Professional Documents
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assessment
How to interview depressed patients and tailor
treatment
Richard L. Frierson, MD; Margaret Melikian, DO; Peggy C.
Wadman, MD
Suicide is the eighth leading cause of death in the United States (1). In
2002, more than 30,000 people will commit suicide in this country, the
equivalent of more than 80 suicides a day or one every 20 minutes. Self-
directed violence will result in more than 600,000 emergency department
visits.
Because primary care physicians are trained to diagnose and treat medical
illness (including depression), they are accustomed to dealing with patients
who seek help for problems and who desire to live rather than to die. A
suicidal patient may evoke significant strong emotions in a physician, such
as anger toward the patient or fear of losing the patient, of personal failure
in preventing suicide, or of medicolegal consequences if the patient makes
a serious or successful suicide attempt. However, despite these emotions,
physicians have tremendous potential to respond to this call to action by
arming themselves with the knowledge and skill to successfully treat
depressed patients and prevent suicide.
A recent survey of physicians who lost a patient to suicide found that risk
assessments had been completed in only 38% of cases (7). Another study
(8) suggests that many primary care physicians have an age bias that
makes them less likely to intervene or contemplate treating elderly suicidal
patients. Also, adequate assessment and management of suicidal ideation
become a time-consuming process that may significantly increase job
stress for already stressed physicians (9). We may be reluctant to ask what
we do not want to hear. A patient's admission of suicidal ideation makes
our jobs more difficult, and suicide risk assessment cannot be done
quickly.
Demographics
The rate of suicide in the United States is 10.6 per 100,000. Ninety percent
of people who commit suicide have a diagnosable mental disorder--
commonly depression or substance abuse (10). In 1997, suicides
outnumbered homicides by a 3:2 ratio. Suicides were twice as common as
deaths due to HIV and AIDS. Firearm use is the most common method of
committing suicide for both men and women and accounts for 58% of all
suicides. Four times as many men as women die by suicide, but women are
more likely to attempt suicide. White men commit 72% of all suicides
(11).
Risk factors
Psychotic symptoms
After assessing a patient's risk for suicide, physicians are faced with the
important decision of how to best care for the patient. Although most
patients with suicidal ideation can be treated as outpatients, others require
hospitalization. It is useful to categorize depressed patients who are
potentially suicidal into three groups: (1) patients with ideation, plan, and
intent, (2) patients with ideation and plan but without intent, and (3)
patients with ideation but no plan or intent.
Conclusion
Not all suicides are preventable, but a methodical approach to suicide risk
assessment enables physicians to treat severely depressed patients and
decrease the morbidity and mortality rates among those who make serious
suicide attempts. In addition, the stress of identifying and managing a
potentially suicidal patient may be reduced with an organized approach.
Finally, a comprehensive risk assessment helps reduce physician liability.
Although errors of judgment (ie, failure to accurately assess suicide
potential) are inevitable, errors of omission (ie, failure to adequately assess
suicide potential) are preventable if physicians take time to perform a
thorough suicide risk assessment.
References
1.
National Center for Injury Prevention and Control. Fact book for
the year 2000: suicide and suicidal behavior. Available at:
http://www.cdc.gov/ncipc/pub-res/factbook
/suicide.htm. Accessed Apr 8, 2002
2.
US Public Health Service. The surgeon general's call to action to
prevent suicide. Washington, DC: US Public Health Service, 1999.
Available at:
http://www.surgeongeneral.gov/library
/calltoaction/calltoaction.htm. Accessed Apr 8, 2002
3.
Power K, Davies C, Swanson V, et al. Case-control study of GP
attendance rates by suicide cases with or without a psychiatric
history. Br J Gen Pract 1997;47(417):211-5
4.
Harwood DM, Hawton K, Hope T, et al. Suicide in older people:
mode of death, demographic factors, and medical contact before
death. Int J Geriatr Psychiatry 2000;15(8):736-43
5.
Vassilas CA, Morgan HG. General practitioners' contact with
victims of suicide. BMJ 1993;307(6899):300-1
6.
Conwell Y. Suicide in elderly patients. In: Schneider LS, Reynolds
CF III, Lebowitz BD, et al. Diagnosis and treatment of depression in
late life: results of the NIH Consensus Development Conference.
Washington, DC: American Psychiatric Press, 1994:397-418
7.
Milton J, Ferguson B, Mills T. Risk assessment and suicide
prevention in primary care. Crisis 1999;20(4):171-7
8.
Uncapher H, Arean PA. Physicians are less willing to treat suicidal
ideation in older patients. J Am Geriatr Soc 2000;48(2):188-92
9.
Shea SC. The practical art of suicide assessment: a guide for mental
health professionals and substance abuse counselors. New York: John
Wiley, 1999:109-23
10.
Conwell Y, Brent D. Suicide and aging. I. Patterns of psychiatric
diagnosis. Int Psychogeriatr 1995;7(2):149-64
11.
National Institute of Mental Health. Suicide facts. Available at:
http://www.nimh.nih.gov/research/suifact.htm. Accessed Apr 8, 2002
12.
Patterson WM, Dohn HH, Bird J, et al. Evaluation of suicidal
patients: the SAD PERSONS scale. Psychosomatics 1983;24(4):
343-9
13.
Moscicki EK. Identification of suicide risk factors using
epidemiologic studies. Psychiatr Clin North Am 1997;20(3):499-517
14.
Roy A. Suicide. In: Kaplan HI, Sadock BJ, eds. Kaplan and Sadock's
synopsis of psychiatry: behavioral sciences/clinical psychiatry. 8th
ed. Baltimore: Williams & Wilkins, 1998:867-72
15.
Lyness JM, Cornwell Y, Nelson JC. Suicide attempts in elderly
psychiatric inpatients. J Am Geriatr Soc 1992;40(4):320-4
16.
Mann JJ, Waternaux C, Haas GL, et al. Toward a clinical model
of suicidal behavior in psychiatric patients. Am J Psychiatry
1999;156(2):181-9
17.
Conner KR, Cox C, Duberstein PR, et al. Violence, alcohol, and
completed suicide: a case-control study. Am J Psychiatry
2001;158(10):1701-5
18.
Jamison KR. Suicide and manic-depressive illness. In: Jacobs DG,
ed. The Harvard Medical School guide to suicide assessment and
intervention. San Francisco: Jossey-Bass, 1999:255-6
19.
Kroll J. Use of no-suicide contracts by psychiatrists in Minnesota.
Am J Psychiatry 2000;157(10):1684-6
S
ex (male)
A
ge (elderly or adolescent)
D
epression
P
revious suicide attempts
E
thanol abuse
R
ational thinking loss (psychosis)
S
ocial supports lacking
O
rganized plan to commit suicide
N
o spouse (divorced > widowed > single)
S
ickness (physical illness)
Adapted from Patterson et al (12).
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