve mental health professionals’
understanding of these issues.
TABLE 3. Multivariate Linear Regression Model With DDPRQ and DSI as Dependent
Variables (P≤0.05)
Perceived Difficulty (DDPRQ)
ICPT and MATCH (N =176)
Perceived Difficulty (DSI)
ICPT and MATCH (N =176)
Variables B SE βP OR Wald 95% CI P
Sociodemographic variables
Age 0.09 0.03 0.22 0.003
Sex (male vs. female) 2.33 0.83 0.20 0.006
Marital status (married
vs. unmarried)
1.92 0.85 0.17 0.025
Grading of suicidality (high vs. not high)
No suicidality REF REF REF REF REF REF REF REF
Low 1.44 0.89 0.12 0.109 0.89 0.09 0.414-1.907 0.762
Moderate 1.10 0.97 0.08 0.262 3.04 7.37 1.355-6.854 0.007
High 3.96 1.44 0.21 0.006 7.11 7.99 1.843-27.435 0.005
Bold indicates statistically significant values (Pr0.05).
DDPRQ indicates Difficult Doctor-Patient Relationship Questionnaire23,24;DSI,Difficulty Single-item, a
single item measuring the difficulty of the patient as perceived by the professional; ICPT, Interpersonal
Community Psychiatric Treatment Study15,16;MATCH,MATCH-cohortstudy
14; OR, odds ratio; REF,
reference.
Journal of Psychiatric Practice Vol. 29, No. 2 March 2023 119
SUICIDAL BEHAVIOR AND PERCEPTION OF PATIENT DIFFICULTY
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CONCLUSION
We observed that perceived difficulty is sig-
nificantly associated with moderate and high grad-
ings of suicidality, increasing age, female sex, and
unmarried status.
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