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Primary Care Providers’ Views Regarding Assessing and Treating Suicidal Patients
Abstract
Primary care providers (PCPs) usually do not explore patient suicidality during routine visits. Factors that predict PCP attitudes toward the assessment and treatment of suicidality were examined via an online survey of 195 practicing PCPs affiliated with medical schools in the United States. PCPs who perceived themselves as competent to work with suicidal patients were more willing to assess and more willing to treat suicidal patients, with the perception of competency fully explaining the relationship between training and willingness to treat. Female gender predicted lower self-perceived competency, while in-office access to professional mental health (MH) consultation predicted greater self-perceived competency. Higher self-perceived general competence predicted lower subjective valuation of access to MH consultation. Multiple linear regression analysis indicated a three-way interaction between training, gender, and valuation of MH consultation as predictors of perceived competency, with training generally being associated with greater perceived competency to treat suicidality. Relative to their male counterparts, female PCPs have lower confidence in assessing and treating suicidality. Perceived competence in risk assessment should be given more attention in medical training because of its role in PCPs' willingness to treat suicidality.
... The relationship between knowledge, confidence and attitudes It was common across studies to consider the influence of HCPs' knowledge of and confidence in caring for people at risk of suicide on their attitudes towards suicide. Twenty papers used cross- sectional methods (Table 1) to assess this relationship and reported consistently that increasing levels of knowledge led to more positive attitudes about suicide ( Bajaj et al., 2008;Betz et al., 2013;Carmona-Navarro & Pichardo-Martinez, 2012;Chan, Batterham, Christensen, & Galletly, 2014;Egan, Sarma, & O'Neill, 2012;Eynan et al., 2015;Gale et al., 2016;Graham, Rudd, & Bryan, 2011;Grimholt, Haavet, Jacobsen, Sandvik, & Ekeberg, 2014;Hoifodt et al., 2007;Jiao et al., 2014;Keogh, Doyle, & Morrissey, 2007;Kishi, Kurosawa, Morimura, Hatta, & Thurber, 2011;Kodaka, Inagaki, Postuvan, & Yamada, 2013;Neville & Roan, 2013;Obando Medina et al., 2014;Smith, Silva, Covington, & Joiner, 2014;Srivastava & Tiwari, 2012;Sun, Long, & Boore, 2007). Based on testing of varied education levels, Sun et al. (2007) found that higher levels of education among nurses were correlated with higher positive scores on a scale measuring attitudes towards suicidal behavior. ...
... Twelve studies explored the relationship between HCPs' experiences (professional or personal) with suicide and attitudes and knowledge (Bocquier et al., 2013;Brunero et al., 2008;CarmonaNavarro & Pichardo-Martinez, 2012;Chan et al., 2014;Fairman, Thomas, Whitmore, Meier, & Irwin, 2014;Feldman et al., 2007;Graham et al., 2011;Hoifodt et al., 2007;Kishi et al., 2011;Kodaka, Inagaki, Postuvan, et al., 2013;Sun et al., 2007). ...
... Moreover, pharmacists with a personal history of suicidal thoughts were more willing to help suicidal patients . On the other hand, willingness to assess and willingness to treat may be two different concepts that differ among primary health care professionals, as reported by Graham et al. (2011). For example, among primary care providers in the US, personal experience with mental illness was found to be "positively associated with willingness to asses, but not to treat, suicidal patients" (Graham et al., 2011). ...
Health care professionals are paramount to the prevention and management of suicidal thoughts and behaviors. Confidence in caring for people at risk of suicidal thoughts and behaviors is influenced by knowledge of and attitudes towards suicide. This systematic review aimed to explore health care professionals’ knowledge of and attitudes towards suicide, as well as, their confidence in caring for people at risk of suicidal thoughts and behaviors. A systematic search of four electronic databases over ten years was conducted. Following retrieval of 1723 abstracts, 46 primary research publications were included, involving both cross-sectional (n = 27) and intervention study designs (n = 19). Knowledge of, attitudes towards and confidence in caring for people at risk of suicidal thoughts and behaviors were explored among primary health care professionals, specialists and health care students. The influence of training and education, type of health care professional, country of practice and prior experience with suicide were highlighted among included studies. Health care professionals’ knowledge of, attitudes towards and confidence in caring for people at risk of suicide are complex, interrelated constructs that shape their behaviors and may impact patient outcomes. Suicide training and education is necessary within health care curricula and as part of health care professionals’ continuing professional development.
... Although we are not aware of any suicide-related competency measures developed for rehabilitation support staff specifically, suicide assessment competency measures have been developed for use in other, more clinically trained populations, such as nurses, physicians, and psychology trainees (e.g., Cramer, Johnson, Mclaughlin, Rausch, & Conroy, 2013;Graham, Rudd, & Bryan, 2011). Two such published measures are the Suicide Competency Inventory (SCI; Graham et al., 2011) and the Suicide Competency Assessment Form (SCAF; Cramer et al., 2013). ...
... Although we are not aware of any suicide-related competency measures developed for rehabilitation support staff specifically, suicide assessment competency measures have been developed for use in other, more clinically trained populations, such as nurses, physicians, and psychology trainees (e.g., Cramer, Johnson, Mclaughlin, Rausch, & Conroy, 2013;Graham, Rudd, & Bryan, 2011). Two such published measures are the Suicide Competency Inventory (SCI; Graham et al., 2011) and the Suicide Competency Assessment Form (SCAF; Cramer et al., 2013). The SCI is a measure that assesses professionals' willingness, comfort, and perceived competency in asking about suicidality and working with clients who are or have been suicidal. ...
... Scree plot for the suicide competency inventory (Graham et al., 2011). supporting the adequacy of these data for factor analysis. ...
We analysed the psychometric properties of two published self-report suicide assessment competency rating scales – the Suicide Competency Inventory (SCI) and the Suicide Competency Assessment Form (SCAF) – in a sample of 93 public-sector vocational rehabilitation support staff from six states in the United States. Both measures demonstrated very good to excellent internal consistency in our sample. Exploratory factor analysis with principal axis factoring indicated the SCI loads on a two-factor model in this sample, as opposed to the three-factor model proposed by the measure's authors. The SCAF loaded on a single factor, consistent with the theoretical model proposed by the original authors. The SCI and SCAF were highly correlated with each other, providing initial evidence of convergent construct validity. These results provide initial support for the use of these measures as a reliable and valid means of assessing perceived suicide assessment competency in vocational rehabilitation support staff.
... 9,10 Primary healthcare physicians have reported insufficient time to conduct suicide risk assessments within a single consultation 11,12 and many physicians cite low confidence in their risk assessment skills. 11,13,14,15 As a result of these barriers, the rate of inquiry for SI in primary care settings is low, even when patients present with depression or requests for antidepressants (36%-42% according to Feldman et al. 8 Computerized assessment has been suggested as a way to overcome patient-related barriers to SI disclosure, providing more accurate information to healthcare professionals than face-to-face enquiries. 16 The current research uses such data, collected in a computerized self-reported environment to develop a detection tool for SI. ...
... This is very different from a suicide screening tool, of which there are many, usually asking very direct questions about suicide planning and previous attempts. 14,15,17,18 The tool developed as part of the present study predicts the probability of SI using sociodemographic risk factors for SI, alcohol and substance use, and psychological distress as measured using the Kessler Psychological Distress Scale-6 (K6). ...
... It was seen as a rapid but effective method of engaging patients in a conversation about their MH, and if necessary, asking some of the more direct questions about suicide found in the commonly used suicide screeners. 14,15,17,18 The anonymous online nature of the data used to develop this tool and the nonthreatening nature of the questions included in the tool (no mention of suicide) mean that the eSID may be more reliable than a clinical inquiry about SI, in which questions that are more explicit are used. However, this is intended only as an SI detection tool, to be followed up with standard screening and a clinical assessment of risk when there is some indication of suicidal concern. ...
Background:
Suicidal patients often visit healthcare professionals in their last month before suicide, but medical practitioners are unlikely to raise the issue of suicide with patients because of time constraints and uncertainty regarding an appropriate approach.
Introduction:
A brief tool called the e-PASS Suicidal Ideation Detector (eSID) was developed for medical practitioners to help detect the presence of suicidal ideation (SI) in their clients. If SI is detected, the system alerts medical practitioners to address this issue with a client. The eSID tool was developed due to the absence of an easy-to-use, evidence-based SI detection tool for general practice.
Material and methods:
The tool was developed using binary logistic regression analyses of data provided by clients accessing an online psychological assessment function. Ten primary healthcare professionals provided advice regarding the use of the tool.
Results:
The analysis identified eleven factors in addition to the Kessler-6 for inclusion in the model used to predict the probability of recent SI. The model performed well across gender and age groups 18-64 (AUR 0.834, 95% CI 0.828-0.841, N?=?16,703). Healthcare professionals were interviewed; they recommended that the tool be incorporated into existing medical software systems and that additional resources be supplied, tailored to the level of risk identified.
Conclusion:
The eSID is expected to trigger risk assessments by healthcare professionals when this is necessary. Initial reactions of healthcare professionals to the tool were favorable, but further testing and in situ development are required.
... measures have not been evaluated for reliability or validity in rehabilitation counselors, leading to the question of whether these measures and their proposed structure provide valid and reliable data on perceived suicide assessment comfort and competency in this population specifically. Thus, the purpose of the present study is to evaluate the internal consistency, factor structure, and convergent validity of two published suicide assessment competency measures-the Suicide Competency Inventory (SCI; Graham et al., 2011) and the Suicide Competency Assessment Form (SCAF; Cramer et al., 2013)-in a multistate sample of vocational rehabilitation counselors to better establish their suitability for use in this population. The SCI is a measure that assesses professionals' level of comfort with and willing to assess for suicidality and work with clients who are or have been suicidal. ...
... The factor loadings for each item on their respective factor can be seen in Table 2. Qualitative review of the items suggests the same factor structure as proposed by Graham et al. (2011): a two-item competency factor, a four-item willingness to treat factor, and a five-item willingness to assess factor. Although a two-item factor is rather small, the factor loadings in Table 2, coupled with the eigenvalues mentioned above, indicate that the two competency items do indeed load best on their own factor. ...
... Although a two-item factor is rather small, the factor loadings in Table 2, coupled with the eigenvalues mentioned above, indicate that the two competency items do indeed load best on their own factor. The internal consistency for the willingness to treat factor (Graham, Rudd, & Bryan, 2011 was excellent (α = .96), and the internal consistency for the competency (α = .87) ...
We analyzed the psychometric properties of two published self-report suicide assessment competency rating scales—the Suicide Competency Inventory (SCI) and the Suicide Competency Assessment Form (SCAF)—in a multistate sample of 223 public-sector vocational rehabilitation counselors. Both measures demonstrated very good to excellent internal consistency in our sample. Exploratory factor analysis indicated the SCI loads on a three-factor model whereas the SCAF loads on a single factor; these are consistent with the theoretical scale structures proposed by the original authors of the scales. In addition, both scales were highly correlated with each other, providing strong initial evidence of construct validity. In sum, our results support the use of these measures as a reliable and valid means of assessing perceived suicide assessment competency in rehabilitation counselors.
... For example, knowledge on how to assess risk in young adults with an explanation of risk factors and warning signs of suicide for young people; communication and therapeutic skills including managing challenging consultations with young adults and/or those with complex presentations; how to manage doctor-patient confidentiality when other parties such as parents or schools/universities are to be involved; how to access specialist services and/or support for young adults who are at risk of suicide [37,41,63,64]. Sufficient comprehensive training will increase GP-perceived competency [65] and will, in turn, decrease the anxiety and discomfort experienced by some GPs when working with suicidal patients [66]. GPs who perceive themselves as competent to work with suicidal patients are more likely to enquire about suicide [18,19], and are more willing to assess and treat suicidal patients [29,65]. ...
... Sufficient comprehensive training will increase GP-perceived competency [65] and will, in turn, decrease the anxiety and discomfort experienced by some GPs when working with suicidal patients [66]. GPs who perceive themselves as competent to work with suicidal patients are more likely to enquire about suicide [18,19], and are more willing to assess and treat suicidal patients [29,65]. Assessing the effectiveness of training will also be important. ...
The aim of this review was to understand the barriers and facilitators facing GPs and young adults in raising and addressing suicide in medical appointments. A mixed-methods systematic review was conducted of qualitative and quantitative studies. The focus was papers that explored barriers and facilitators experienced by young adults aged 18 to 26, and GPs working in primary care environments. Nine studies met the inclusion criteria. Four studies provided information on young adults’ views, four on GPs, and one considered both GP and young adults’ viewpoints. Nine barrier and seven facilitator themes were identified. Unique to this review was the recognition that young adults want GPs to initiate the conversation about suicide. They see this as a GP’s responsibility. This review further confirmed that GPs lack the confidence and skills to assess suicide risk in young adults. Both findings combined could explain previous results for reduced identification of suicide risk in this cohort. GP training needs considerable focus on addressing skill deficiencies and improving GP confidence to assess suicide risk. However, introducing suicide risk screening in primary care for young adults should be a priority as this will overcome the need for young adults to voluntarily disclose thoughts of suicide.
... Inadequate training likely contributes to PCPs not assessing and managing psychiatric crises; Graham et al found that PCPs felt more competent to assess and treat suicidality after formal training. 12 Since solely screening for suicidal ideation does not reduce suicide attempts, 13 professional training on how to assess and then manage a crisis is crucial. There have been a few calls to address this training need in residency curricula where practice patterns for PCPS are established. ...
... Educating physicians on all crises is critical because these other crises will continue to occur in primary care. As Graham et al have shown, 12 if physicians have not obtained professional training, they are less willing to assess and treat, and if training is only focused on suicidal ideation, a significant number of potential crises will be missed, with potentially lethal consequences. ...
Background and Objectives
Primary care physicians (PCPS) are increasingly responsible for managing mental health, which can involve assessment and management of a psychiatric crisis. Psychiatric crises can include acute suicidal or homicidal ideation and capacity-impairing psychosis. Evidence suggests PCPs do not consistently assess or manage psychiatric crises and it is unclear how to train PCPs to address these potentially lethal scenarios. The main objective was to increase PCP resident confidence in assessing and managing a range of psychiatric crises.
Methods
In a family medicine residency program that trains PCPs, we developed a three, 1-h didactic series and point-of-care reference documents. The curriculum focused on screening, outpatient management, inpatient criteria, logistics of voluntary and involuntary admission, and legal considerations. Resident confidence was measured by questionnaire before and 3 months after curriculum completion.
Results
Prior to training, residents did not feel confident in assessing and managing psychiatric crises, except a slight majority (62%) in screening for suicidal and homicidal ideation. Resident confidence significantly increased for every aspect of assessing and managing psychiatric crises after the training (all P-values < .05), with the largest improvements for further assessing hallucinations, delusions, and suicidal and homicidal ideation.
Conclusions
As PCPs increasingly manage mental illness, they will encounter a range of psychiatric crises in clinic. This study demonstrates that a brief training intervention and point-of-care resources can significantly increase PCP confidence to assess and manage these urgent, dangerous scenarios.
... In this cross-sectional survey of 506 staff working in SUD or mental health treatment settings, we found that self-efficacy in taking actions to address suicide, perceived effectiveness in reducing suicide risk, and recent training on suicide prevention topics were significantly associated with actions to address suicide risk among patients, which are all consistent with existing literature (Botega et al., 2007;Conner, Wood, Pisani, & Kemp, 2013;Delgadillo et al., 2014;Graham, Rudd, & Bryan, 2011;Matthieu, Chen, Schohn, Lantinga, & Knox, 2009;Smith, Silva, Covington, & Joiner, 2014;Wakai et al., 2020). Unique to this study, the vast majority (70.5%) of SUD treatment providers reported having worked with patients who attempted suicide-highlighting the high proportion of SUD patients who screen positive for suicide risk-yet reported less frequent delivery of best practices in suicide prevention, lower self-efficacy for specific practices, lower perceived effectiveness in reducing suicide risk, and completion of fewer suicide-specific trainings compared to mental health treatment providers. ...
... Though requiring suicide screening of individuals in addiction treatment (Commission on Accreditation of Rehabilitation Facilities, 2019) is a promising first step to facilitating identification of suicide risk and delivery of care in SUD treatment, our study highlights key factors that may serve as barriers, including that SUD providers do not feel equipped to identify and treat suicide risk among patients, have not had sufficient training, and are not routinely taking even basic actions to prevent suicide among their high-risk patient populations. Other studies have explained how these factors relate to practice in that without a basic feeling of competence, providers may be fearful and less willing to identify and address suicide risk (Graham et al., 2011;LoParo, Florez, Valentine, & Lamis, 2019;Poremski et al., 2016;Smith et al., 2014). Other barriers may relate specifically to the SUD treatment system itself, including a higher proportion of unlicensed staff who may feel that these activities are outside their scope of practice, even if they had training. ...
Background
Despite prevention and treatment efforts, opioid overdose deaths continue to rise in the United States and totaled 46,802 in 2018. This public health crisis is closely linked with suicide, with those who misuse opioids at six times the risk of death by suicide. Suicide prevention in substance use disorder (SUD) treatment may be a critical step in saving lives and promoting recovery among those at risk for opioid overdose.
Methods
We distributed an electronic survey to clinicians in mental health and SUD treatment in nine health systems across New York State from November 2018 to January 2019. The goal of the survey was to assess attitudes, perceptions, practice, and training needs among SUD treatment providers and how they differ from those of mental health providers.
Results
A total of 633 clinicians responded to the survey (62.4% response rate). Seventy-one percent of SUD providers reported working with a client who attempted suicide. Even so, less than half of SUD providers reported routinely screening new (48.9%) or existing patients (25.6%) for suicidal thoughts/behaviors; overall, 28.4% of SUD providers reported low levels of action to address suicide risk, compared to 9.0% of mental health providers (p<0.001). Perceived self-efficacy and effectiveness at reducing a patient’s risk of suicide and training completion were strongly associated with routine delivery of suicide safer care in adjusted logistic regression models.
Conclusions
The results of this study identify key areas for targeted training and technical assistance to increase the provision of quality suicide safer care in SUD treatment.
... Veterans may see Primary Care as a safe location to discuss mental health issues. There can be a substantial amount of team anxiety about suicide risk assessment (Graham, Rudd, & Bryan, 2011). This anxiety is evident in the literature, with some studies showing that community physicians do not routinely ask depressed patients about suicide (Feldman et al., 2007). ...
... Sometimes consulting with a team member about suicide risk and merely confirming clinical decisions can assist the team. This is consistent with research showing that having access to mental health consultation increased willingness to treat suicidal patients (Graham et al., 2011). ...
The Veterans Administration (VA)’s Patient Aligned Care Team (PACT) model has been a cornerstone of primary care in the VA healthcare system and has indicated the need for an organizational cultural shift towards interdisciplinary care. Most of the focus in PACT has been on the traditional providers of the medical model, with little attention focused on the role of the psychologist. This paper examines how psychologists can assist in the PACT model and, in particular, within the team VA huddle. Literature on the PACT model, mental health in PACT, and the advantages of the huddle are reviewed. Lessons learned within a large VA clinic are also discussed. Psychologists’ ability to be a clinician, teambuilder, and system specialist is discussed and how it benefits the PACT and the huddling process. Practical recommendations are made for how to best assist during the huddle, and how to advocate for both the huddle, and for a broader cultural shift in care.
... The finding that QPR training was not related to higher practice scores among behavioral health providers is not entirely surprising giving that the skills taught in QPR are aimed at individuals who do not work primarily in the behavioral health field and might be too elementary for mental health providers (QPR, 2017). In fact, previous research documented that QPRT (Question, Persuade, Refer, and Treat) is not associated with greater knowledge about conducting suicide risk assessment, safety planning, and documenting risk among mental health providers (Gryglewicz, Chen, Romero, Karver, & Witmeier, 2017). ...
... Results suggested that all trainings but QPR were associated with greater self-report confidence on providing suicide-specific care, with AMSR being a stronger predictor of these scores. As mentioned above, it appears that QPR, although effective for nonmental health providers in identifying individuals at risk of suicide (Cross et al., 2007(Cross et al., , 2010Litteken & Sale, 2017), might not be as effective in increasing confidence among clinicians who may already have the knowledge and skills associated with this training (Gryglewicz et al., 2017). All of the other trainings seem to have incremental value in their likelihood to increase comfort and delivery of best practices for suicide prevention (Ellis et al., 2017;Landes et al., 2016;Marshall et al., 2014;Tørmoen et al., 2014). ...
Objective:
This study examined whether (1) behavioral health providers were more likely to implement best practices when they were more confident in their abilities, (2) number of suicide prevention trainings was positively associated with perceived confidence in abilities and implementation of evidence-based practices, and (3) specific trainings were more impactful than others on increasing providers' level of confidence and/or practices.
Method:
Providers (N = 137) at three rural community behavioral health centers who had opportunities to attend multiple suicide prevention trainings completed the Zero Suicide Workforce Survey, a measure to evaluate staff knowledge, practices, and confidence in caring for patients at risk of suicide.
Results:
There was a moderate association between provider's practice and confidence. The number of attended trainings had a significant correlation with both practice and confidence. Particular trainings demonstrated differential effects on provider's practice and confidence.
Conclusion:
These results suggest that behavioral health providers who are confident in their skills in assessing and treating suicide risk are more likely incorporate best practices into their clinical work. Also, it appears there is a small but significant benefit to multiple trainings for increasing both practice and confidence among providers.
... 48 One problem may be the low level of competence and training in suicidality that medical providers report. 49 Nonetheless, research shows that physicians who receive training feel more competent working with individuals at risk for suicide and are more likely to screen for and treat suicidality. 49,50 Training should include information on use of screening tools and appropriate processes for positive screens, including the best care pathways given the level of risk. ...
... 49 Nonetheless, research shows that physicians who receive training feel more competent working with individuals at risk for suicide and are more likely to screen for and treat suicidality. 49,50 Training should include information on use of screening tools and appropriate processes for positive screens, including the best care pathways given the level of risk. Other factors that limit expanded suicide assessment include the complexity of patients' symptoms and conditions, competing demands for providers, and lack of engagement in treatment among patients. ...
Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples.
To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed.
Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states.
In all, 5,894 individuals who died by suicide, and were health plan members in the year before death.
Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site.
Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means.
This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.
... A study on primary care providers (PCPs) found a relationship between training and willingness to treat, i.e. PCPs who perceived themselves as competent in suicide prevention were more willing to assess and treat patients who are suicidal (Graham et al., 2011). The effectiveness of training programs has, however, not been sufficiently studied (Cross et al., 2019). ...
... Erbuto et al., 2021;Graham et al., 2011). Alguns com resultados de melhoria ao 3º e 6º mês após a formação(Coppens et al., 2018).Kishi et al. (2014) salientam que os enfermeiros que trabalham em contextos psiquiátricos e com formação prévia revelam mais conhecimentos, mais confiança e atitudes mais positivas perante o individuo suicida. ...
... In another instance, [10] revealed that mental health care providers in Uganda showed negative attitudes toward suicide behaviour. In contrast, two studies conducted in USA and Norway exhibited favourable attitudes among health care providers about suicide [11] [12]. Collectively, these studies outline a relatively negative attitude among Other publications conducted in India and Japan [1] [13] [14] questioned the medical students' attitudes towards patients with suicidal behaviour and showed that the attitudes of medical students range between negative and uncertain attitudes. ...
... Besides, suicide is not part of the routine checkup in primary health care (PHC) settings. The PHCWs find it hard to ask about suicidality due to the stigma surrounding suicidality [12]. Some attitudes include considering suicide an immoral or criminal act, thereby blaming the individuals presenting with suicidality [13]. ...
Background
Suicide is one of the leading causes of death globally, with over 75% of all suicides occurring in low-and middle-income Countries. Although 25% of people have contact with their health care workers before suicide attempts, most never receive proper suicide assessment and management. We explored primary care health workers' knowledge, attitudes, and experiences in evaluating and managing suicidality in structured primary healthcare services in Uganda.
Methods
This was a cross-sectional qualitative study among health workers in southwestern Uganda from purposively selected health facilities. A semi-structured interview guide was used, and data were analyzed using thematic analysis.
Results
The in-depth interviews were conducted with 18 individuals (i.e., five medical doctors, two clinical officers, two midwives, and nine nurses) from 12 health facilities in the five selected districts. Four themes emerged from the discussions: a) Knowledge and attitudes of primary healthcare workers in the assessment and management of suicidality, b) Experiences in the assessment and management of suicidality, c) challenges faced by primary healthcare workers while assessing and managing suicidality, and d) Recommendations for improving assessment and management of suicidality in PHC.
Most participants were knowledgeable about suicide and the associated risk factors but reported challenges in assessing and managing individuals with suicide risk. The participants freely shared individual experiences and attitudes in the assessment and management of suicide. They also proposed possible ways to improve the evaluation and management of suicidality in PHC, such as setting up a system of managing suicidality, regularizing community sensitization, and training health workers.
Conclusion
Suicidality is commonly encountered by primary health care workers in Uganda who struggle with its assessment and management. Improving the knowledge and attitudes of primary health care workers would be a big step towards ensuring equitable services.
... Suicide Competency Inventory. The suicide competency measure is a modified version of the 11-item Suicide Competency Inventory (SCI) developed by Graham, Rudd, and Bryan (2011). The original measure included three additional items assessing suicide training and experience; these were not included in the present study because the purpose was to assess perceived suicide competency and comfort. ...
The following study investigated VR professionals' perceptions of recent policy changes under the Workforce Innovation and Opportunity Act (WIOA) of 2014. As a consequence of WIOA amendments, the minimum education requirements have changed; thus, perceptions of education level and professional certification on successful outcomes were two primary areas of interest. Findings from 209 survey participants across State agencies revealed VR professionals believe WIOA changes have impacted employment outcomes within six central domains: caseload, quality of services, pre-employment transition services (pre-ETS), counseling/consumer relationships, documentation of counselor/consumer interactions and services provided, and VR agency management. Obtaining a master's degree and/or Certified Rehabilitation Counselor certification was perceived as beneficial for overall employment outcomes by improving aspects such as counselor qualifications, counselor-consumer relationships, and quality of services provided. The focus of this article is to explore the frequency of these perceptions and to provide recommendations for future study and considerations regarding WIOA implementation.
... 72,77 Studies have also found that trainings can increase both PCP willingness and confidence to screen for suicide. 63,78 This provides further evidence that incorporating provider training is a critical element of future implementation programs. ...
Purpose:
Universal suicide risk screening has the potential to address the disproportionately high rates of suicide in the rural United States, as 83% of people who have died by suicide have visited a health care provider in the year prior to their deaths, and rural patients are more likely to visit medical professionals than behavioral health professionals for mental health concerns. This study describes the opinions of primary care providers (PCPs) practicing in a primarily rural state regarding universal suicide risk screening, barriers to implementation, and strategies to increase the feasibility of screening in their practices.
Methods:
In-depth, individual semistructured qualitative interviews were conducted with a sample of PCPs practicing in West Virginia (N = 15). Applied thematic analysis of the data was completed by a team of 3 coders using a consensus-coding methodology.
Findings:
The majority of PCPs supported the practice of screening, but they identified multiple barriers, including a lack of access to mental health and crisis support services, concerns about clinic flow and follow-up with suicidal patients, cultural beliefs specific to rural Appalachia, and provider discomfort with screening. Strategies suggested to address these barriers included the use of technology for screening, a multidisciplinary team approach, streamlined methods for screening and risk assessment, co-located behavioral health, and additional trainings for PCPs on the topic of suicide.
Conclusion:
Future research should examine the efficacy of universal suicide risk screening programs in rural adult primary care that utilize these strategies in diverse samples with longitudinal data.
... Além disso, algumas revisões sistemáticas indicam que a educação médica em relação ao reconhecimento e tratamento da depressão pode reduzir os índices de suicídio 11 . Estudo realizado nos Estados Unidos mostrou que há relação entre a formação e a capacidade de tratar pacientes suicidas; profissionais que se sentem capazes de tratar tais indivíduos podem compreendê-los melhor e, consequentemente, tratar melhor esses casos 25 . Alguns estudos relatam também queda nos índices de suicídio após implementação da educação contínua sobre depressão para clínicos gerais 26 . ...
Considering suicide is a public health problem, this study identified misconceptions about patients at risk of suicide as well as strategies to manage patients and their families, also verifying changes in conceptions and attitudes throughout graduation. We applied a questionnaire with five categories: “medical confidentiality,” “deontology,” “medical negligence,” “graduation,” and “myths and conceptions”. One hundred and twenty-six subjects participated in the research: 45 (35.7%) first-year medical students, 48 (38.1%) interns, and 33 (26.2%) doctors. The variables were analyzed, and the difference between groups was significant for 15 questions (62.5%). In one question (myths and conceptions) the answers were distant from the expected, and in two questions (myths and conceptions, deontology) the result did not give adequate information. We observed improvements at medical graduation for most of the studied aspects; among the deficiencies, we highlight those related to compulsory notification, electroconvulsive therapy, and the responsibility of doctors.
... 12 PCPs who feel competent in suicide prevention are more willing to assess and treat suicidal patients in health care and community settings. [13][14] One goal of the National Strategy for Suicide Prevention is to increase the proportion of health care providers who receive training in the assessment and management of patients with risk of death by suicide. Indeed, this can be greatly reduced by 20%-70% via training of communitybased mental health providers by recognizing and responding appropriately to suicidal individuals. ...
Mental health continues to be a significant concern both globally and locally in Hawai'i, with nearly half of all mental illness beginning in childhood or adolescence. A shortage of mental health providers has led to less than a third of patients receiving appropriate and timely care. Primary care providers are often the first-line responders to untreated mental health conditions, but they are often underprepared to address these conditions. To help provide guidance to primary care providers and other first-line responders, a child and adolescent mental health resource manual was developed, that is tailored to Hawai'i. This manual was presented at several pediatric didactic sessions and general conferences to describe its evolution, utility, to elicit feedback, as well as for an initial distribution. While feedback was overall positive, future manual development and strategic updates will be made to insure its suitability and timeliness, while continuing circulation efforts to primary care providers will ultimately benefit a greater proportion of children in need.
... Hultsj€ o, W€ ardig, and Rytterstr€ om (2019) describe how HCPs reflect on the influence of organizational changes on a suicidal patient's fragile state. The impacts of suicide care affect both the professional and personal lives of HCPs (Draper et al. 2014;Graham, Rudd & Bryan 2011;Joyce & Wallbridge 2003). Whitworth (1984) describes this impact in terms of an interpersonal conflict between the lifeoriented core of the work of mental health nurses and keeping someone alive who does not want to live. ...
People who attempt suicide as well as those who actually take their own life often have communicated their suicidal thoughts and feelings to healthcare professionals in some form. Suicidality is one of the most challenging caring situations and the impacts of suicide care affect both the professional and personal lives of healthcare professionals. This study investigates how mental health professionals perceive suicide while providing psychiatric care and how this perception impacts their continued care work. This qualitative exploratory study includes 19 mental health professionals in psychiatry who had provided care for patients who had taken their own life. Analysis followed the principle of phenomenography. The findings reveal that these healthcare professionals experienced an internal conflict that affected them both personally and professionally. In response to these conflicts, the healthcare professionals developed strategies that involved a safety zone and increased vigilance. Those who were able to commute and balance a safe spot and learning to be more vigilant seem to have developed as a result of patient's suicide. These findings have the potential to help establish a post‐suicide caring process where healthcare professionals learn to make better suicide assessments, become more open to talking about death with patients, and develop a humbler approach to understanding a patient's suicide.
... [21][22] Furthermore, primary care physicians who feel competent in suicide prevention are more likely and willing to assess and treat suicidal patients in health care and community settings. [23][24] One of the goals of the National Strategy for Suicide Prevention is to increase the proportion of health care providers who receive training in the assessment and management of suicide risk. 25 The risk of suicide death can be significantly reduced (20%-70%) by training community-based health providers to recognize and respond to individuals feeling suicidal. ...
... Suicide-related trainings designed for nurse care managers and primary care providers have been found to increase suicide detection among primary care patients (Nutting et al., 2005;Pfaff, Acres, & McKelvey, 2001) and have been found to help decrease the number of false negatives identified by providers along with a minimum of false positives (Pfaff et al., 2001). Primary care physicians who have received training in suicide also have reported increased confidence in assessing suicidality (Kaplan, Adamek, & Martin, 2001), improved selfperceived competency in dealing with suicidal patients, and increased willingness to treat suicidality among their patients (Graham, Rudd, & Bryan, 2011). ...
Although primary care practices have the potential to be crucial intervention points for suicide prevention in rural areas of the United States, primary care staff are often underequipped to deal with suicide and have limited access to high-quality training opportunities on this topic. This manuscript reports on posttest data collected from a sample of primary care staff (N = 16) regarding the acceptability of a brief, online interactive training webinar designed for primary care practices in rural West Virginia. The majority of participants reported the webinar was relevant to their practices (73.3%) and that they would recommend it to a fellow professional (75.0%). Higher proportions of participants reported confidence (75.0%) and comfort (68.8%) asking patients about suicide than they did regarding their ability to complete a risk assessment (50.1%) and a safety plan (56.3%) with a suicidal individual. Only half (56.3%) thought it was important to screen all primary care patients for suicide. Future research should use tracked pre- and posttest data to evaluate the effectiveness of trainings that include a focus on risk assessment and safety planning, education about the potential benefits of universal suicide risk screening, and that can be delivered through asynchronous methods.
... The prevention of suicide often depends on a delicate collaboration between multiple agents and agencies in which availability and timing, knowledge and communication, relationships and trust, all contribute. Certainly, prevention is not clear cut [17] In common with other research in this area we found considerable and complex challenges to engagement with the health care system, some structural, others cultural [18,19]. ...
Background
Although Primary care is crucial for suicide prevention, clinicians tend to report completed suicides in their care as non-preventable. We aimed to examine systemic inadequacies in suicide prevention from the perspectives of bereaved family members and GPs.
Methods
Qualitative study of 72 relatives or close friends bereaved by suicide and 19 General Practitioners who have experienced the suicide of patients.
Results
Relatives highlight failures in detecting symptoms and behavioral changes and the inability of GPs to understand the needs of patients and their social contexts. A perceived overreliance on anti-depressant treatment is a major source of criticism by family members. GPs tend to lack confidence in the recognition and management of suicidal patients, and report structural inadequacies in service provision.
Conclusions
Mental health and primary care services must find innovative and ethical ways to involve families in the decision-making process for patients at risk of suicide.
... Suicide Competency Inventory (SCI). The suicide competency measure is a modified version of the 11-item suicide assessment competency measure developed by Graham, Rudd, and Bryan (2011). The original measure included three additional items assessing suicide training and experience; these were not included in the present study because the purpose was to assess perceived suicide competency and comfort. ...
Despite the well-documented elevated rates of suicidality among people with disabilities, no published research has examined rehabilitation counselors’ experiences or perceived competency in suicide assessment or intervention. In the present study, we surveyed 223 vocational rehabilitation (VR) counselors from state VR offices in eight states regarding their experiences with, knowledge of, and perceived comfort with and competency in suicide assessment and intervention. Almost a quarter of participants worked with suicidal clients once a month or more, with more than half reporting working with suicidal clients at least once a year. Two thirds of participants reported having received some training related to suicide, and participants demonstrated both a good knowledge of suicide myths and facts, and a willingness to work with suicidal clients. However, most participants did not perceive themselves as being competent in core skills related to suicide assessment and intervention. These results suggest that more clinical training in suicide assessment and intervention is needed for VR counselors.
... In a psychological autopsy study of older adults who died by suicide, suicide warnings were ignored or missed due to not recognizing the seriousness of such threats, feeling helpless to effect change, feeling isolated in ability to consult with colleagues, and acceptance or normalization of the desire to die because of the aging process (Kjølseth & Ekeberg, 2012). Additionally, primary care physicians with lower perceived competency in managing suicide risk indicated lower levels of willingness to assess or treat suicidal patients (Graham, Rudd, & Bryan, 2011). ...
... However, some PCPs may not feel competent in screening for suicide risk. 9,10 Most individuals who are suicidal visit their PCP shortly before they attempt suicide, any time from 1 week to 6 months prior to their act of suicide. Most often, such visits are within 3 months. ...
Suicide in older adults is continuing to rise and, as the older population increases, so will the rate of suicide. By learning more about the risk factors, assessment areas to explore, and ways to improve treatment, primary care providers can help decrease the incidence of suicidal behaviors in this population.
... Previous studies have presented that inpatient suicide affected nurses personally and professionally in mental health settings. Studies on psychiatrists demonstrated grief, low mood, or thought of taking early retirement [21] . Some literature showed they were emotionally shaken and felt guilty, press, failure and self-scrutiny [10,17,22] . ...
Aims: To explore the impact of inpatient suicides on nurses working in front-line, the patterns of regulation and their needs for support.
Methods: Data were collected through purposive sampling by conducting semi-structured and individual in-depth interviews in a tertiary referral hospital in China. Colaizzi's seven-step phenomenological method was simultaneously used by two interviewers.
Results: Reactions to inpatient suicides revealed three central themes: (1) inpatients were highly likely to commit suicide, (2) inpatient suicide was difficult to prevent, and (3) nurses lacked the necessary suicide prevention skills. Psychological responses mainly included shock and panic, self-accusation or guilt, sense of fear, and frustration. The impacts on practice were stress, excessive vigilance, and burnout. Avoidance and sharing of feelings played key roles in the regulation patterns of nurses.
Conclusions: Nurses who experienced inpatient suicide became stressed. Effective interventions must be implemented to improve the coping mechanisms of nurses against the negative consequences of inpatient suicide. The findings of this study will allow administrators to gain insight into the impacts of inpatient suicides on nurses in general hospitals. Such information can be used to develop effective strategies and provide individual support and ongoing education. Consequently, nurses will acquire suicide prevention skills and help patients achieve swift recovery.
... Females were found to more often feel guilty and ashamed after a patient suicide and needed more consolation than men in a study of 63 psychiatrists and psychologists in Slovenia [12]. In the primary care setting, a study of primary care providers' attitudes toward assessing and treating suicidal patients found that females had lower self-perceived competence [30]. It is unclear how this selfappraisal might impact upon the female HCP after a patient suicide or, indeed, how accurate it might be. ...
Objective:
To compare the professional and personal impact of patient suicide and sudden death on health care professionals (HCPs) and determine factors associated with these impacts.
Method:
The sample was derived from a sudden death-controlled psychological autopsy study of suicide. HCPs were identified by deceased's next of kin, by other HCPs, from coroners' files and from medical records. The HCPs were interviewed about their last contact with the deceased and the impact of the death on their lives.
Results:
Two hundred eleven HCPs were interviewed following suicide; 92 after sudden death. Suicide deaths were significantly more likely to impact upon the HCP's professional practice [suicide n = 79 (37.4%); sudden death n=9 (9.9%); χ(2) = 22.06, P < .001] and personal life [suicide deaths n = 55 (26.1%); sudden death n = 12 (13.0%); χ(2) = 5.58, P = .018] than sudden deaths. Using multinomial logistic regression, being female and suicide within a week of the consultation predicted professional and personal impacts; having less than 5 years experience predicted professional impact and receipt of support/counseling predicted personal impact.
Conclusion:
Suicide deaths have a greater impact than sudden deaths upon the life of HCPs. Clinical inexperience influences impacts on professional practice and availability of support impacts on personal life.
... 21 As discussed in this supplement and elsewhere, one concern is that general medical providers often lack the training and knowledge needed to identify and treat mental health and suicide risk, as well as limited time to discuss these issues with patients. 22,23 Thus, the current healthcare system relies on the limited number of referrals that make it to specialty mental health care and emergency services, where the skill levels of providers may also be limited with regard to suicide risk management. ...
Context
In 2012, the National Action Alliance for Suicide Prevention’s Research Prioritization Task Force (RPTF) released a series of Aspirational Goals (AGs) to decrease suicide deaths and attempts. The RPTF asked experts to summarize what was known about particular AGs and to propose research pathways that would help reach them. This manuscript describes what is known about the benefits of access to health care (AG8) and continuity of care (AG9) for individuals at risk for suicide. Research pathways are proposed to address limitations in current knowledge, particularly in U.S. healthcare-based research.
Evidence acquisition
Using a three-step process, the expert panel reviewed available literature from electronic databases. For two AGs, the experts summarized the current state of knowledge, determined breakthroughs needed to advance the field, and developed a series of research pathways to achieve prevention goals.
Evidence synthesis
Several components of healthcare provision have been found to be associated with reduced suicide ideation, and in some cases they mitigated suicide deaths. Randomized trials are needed to provide more definitive evidence. Breakthroughs that support more comprehensive patient data collection (e.g., real-time surveillance, death record linkage, and patient registries) would facilitate the steps needed to establish research infrastructure so that various interventions could be tested efficiently within various systems of care. Short-term research should examine strategies within the current healthcare systems, and long-term research should investigate models that redesign the health system to prioritize suicide prevention.
Conclusions
Evidence exists to support optimism regarding future suicide prevention, but knowledge is limited. Future research is needed on U.S. healthcare services and system enhancements to determine which of these approaches can provide empirical evidence for reducing suicide.
... Some GPs find it stressful to manage patients who express or act upon ideas of committing suicide. 12 The DD-GPL provided assessment and advice, with no ongoing care or case management. Nevertheless, across the sites, some GPs expected that the registrar would become the primary medical contact for some patients, particularly those with more acute presentations or at higher risk of suicide, self-harm or deterioration in mental or functional state. ...
To describe the organisational, clinical and pragmatic features of a GP liaison service established by the Division of Mental Health in the Darling Downs Hospital and Health Service catchment to facilitate the care of rural patients and improve communication between primary and specialist care.
The GP liaison service was created using funding from the Commonwealth STP initiative to provide weekly registrar clinics to primary care providers in the Darling Downs. The service was eagerly accepted by providers who saw patient benefits outweighing financial considerations. Expectations of a greater level of care than the assessment and advice provided reflects the large unmet need for mental health services in rural areas. GPs expressed enthusiasm for true collaborative care, such as case management overseen by the public mental health service but based at GP offices.
... Some GPs find it stressful to manage patients who express or act upon ideas of committing suicide. 12 The DD-GPL provided assessment and advice, with no ongoing care or case management. Nevertheless, across the sites, some GPs expected that the registrar would become the primary medical contact for some patients, particularly those with more acute presentations or at higher risk of suicide, self-harm or deterioration in mental or functional state. ...
To describe the organisational, clinical, and pragmatic features of a GP Liaison service established by the Division of Mental Health in the Darling Downs Hospital and Health Service catchment to facilitate the care of rural patients and improve communication between primary and specialist care.
... Sixty-seven clinicians opted-out of the study; 115 e-mail addresses bounced back; 222 PCPs were identified as ineligible through their response to the eligibility question in the survey or a description of their profession (e.g., psychiatrists, emergency room physicians); and 114 notified the first author they were ineligible, uninterested in participating, or could not access the survey because of technical difficulties (see Figure 1). A total of 552 eligible PCPs completed the survey, resulting in a 20% response rate, which is typical for online surveys of healthcare providers (e.g., Danhauer, David, Johnson & Meyer, 2009;Graham, Rudd & Bryan, 2011;Johnson et al., 2008). Respondents were not significantly different from nonrespondents regarding age, profession, or time since licensure, but they were more likely to be female (65% vs. 53%; p < .01). ...
... These findings are important because the majority of individuals with eating disorders do not seek treatment for their eating disorder (Fairburn et al., 2000;Mond et al., 2007;Hart et al., 2011), and those who do, often receive treatment from a general practitioner (Mond et al., 2007). Importantly, several studies suggest that suicide risk assessments are often conducted by general practitioners only when patients appear depressed or inquire about medication for depressive symptoms (Hooper et al., 2012;Graham et al., 2011;Feldman, et al. 2007;Williams, et al. 1999). As such, the current study highlights that suicidality may be overlooked in individuals with BN who do not present with comorbid disorders and may be underestimated in those with depression and/or substance use and BN. ...
A convenience sample of community health care providers (N = 19) was asked to preview and rate the acceptability of the Ask Suicide-Screening Questions (ASQ) tool and the ASQ Brief Suicide Safety Assessment (BSSA) guide. Providers were also asked about potential barriers to implementation. The majority of participants stated they would be comfortable screening for suicide with the ASQ tool (78.9%; N = 15), that they would recommend the ASQ tool and the BSSA to colleagues (84.2%; N = 16), and that they were "satisfied" or "highly satisfied" with the ASQ and BSSA (88.2%; N = 13). Barriers to implementation reported included a lack of knowledge regarding suicide risk screening and lack of access to behavioral health resources. Education regarding the ASQ, the BSSA, and suicide risk screening are highlighted as crucial elements for future implementation.
Advanced practice RNs (APRNs) are in a unique position to address suicide by conducting assessments at each contact with all patients. A study conducted in 2017 examined APRNs' attitudes toward suicide by analyzing quantitative data. After completing the survey, participants were able to comment on their experiences with suicide and provide opinions about the study. The comments yielded qualitative data that contain personal, powerful messages about the participants' experiences. Examining these comments raises awareness about our practice and experiences with suicide. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].
Improving oral health outcomes in Hawai'i for children and families remains a high priority. Children in the state are leading the nation with the highest caries rates, while women before, during, and after pregnancy are failing to receive regular and necessary dental care resulting in poor health outcomes. To answer for this need, an educational intervention was conducted among families enrolled in the Kapi'olani Medical Center for Women and Children's Women, Infant, and Children program (WIC) in O'ahu. The project included the following activities: (1) identification the oral health beliefs and behaviors of families, (2) providing oral health education to families, and (3) reassessing beliefs and behaviors in 3-6 months to document the impact of theeducation session. Participants consisted of 81 families resulting in the data on 176 children and 4 pregnant women. Of the 81 families, 40 representing84 children completed the follow-up oral health questionnaire. Results of the assessment and education demonstrated a positive impact on the family's oral health behaviors. Parents were 6.61 times as likely to report using fluoride toothpaste in the follow-up visit compared to their initial visit (95% confidence interval [CI] = 3.12-14.00). Additionally, statistically significant changes were noted in the frequency of children's daily tooth brushing (odds ratio [OR] = 2.15, 95% CI = 1.33-3.46), as well as in the incidence of children receiving fluoride varnish application over time (OR = 2.66, 95% CI = 1.50-4.73). These results provide further evidence that initiating a simple educational intervention can have a positive impact on oral health behaviors in groups that are at highest risk for developing dental disease in Hawai'i.
Experience with pediatric transport and pediatric-specific training for paramedic students and practicing paramedics is lacking nationally. Kapi‘olani Community College (KCC) conducts the only paramedic training program in the state and has recently expanded its pediatric training section. KCC and the John A. Burns School of Medicine (JABSOM) collaborated on a simulation-based pediatric pre-hospital provider training course titled PediSTEPPs-H (Pediatric Simulation Training for Emergency Pre-hospital Providers in Hawai‘i), which was developed and piloted in 2019, to supplement the students’ didactic and clinical experiences. The program was developed using Kern’s 6-step approach to curriculum development in medical education. The PediSTEPPs-H pilot course was co-facilitated by faculty from both campuses and enrolled 12 students in the first cohort. Program evaluation demonstrated high student satisfaction and included feedback regarding curriculum elements for further refinement. The PediSTEPPs-H pilot program evaluation provided direction that the course be offered annually for all KCC paramedic students and as continuing professional development program for practicing paramedics in Hawai‘i.
Purpose
To evaluate the feasibility and impact of a suicide risk screening program in a rural West Virginia primary care practice.
Methods
Patients presenting for routine and sick visits were asked to participate in electronic suicide risk screening using the Ask Suicide-Screening Questions (ASQ) tool; screen positive individuals were assessed with the ASQ Brief Suicide Safety Assessment (BSSA). Screening program feasibility was evaluated by the proportion of patients consenting to participate, participant ASQ and BSSA completion rates, and response to a question asking whether Primary Care Providers (PCPs) should ask about suicide. Screening impact was evaluated quasi-experimentally by comparing electronic medical record (EMR) documentation of suicide risk screening, assessment, and risk determination in practice patients before and after implementing the screening program.
Findings
Over half of the patients approached agreed to participate in a research study about suicide (N = 196; 57.7%). Feasibility of the screening program was demonstrated by the high completion rates for the ASQ (99.0%) and the BSSA (100.0%) among study participants. Additionally, 95.4% (N = 187) of participants agreed PCPs should screen patients for suicide. Suicide screening rates rose significantly between the baseline and intervention phases (5.8% to 61.0%; X² = 200.61, p < .001), as did suicide risk detection rates (0.7% to 6.2%; X² = 12.58, p < .001).
Conclusion
Suicide risk screening was feasible and well-accepted by adult patients in rural primary care and has potential to improve suicide risk detection in this setting.
Background: Subthreshold psychotic experiences are known to confer a risk for suicidality. Yet, despite evidence of a strong aetiological trauma-psychosis pathway, the coalesced effect of such concurrences on suicide risk is largely discounted. Objective: Our aims were to examine the impact of different manifestations of lifespan trauma and psychotic-like experiences (PE) on the risk of suicidal thoughts and attempts using an exploratory person-centred approach. Method: Data from the Adult Psychiatric Morbidity Survey (N= 7,403) was analysed. Psychotic-like experiences were assessed using the Psychosis Screening Questionnaire (PSQ) alongside items probing childhood and adult trauma, in addition to twelve-month suicide thoughts and attempt. Results: A manual 3-step latent class analysis elicited four distinct profiles, namely a socially disconnected/high PE, a sexual victimisation/moderate PE, a lifespan trauma/low PE and a baseline class. The socially disconnected class, characterised by a moderate likelihood of social disconnection, a high probability of various PE endorsements, yet a low likelihood of other significant trauma, showed the greatest risk of twelve-month suicide ideation (OR=13.0, 95%CI=8.539 – 19.021) and attempt (OR=24.2, 95%CI=10.349 – 56.860). Conclusions: Neither multiple nor recurrent traumatic experiences invariably result in the emergence of PEs. Instead, a sense of social disconnection may be either resultant of PEs, or alone sufficient to cultivate such symptom presentations, even in the absence of prior traumas. Moreover, just as traumatic encounters increase the risk of suicidality, so too might seemingly more innocuous adversities such as poor-quality social relationships further elevate the risk, particularly when proximal and coupled with the simultaneity of PEs.
Objectives:
Nearly half of all men who die by suicide visit a primary care clinician (PCC) in the month before death, yet few disclose suicide thoughts. We solicited stakeholders' views to guide development of a tailored multimedia program to activate middle-aged men experiencing suicide thoughts to engage with PCCs.
Methods:
We conducted semi-structured interviews with 44 adults self-identifying as: suicide attempt survivor; family member/loved one of person(s) who attempted or died by suicide; PCC; non-PCC office staff; health administrator; and/or prevention advocate. We coded recorded interview transcripts and identified relevant themes using grounded theory.
Results:
Two thematic groupings emerged, informing program design: structure and delivery (including belief the program could be effective and desire for use of plain language and media over text); and informational and motivational content (including concerns about PCC preparedness; fear that disclosing suicide thoughts would necessitate hospitalization; and influence of male identity and masculinity, respectively, in care-seeking for and interpreting suicide thoughts).
Conclusion:
Stakeholder input informed the design of a primary care tailored multimedia suicide prevention tool.
Practice implications:
In revealing a previously unreported barrier to disclosing suicide thoughts to PCCs (fear of hospitalization), and underscoring known barriers, the findings may suggest additional suicide prevention approaches.
The goal of the following chapter is to serve as a primer on suicidality presenting in primary care and how integrated care can support improvements in practice. The state of current screening and treatment for suicidality within primary care will be reviewed, including current training of primary care providers and needed areas of additional training and support. The ways in which integrated care can be utilized to improve practice in primary care as related to suicidality will be addressed, and a brief overview of the Primary Care Behavioral Health (PCBH) model will be provided. Finally, the specifics of the PCBH program in which the authors practice will be discussed as an example of how care is provided in a Federally Qualified Health Center.
Objective:
To explore what percentage of suicide decedents (SDs) vs controls were assessed for suicidality at medical appointments in the year before death.
Patients and methods:
Using the Rochester Epidemiology Project, 66 SDs dying in Olmsted County, Minnesota, between January 1, 2000, and December 31, 2009, were identified and matched with 141 age- and sex-matched controls. Blinded chart review determined how often providers screened and subjects endorsed suicidal ideation (SI). Positive indicators included chart notes recording SI and/or Patient Health Questionnaire-9 scored more than 0 on question 9.
Results:
We found that only 29 of 66 (43.9%) SDs and 14 of 141 (9.9%) controls had been screened at any point by any means (P < .001). Only 25.8% (17 of 66) of SDs expressed SI, whereas 58.6% of screened SDs (17 of 29) did so, though none at final appointments before death. No control ever expressed SI. While the majority of both cases and controls went unscreened, providers were more likely to screen SDs (P < .001; odds ratio [OR], 9.0; 95% CI, 3.6-22.0), even with controlling for mental health diagnoses (P = .02; OR, 3.6; 95% CI, 1.2-10.6).
Conclusions:
With providers screening less than half of SDs at any point in the year before death, and less than 60% of SDs ever endorsing SI, including none at final appointments, the findings of this naturalistic study bring into question both current screening practices and screening effectiveness. Nonetheless, when SDs were screened, they were significantly more likely to endorse SI than were controls, not 1 of whom ever expressed SI. Taken together, these data suggest that patients expressing SI at any point are at elevated risk for eventual suicide.
This study obtained the perspectives of 11 providers employed in Veteran Affairs (VA) primary care clinics across four states regarding the factors that influence the assessment and management of suicide risk. Qualitative data was analyzed using a hybrid inductive-deductive thematic analysis approach. Themes highlighted the impact of a trusting patient-provider relationship, multidisciplinary team-based care, education about suicide prevention from integrated behavioral health providers, reliable access to mental health care, and VA system-wide suicide prevention efforts in supporting generalists' ability to effectively assess and manage Veterans' suicide. Recommendations for enhancing evidence-based care for suicide risk in primary care are discussed.
Suicide is a significant issue in the United States and worldwide, and its prevention is a public health imperative. Primary care practices are an important setting for suicide prevention, as primary care providers have more frequent contact with patients at risk for suicide than any other type of health-care provider. The Western Interstate Commission for Higher Education, in partnership with the Suicide Prevention Resource Center, has developed a Suicide Prevention Toolkit and an associated training curriculum. These resources support the education of primary care providers in evidence-based strategies for identifying and treating patients at risk for suicide. The application of this curriculum to post-graduate medical training is presented here.
© The Author(s) 2015.
As healthcare trends towards a system of care approach, providers from various disciplines strive to collaborate to provide optimal care for their patients. While a multidisciplinary approach to suicide risk assessment and management has been identified as important for reducing suicidality, standardized clinical guidelines for such an approach do not yet exist. In this article, authors propose the adoption of the therapeutic risk management of the suicidal patient (TRMSP) to improve suicide risk assessment and management within multidisciplinary systems of care.
The TRMSP, which has been fully articulated in previous articles, involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. Augmenting clinical risk assessments with reliable and valid structured instruments serves several functions, including ensuring important aspects of suicide are addressed, establishing a baseline for suicidal thoughts and behaviors, facilitating interprofessional communication, and mitigating risk. Similarly, a two-dimensional risk stratification qualifying suicide risk in terms of both severity and temporality can enhance communication across providers and settings, and improve understanding of acute crises in the context of chronic risk. Finally, safety planning interventions allow providers and patients to collaboratively create a personally meaningful plan for managing a suicidal crisis that can be continually modified across time with multiple providers in different care settings.
In a busy care environment, the TRMSP can provide concrete guidance on conducting clinically and medicolegally sound suicide risk assessment and management. This collaborative and comprehensive process would potentially improve care of patients with suicidality, optimize clinical resources, decrease unnecessary and costly admissions, and mitigate medicolegal risk. The TRMSP may serve as a foundation for building a standardized, collaborative, stepped care approach that patients, individual providers, and the healthcare system can all benefit from.
Objective: Primary care physicians are increasingly providing psychiatric care in the United States. Unfortunately, there is limited learning opportunity or exposure to psychiatry during their residency training. This survey was conducted to assess primary care resident interaction with mental health professionals and their satisfaction, knowledge, preference, and comfort with the delivery of mental health care in primary health care settings.
Method: On the basis of available published literature, a 20-question survey was formulated. Following receipt of the institutional review board’s approval, these questions were sent via e-mail in February 2012 to internal and family medicine residents (N = 108) at 2 teaching hospitals in southwest Virginia. Analysis of the electronically captured data resulted in a response rate of 32%. Descriptive analysis was used to examine the results.
Results: The responses were equally divided among male and female residents and family medicine and internal medicine residents. There were several interesting findings from the survey. No correlations were noted between the gender of residents, type or location of the medical school, or having had a psychiatric rotation during residency and the reported comfort level treating patients with psychiatric illness or the desire to see psychiatric patients in the future. A positive correlation was found between the residents’ training level and their belief about the percentage of mental health providers who have mental health problems.
Conclusions: The current training model to acclimate primary care residents to the field of mental health appears to have major limitations. Results of this pilot survey can serve as a guide to conduct prospective, multicenter studies to identify and improve psychiatric training for primary care residency programs.
Objective:
To compare depression identification and management perceptions and practices between professions and disciplines in primary care and examine factors that increase the likelihood of administering a standardized depression screening instrument, asking about patients' depressive symptoms, and using best practice when managing depressed adolescents.
Methods:
Data came from an online survey of clinicians in Minnesota (20% response rate). Analyses involved bivariate tests and linear regressions.
Results:
The analytic sample comprised 260 family medicine physicians, 127 pediatricians, 96 family nurse practitioners, and 54 pediatric nurse practitioners. Overall, few differences emerged between physicians and nurse practitioners or family and pediatric clinicians regarding addressing depression among adolescents. Two factors associated with administering a standardized instrument included having clear protocols for follow-up after depression screening and feeling better prepared to address depression among adolescents.
Conclusions:
Enhancing clinicians' competence to address depression and developing postscreening protocols could help providers implement universal screening in primary care.
By design or by default, primary care providers (PCPs)are frequently the vanguard in the fight against suicide. Recent studies have highlighted programs to improve screening and prevention of suicidality in the medical home, particularly among high-risk patients, such as adolescents, the elderly, and veterans. Increasing efforts are also being paid to improving the PCP's skill in assessing for suicidality. However, it is becoming increasingly apparent that screening alone will not significantly lower suicide rates until it occurs within a well-integrated system that facilitates timely referral to more intensive mental health services for those patients who need them. Unfortunately, such systems are sorely lacking in many, if not most, areas of the USA.
In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators. (46 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Objectives-This report presents final 2011 data on U.S. deaths, death rates, life expectancy, infant mortality, and trends by selected characteristics such as age, sex, Hispanic origin, race, state of residence, and cause of death.
All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.
BACKGROUNDDepression treatment is often initially sought from primary care physicians.
OBJECTIVETo explore the influence of physician personality on depression assessments.
DESIGNSecondary analysis of data collected in a randomized controlled trial.
SETTINGOffices of primary care physicians in Rochester, NY.
PARTICIPANTSForty-six physicians; six female actors.
InterventionEighty-six unannounced standardized patient (SPs) visits; physicians saw one SP with major depression and one with adjustment
disorder.
MEASUREMENTSSPs listened to audiotapes and completed a form on doctoring behaviors and symptom inquiry immediately following the visit.
For the assessment of diagnostic documentation, SPs’ medical records were reviewed. Physician personality was assessed via
items from the NEO-PI-R.
RESULTSPhysicians who are more dutiful and more vulnerable were more likely to document a diagnosis of depression; those who are
more dutiful also asked fewer questions concerning mood symptoms.
LIMITATIONRoles portrayed by the SPs may not reflect the experience of a typical primary care patient. Most of the PCPs were white men.
The sample of PCPs was limited to a single geographic location. Effect sizes were modest.
CONCLUSIONSThe clinical, educational, and translational, implications of research showing that physician personality traits could affect
practice behaviors warrant consideration. Current models of treatment for depression in primary care could be engineered to
accommodate the variability in physician personality. Given that there is no single “correct” way to ask about mood disorders
or suicide, clinicians are encouraged to adopt an approach that fits their personal style and preferences.
Depression is a common disorder in the primary care setting; it is associated with considerable distress and dysfunction. The management of depressed primary care patients can be complicated by the fact that these patients may lack insight into the cause of their symptoms and report only the somatic manifestations of their disorder to their physicians. Primary care patients may also be reluctant to accept a diagnosis of depression or referral to a mental health specialist. Primary care physicians may feel they lack the time or the training to adequately address their patients' depressive disorders. This paper presents a model for identifying, evaluating, and treating depression which has been specifically developed to help primary care physicians overcome these barriers.
To review the literature on gender differences and issues of self-confidence in medical students and to present original research on observers' perceptions of medical student confidence.
One hundred forty-one 3rd year medical students at Indiana University School of Medicine were videotaped during their objective structured clinical examination (OSCE). Trained coders rated how confident the student appeared and coded a variety of nonverbal behaviors at the beginning, middle, and end of the interaction. Analysis focused on gender differences in coders' ratings of perceived confidence.
Female medical students were viewed as significantly less confident than male medical students (F(1,133)=4.45, p<0.05), especially at the beginning of the interaction.
Past research indicates that despite performing equally to their male peers, female medical students consistently report decreased self-confidence and increased anxiety, particularly over issues related to their competence. In a standardized patient interaction examination situation, female medical students also appeared significantly less confident than male medical students to independent observers.
Medical educators should focus on issues of female students' confidence, increasing faculty sensitivity, and publicly recognizing and discussing perceptions of confidence.
Objectives—This report presents 2009 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal characteristics including age, live-birth order, race and Hispanic origin, marital status, hypertension during pregnancy, attendant at birth, method of delivery, and infant characteristics (period of gestation, birthweight, and plurality). Birth and fertility rates by age, live-birth order, race and Hispanic origin, and marital status also are presented. Selected data by mother’s state of residence are shown, as well as birth rates by age and race of father. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. Methods—Descriptive tabulations of data reported on the birth certificates of the 4.13 million births that occurred in 2009 are presented. Denominators for population-based rates are postcensal estimates
Physicians are expected to effect patient care by giving orders to members of a healthcare team. Because women are socialized to be less directive than men, the assertive behavior required of new physicians may be experienced differently by male and female residents. We sought to explore the effects of gender and year of training on residents' experiences and perceived ability to direct patient care.
This was a mixed-methods, cross-sectional, descriptive study employing a quantitative written survey and qualitative interviews among internal medicine residents at an academic health center. Measurements included questionnaires and interviews about stress, assertiveness, and personal factors that influence their effectiveness in directing patient care. Analyses examined differences by gender and year of training.
One hundred residents were invited to participate; 65 returned questionnaires, and 16 of these residents were interviewed. Compared with male residents, female residents selected less assertive behaviors for clinical scenarios (p = 0.047) and were more likely to perceive gender as inhibiting their ability to influence patient care (p < 0.01). Stress associated with being assertive varied more with experience than gender. Interviews corroborated these findings and supported the complexity of gender norms for behavior for female residents in a directive leadership position.
When compared with male peers, female residents reported more gender issues in residency and chose less assertive behaviors in clinical scenarios. Experience mitigated some gender differences. Our findings suggest that discussion of the existing research on prescriptive gender norms for behavior and leadership may be warranted in resident orientation.
In this article, we attempt to distinguish between the properties of moderator and mediator variables at a number of levels. First, we seek to make theorists and researchers aware of the importance of not using the terms moderator and mediator interchangeably by carefully elaborating, both conceptually and strategically, the many ways in which moderators and mediators differ. We then go beyond this largely pedagogical function and delineate the conceptual and strategic implications of making use of such distinctions with regard to a wide range of phenomena, including control and stress, attitudes, and personality traits. We also provide a specific compendium of analytic procedures appropriate for making the most effective use of the moderator and mediator distinction, both separately and in terms of a broader causal system that includes both moderators and mediators.
Many countries have set targets for suicide reduction, and suggested that mental health care providers and general practitioners have a key role to play.
A systematic review of the literature.
Among those in the general population who commit suicide, up to 41% may have contact with psychiatric inpatient care in the year prior to death and up to 9% may commit suicide within one day of discharge. The corresponding figures are 11 and 4% for community-based psychiatric care and 83 and 20% for general practitioners.
Among those who die by suicide, contact with health services is common before death. This is a necessary but not sufficient condition for clinicians to intervene. More work is needed to determine whether these people show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.
To describe the clinical circumstances in which psychiatric patients commit suicide.
National clinical survey. Setting: England and Wales.
A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death.
Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending.
10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases.
Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.
This study examined rates of contact with primary care and mental health care professionals by individuals before they died by suicide.
The authors reviewed 40 studies for which there was information available on rates of health care contact and examined age and gender differences among the subjects.
Contact with primary care providers in the time leading up to suicide is common. While three of four suicide victims had contact with primary care providers within the year of suicide, approximately one-third of the suicide victims had contact with mental health services. About one in five suicide victims had contact with mental health services within a month before their suicide. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Older adults had higher rates of contact with primary care providers within 1 month of suicide than younger adults.
While it is not known to what degree contact with mental health care and primary care providers can prevent suicide, the majority of individuals who die by suicide do make contact with primary care providers, particularly older adults. Given that this pattern is consistent with overall health-service-seeking, alternate approaches to suicide-prevention efforts may be needed for those less likely to be seen in primary care or mental health specialty care, specifically young men.
Suicide is the 11th leading cause of death and the seventh leading cause of years of potential life lost in the United States. Although suicide is of great public health significance, its clinical management is complicated.
The authors systematically reviewed the literature to determine whether screening for suicide risk in primary care settings decreases morbidity, mortality, or both.
MEDLINE (1966 to 17 October 2002), PsycINFO, Cochrane databases, hand-searched bibliographies, and experts.
For screening, only English-language studies performed in primary care settings were examined. For treatment, randomized, controlled trials and cohort studies were included if they were performed in any setting where suicide completions, suicide attempts, or suicidal ideation were reported.
A primary reviewer abstracted data on key variables of study sample, design, and outcomes; a second reviewer checked information accuracy against the original articles.
No study directly addressed whether screening for suicide in primary care reduces morbidity and mortality. The remainder of the review focused on the questions of reliable screening tests for suicide risk and the effectiveness of interventions to decrease depression, suicidal ideation, and suicide attempts or completion. One screening study provided limited evidence for the accuracy of suicide screening in a primary care setting. Intervention studies provided fair and mixed evidence that treating those at risk for suicide reduces the number of suicide attempts or completions. The evidence suggests mild to moderate improvement for interventions addressing intermediate outcomes such as suicidal ideation, decreased depressive severity, decreased hopelessness, or improved level of function.
Because of the complexity of studying the risk for suicide and the paucity of well-designed research studies, only limited evidence guides the primary care clinician's assessment and management of suicide risk.
Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized.
To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms.
Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none).
Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004.
One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%.
The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits.
Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics.
Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001).
Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.
In 2002, an estimated 877,000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated.
To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research.
Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide.
Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented.
Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.
Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.
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.
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.
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.
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.
Most national suicide prevention strategies set improved detection and management of depression in primary health care into a central position. However, suicidal behaviour among primary-care patients with depressive disorders has been seldom investigated.
In the Vantaa Primary Care Depression Study, a total of 1119 primary-care patients in the City of Vantaa, Finland, aged 20 to 69 years, were screened for depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. Depressive disorders were diagnosed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and the 137 patients with depressive disorder were included in the study. Suicidal behaviour was investigated cross-sectionally and retrospectively in three time-frames: current, current depressive episode, and lifetime. Current suicidal ideation was measured with the Scale for Suicidal Ideation (SSI), and previous ideation and suicide attempts were evaluated based on interviews plus medical and psychiatric records.
Within their lifetimes, 37% (51/137) of the patients had seriously considered suicide and 17% (23/137) attempted it. Lifetime suicidal behaviour was independently and strongly predicted by psychiatric treatment history and co-morbid personality disorder, and suicidal behaviour within the current episode was predicted most effectively by severity of depression.
Based on these findings and their convergence with studies of completed suicides, prevention of suicidal behaviour in primary care should probably focus more on high-risk subgroups of depressed patients, including those with moderate to severe major depressive disorder, personality disorder or a history of psychiatric care. Recognition of suicidal behaviour should be improved. The complex psychopathology of these patients in primary care needs to be considered in targeting preventive efforts.
To examine characteristics of general practice consultations in a New Zealand primary care population of patients who died by suicide.
Case control study design, with data linkage between the RNZCGP Research Unit Database, the National Mortality Database and the Hospital Separation Diagnosis Database (hospital discharges) from 1996 to 2001. The cases were suicides who had attended a general practice contributing data to the Research Unit database. Each case was matched by gender and age to three randomly selected patients from the Research Unit database.
There were 221 cases of suicide identified, of which 60% had a general practice consultation in the 6 months prior to death. The significant exposure variables, corrected OR (95% CI) in the multivariate analysis were: any previous hospital admission (between January 1996 and date of death) for a psychiatric condition, 23.75 (9.01 to 62.63); any notation in the general practice record of depression, suicidal ideation or self-harm, 14.97 (4.61 to 48.65); previous hospital admission with self-harm, 8.39 (1.73 to 40.65); and general practice prescription of sedatives, 4.34 (1.69 to 11.10).
In general, general practice patients who commit suicide have higher rates of depression, suicidal ideation, previous self harm, and sedative prescription than average.
Previous research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents' perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties.
Cross-sectional, national mail survey of resident physicians in their last year of training.
Eleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%).
Male residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty.
Across primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents' preparedness to provide cross-cultural care.
The purpose of this study was to ascertain physician characteristics associated with exploring suicidality in patients with depressive symptoms and the influence of patient antidepressant requests.
Primary care physicians were randomly recruited from 4 sites in northern California and Rochester, NY; 152 physicians participated (53%-61% of those approached). Standardized patients portraying 2 conditions (major depression and adjustment disorder) and 3 antidepressant request types (brand specific, general, or none) made unannounced visits to these physicians between May 2003 and May 2004. We examined factors associated with physician exploration of suicidality.
Suicide was explored in 36% of 298 encounters. Exploration was more common when the patient portrayed major depression (vs adjustment disorder) (P = .03), with an antidepressant request (vs no request) (P=.02), in academic settings (P <.01), and among physicians with personal experience with depression (P <.01). The random effects logistic model revealed a significant physician variance component with rho = 0.57 (95% confidence interval, 0.45-0.68) indicating that there were additional, unspecified physician factors determining the tendency to explore suicide risk. These factors are unrelated to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confidence in treating depression.
When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality. Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help. Research is needed to further elucidate physician characteristics associated with the assessment of suicidality.
The aim of our study was to investigate the influence of gender, loss of academic year(s), confidence and attitudes of students on the clinical experience gained by undergraduate education. The survey was conducted during 2004 and 2005 in a sample of 182 students of the 5th and the 6th year at J.J. Strossmayer University School of Medicine in Osijek. The participants were grouped and matched according to their gender, regular studying, the number of time(s) student has performed certain practical medical procedure and the self-confidence arisen by performing one. Furthermore, participants were grouped and compared due to their own assessment of their own practical and theoretical medical knowledge, courses which provide them the least and oppositely--the most practical medical knowledge and their attitude toward current medical faculty curriculum on clinical courses as well as the possibilities of improving them. Fisher's exact test and chi2-test were used to estimate statistical differences between the groups and the parameters in research, while coefficient of contingency was introduced with the aim of defining their correlation. The results showed statistically significant differences between male students who performed more practical medical procedures than female (p < 0.001), non-repeaters performed medical procedures more often than repeaters (p < 0.001, C = 0.658) while repeaters thought higher of their theoretical knowledge than non-repeaters (p < 0.005). Data analysis showed statistically significant correlation between clinical experience and the level of confidence (C = 0.944). This study confirmed influence of male gender, regular studying, better opinion about one's own practical skills and higher confidence in one's own work on greater number of clinical skills performed during undergraduate education.
Depression is a highly prevalent condition in primary care settings. In our previously reported work, we investigated the processes and conditions that influence primary care clinicians' recognition of depression. Three conditions influence the recognition of depression: familiarity with the patient, time available, and clinical experience. This article further describes the role of clinical experience in depression care.
The grounded theory method was used to guide data collection and analysis. In-depth, in-person interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed.
We identified 3 areas that comprise clinical experience relevant to depression care: (1) knowing one's professional role, (2) knowing oneself, and (3) knowing one's patients. In knowing one's professional role, 4 subdimensions were identified: (1) becoming familiar with illness patterns and clinical skills, (2) learning what works in the real world, (3) understanding what being a doctor is about, and (4) thinking of the whole person. The analysis indicated that clinical experience results from professional and personal growth during interactions with patients. The outcome of this developmental process was the achievement of comfort with depression care, a critical mediating variable that influenced primary care clinicians' recognition of depression.
The developmental process of attaining comfort in managing depression warrants further exploration. Developing interventions to speed this process offers another approach to enhancing care for the management of depression.
Objectives-This report presents final 2014 data on U.S. deaths, death rates, life expectancy, infant mortality, and trends, by selected characteristics such as age, sex, Hispanic origin, race, state of residence, and cause of death.
Aim: To compare patients' rates of endorsement of suicidal ideation during routine medical appointments with their primary care provider (PCP) versus rates of endorsement on a self-report symptom screening measure. Methods: PCPs referred 338 patients with identified psychosocial health-related issues to a behavioral health consultant (BHC) service fully integrated in a family medicine clinic. All referred patients completed the Behavioral Health Measure-20 (BHM) as part of routine clinical practice. Results: Of the 338 patients referred to the BHC service, 42 (12.4%) screened positive for suicidal ideation, of which only 7 (2.1%) disclosed suicidal ideation to their PCP during the medical appointment immediately preceding referral to the BHC. Use of the BHM to screen primary care patients referred to the BHC improved detection of patients with suicidal ideation by 600%. Conclusions: Routine suicide screening of primary care patients using a brief self-report measure can substantially improve the ability to identify at-risk patients in primary care, which can contribute to early detection and enhanced clinical decision-making.
Background: There is widespread consensus on the benefits of incorporating preventive medicine into health care delivery and on the need for increased medical school teaching in this area. The substantial evidence linking personal behaviors to leading causes of death supports our concentration on teaching strategies to promote behavioral change as a fundamental skill for physicians. Description: We designed, implemented, and evaluated a preventive medicine module for 3rd-year medical students. Instruction was based on the integration of preventive services into clinical practice using learner-centered and competency-based instructional approaches for students and patients. A counseling model that is generalizable to a variety of risky personal behaviors and that integrates physician-patient communication strategies was used. Evaluation: We found no appreciable change in attitudes, but our study found significantly increased levels of student self-confidence in ability to both screen for risk factors and effect behavioral change in their patients. Students who participated in the preventive medicine module demonstrated greatly increased ability to modify patient behavior. Conclusion: Our teaching model, based on adult learning theory and integrated into the medicine clerkship, was effective in increasing students' self-efficacy and competence in behavioral change counseling.
Electronic mail (e-mail) has been used to distribute surveys and collect data from online users for almost fifteen years. However, some have suggested that the use of e-mail is becoming obsolete. This study analyzes response rates to e-mail surveys undertaken since 1986 and examines five influences to response rates: the year the study was undertaken, the number of questions in the survey, the number of pre-notification contacts, the number of follow-up contacts and survey topic salience. Response rates to e-mail surveys have significantly decreased since 1986. Correlation and regression analyses suggest that year that the survey was undertaken and number of follow-up contacts had the most influence on response rates. A discussion of other influences and future research into this area is provided.
Depression is inadequately treated in primary care (PC), primarily because of a failure to recognize symptoms of depression. The results can be catastrophic and include death by suicide. The prevention of suicide is a critical function of physicians. The recognition of depression is the first step to preventing suicide because suicide predominately occurs during depression. The traditional, comprehensive psychiatric interview typically taught by academic psychiatry may inhibit recognition in PC settings because it takes too much time. Attempts to integrate a brief psychiatric interview into the PC-patient interaction to meet these needs of increasing recognition have had mixed results. Instruction to medical students on psychiatry in the use of an ultra-brief screening instrument for these disorders, suitable for the time-pressured PC environment, could help attain the goal of improved recognition. A Four-Question, 90-Second Depression Screen is described and recommended. The author offers a detailed format for establishing an interview course to impart such skills that is appropriate for students and residents in their psychiatry or PC rotations.
To describe the prevalence and clinical characteristics of primary care patients who report suicidal ideation during the month before their medical visit.
Analysis of a self-administered suicidal ideation screening item using sociodemographic data, treatment history, and clinical data from structured interviews.
Three Rhode Island private family practices, a South Carolina family medicine residency, and a California prepaid internal medicine group practice.
Adult primary care patients (N = 2,749), 18 to 70 years old, who are able to read and write English, able to complete study forms, and willing to provide informed consent.
Sixty-seven (2.44%) of the patients reported suicidal ideation ("feeling suicidal") during the past month, and most of those patients (58.2%) received no mental health care during that time. The adjusted risk of suicidal ideation was significantly elevated for patients with self-reported fair or poor physical health (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5, 4.1), fair to poor emotional health (OR 18.0; 95% CI 8.8, 37.0), marital distress (OR 4.4; 95% CI 2.2, 8.8), and recent mental health-related work loss (OR 6.3; 95% CI 3.7, 10.5). In the California sample, patients with major depression (R 31.2; 95% CI 12.8, 76.1). generalized anxiety disorder (OR 23.4; 95% CI 8.1, 67.1), and drug abuse or dependence (OR 9.6; 95% CI 2.9, 31.6) were at increased risk of suicidal ideation. The "feeling suicidal" item identified 10 of 12 patients who acknowledged a recent plan to kill themselves.
In these primary care patients, suicidal ideation is strongly associated with mental disorder and mental health-related functional impairment, and can be detected with a single self-report "feeling suicidal" item.
Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal.
To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders.
A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care.
Of 2316 physicians with known eligibility, 1350 (58.3%) returned the questionnaire. Respondents were family physicians (n = 621), general internists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs report recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9%), diagnosis based on formal criteria (33.7%), direct questioning about suicide (58%), and assessment for substance abuse (68.1%) or medical causes of depression (84.1%). Reported treatment practices were watchful waiting only (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant medication prescription (72.5%), and mental health referral (38.4%). Diagnostic evaluation and treatment approaches varied significantly by specialty but not by the type of depression or degree of capitation. Physician barriers differed by specialty more than by degree of capitation. In contrast, organizational barriers, such as time for an adequate history and the affordability of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were common but did not vary by physician specialty or degree of capitation.
A substantial proportion of PCPs report diagnostic and treatment approaches that are consistent with high-quality care. Differences in approach were associated more with specialty than with type of depressive disorder or degree of capitation. Quality improvement efforts need to (1) be tailored for different physician specialties, (2) emphasize the importance of differentiating major depression from other depressive disorders and tailoring the treatment approach accordingly, and (3) address organizational barriers to best practice and knowledge gaps about depression treatment.
Adolescent suicide rates have increased dramatically in recent decades. Suicide is the third leading cause of mortality among persons aged 10 to 19 years. Several official guidelines recommend screening for suicidal behavior in the primary care setting.
To determine the prevalence of adolescent suicidal behavior known to primary care providers and to determine the knowledge, attitudes, and practice of primary care physicians in Maryland regarding screening for risk factors for adolescent suicide.
Cross-sectional study using mailed survey.
Maryland from May to July 1995.
All pediatrician (n = 816) and family physician (n = 592) members of the state chapter of the American Academy of Pediatrics and the American Academy of Family Physicians, respectively, who were actively providing ambulatory care.
Adolescent suicidal behavior known to primary care providers and predictors of routine screening for risk factors for adolescent suicide.
The response rate was 66%. Three hundred twenty-eight physicians (47%) reported that 1 or more adolescent patients attempted suicide in the previous year, but only 158 (23%) either frequently or always screened adolescent patients for suicide risk factors. Significant factors correlating with routine screening for suicide risk factors included frequently or always counseling about the safer storage of firearms in the home (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.8-10.2); agreeing or strongly agreeing that they were sufficiently trained and knew how to screen for risk factors (OR, 3.2; 95%/CI, 1.7-6.3); agreeing or strongly agreeing that they had enough time during the well visit to screen for mental health problems (OR, 2.9: 95% CI, 1.6-5.3); frequently or always counseling about child passenger safety (OR, 2.7; 95% CI, 1.6-4.7); spending more than 5 minutes in anticipatory guidance during the well visit (OR, 2.7: 95% CI, 1.5-4.6); practicing in an urban setting (OR, 2.3; 95)% CI, 1.2-4.7); agreeing or strongly agreeing that physicians can be effective in preventing adolescent suicide and that what they do during an office visit may help prevent adolescent suicide (OR, 2.0; 95% CI, 1.2-3.4); and female sex (OR. 1.9; 95% CI, 1.1-3.2).
Despite the substantial proportion of primary care providers who encountered suicidal adolescent patients, most providers still do not routinely screen their patients for suicidality or associated risk factors. More training is needed and desired by the survey respondents. Patient confidentiality issues must be addressed. Development and widespread use of a short, easily administered, reliable, and valid screening tool are recommended to help busy clinicians obtain more complete information during all visits.
To determine the effectiveness of a training program for general practitioners in recognising and responding to psychological distress and suicidal ideation in young people.
The study, conducted in general practice surgeries in Tasmania, Victoria and Western Australia in 1996 and 1997, used a pre-/posttest design to audit consecutive young patients presenting in the six weeks before and the six weeks after the GPs' participation in the training program.
Consisted of 23 GPs who attended a youth suicide prevention workshop and 423 patients aged 15-24 years who presented to the GPs' surgeries (203 pre-workshop and 220 post-workshop).
GPs attended a one-day training workshop designed to enhance their ability to recognise, assess and manage young patients at risk of suicide.
Scores on three patient self-report inventories (General Health Questionnaire-12 [GHQ-12], Center for Epidemiological Studies Depression Scale [CES-D] and Depressive Symptom Inventory--Suicidality Subscale [DSI-SS]); a GP-completed form for each patient summarising presenting complaint(s), psychological assessment and proposed management plan.
After training, GPs demonstrated increased recognition rates of psychologically distressed patients scoring above the cut-offs of the GHQ-12 (48% increase; odds ratio [OR], 1.748; 95% CI, 0.904-03.381) and CES-D (39.5% increase; OR, 2.067; 95% CI, 1.031-4.143); enquiry about suicidal ideation increased by 32.5% (OR, 1.483; 95% CI, 0.929-2.366); and identification of suicidal patients (determined by DSI-SS score) increased by 130% (OR, 3.949; 95% CI, 1.577-9.888). Training did not lead to any significant change in GPs' patient management strategies.
A one-day training course can significantly enhance GP detection rates of psychological distress and suicidal ideation in young patients, but higher recognition rates do not necessarily lead to changes in patient management.
Men and women interact differently with the learning environment. Women's standards and goals are responsive to social and environmental influences. Men seem relatively indifferent but check their performance against strongly internalized standards. The purpose of this study was to discover how these interactions determined achievement.
A longitudinal study examined students on their first clinical firms. Students' view of the learning environment was measured as their attribution style. Perceived self-efficacy, anxiety and fear of negative evaluation were also measured at the start of the course and again 3 months later. Path analysis was used to connect these measures to achievement assessed in tests of knowledge and skills after a further 3 months.
Men and women showed significant differences. In both, a perception that bad events in the learning environment were persistent and pervasive appeared to be causal of high achievement in tests of knowledge. In men this was dominantly mediated through fear of negative evaluation and anxiety. In women the path appeared to be direct and associated with a sense of reduced self-efficacy. Men also showed two additional and opposing paths to achievement when good events were pervasive and persistent. For some, achievement was improved. Others experienced a reduction in anxiety and performed poorly.
Achievement in men demands arousal. This is greatest in environments that provide frequent opportunities for comparison of their performance with their internal standards. Achievement in women seemed consequential on a re-evaluation of their sense of efficacy in adverse environments. Persisting with attempts to manage learning in a socially unresponsive environment can cause unproductive anxiety and poor performance.
To clarify whether screening adults for depression in primary care settings improves recognition, treatment, and clinical outcomes.
The MEDLINE database was searched from 1994 through August 2001. Other relevant articles were located through other systematic reviews; focused searches of MEDLINE from 1966 to 1994; the Cochrane depression, anxiety, and neurosis database; hand searches of bibliographies; and extensive peer review.
The researchers reviewed randomized trials conducted in primary care settings that examined the effect of screening for depression on identification, treatment, or health outcomes, including trials that tested integrated, systematic support for treatment after identification of depression.
A single reviewer abstracted the relevant data from the included articles. A second reviewer checked the accuracy of the tables against the original articles.
Compared with usual care, feedback of depression screening results to providers generally increased recognition of depressive illness in adults. Studies examining the effect of screening and feedback on treatment rates and clinical outcomes had mixed results. Many trials lacked power to detect clinically important differences in outcomes. Meta-analysis suggests that overall, screening and feedback reduced the risk for persistent depression (summary relative risk, 0.87 [95% CI, 0.79 to 0.95]). Programs that integrated interventions aimed at improving recognition and treatment of patients with depression and that incorporated quality improvements in clinic systems had stronger effects than programs of feedback alone.
Compared with usual care, screening for depression can improve outcomes, particularly when screening is coupled with system changes that help ensure adequate treatment and follow-up.
Suicide is a critical public health problem that primary care physicians potentially can help address given that distressed patients frequently visit them in the weeks and months preceding the successful suicide. This article considers factors placing the patient at high risk for successful suicide and clinical assessment techniques available to the primary care physician. Patients who wish to harm themselves but still lack an articulated plan for doing so can be treated by the primary care physician with the monitoring assistance of a depression care manager and appropriate consultation by a mental health specialist.