Suicidality overlooked in diagnosis of depression

In a randomized trial involving actors portraying patients with major depression, internists and family physicians usually failed to ask these patients about suicidality, even when they correctly made the depression diagnosis.

These primary care physicians were more likely to ask about suicide when the patient made specific requests for medication, compared with patients who made no such request. Physicians made suicidality inquiries about 46% of the time when depressed “patients” asked about medication but only 33% of the time when the same actors did not mention medication.

They knew the patient had depression. They were appropriately prescribing an antidepressant or referring. And yet, they failed to screen for suicidality. He finds this especially worrisome in light of other studies showing that about half of all people seek some sort of professional help during the month prior to their suicide.

Asking about medication also significantly affected whether the physicians actually issued a prescription. Depressed patients who made a brand-specific request left the office with a prescription 53% of the time (although not necessarily with that drug), those who made a general request for medication received a prescription 76% of the time, and those who made no request received a prescription 31% of the time.

The study involved 152 primary care physicians. One trained to portray major depression of moderate severity and the other to portray adjustment disorder with depressed mood — made unannounced visits to each preselected physician. Investigators informed the physicians that they would be visited by standardized patients (Sps) over the next several months and that each SP would present with a combination of common symptoms. They were told that the purpose of the study was to “assess social influences on practice and the competing demands of primary care.

To add verisimilitude, investigators provided each SP with a pseudonym, a fictitious local home and work address, a mobile telephone number, cash for copayment, and an insurance card obtained from a local insurance company. Two weeks after each visit, the physicians received a fax asking them to indicate whether they were suspicious that any of their patients over the past 2 weeks had been an SP. In only 12.8% of visits, they had been “definitely” or “probably” suspicious of at least one patient.

We were in cahoots with the office managers at each of these practices. Standardized patients have been used some in research, but not much, because it’s awfully complicated and expensive. They’re used widely now in medical education . . . as ways of assessing medical students’ competency.

We pointed out that while many primary care physicians find it uncomfortable to inquire about suicidality, it’s not hard to do. For example, they can ask patients to self-administer the Patient Health Questionnaire-9 (PHQ-9) depression scale, which includes a question about suicidality. Or the physician can simply ask, “This past week, have you had any thoughts that life is not worth living or that you’d be better off dead? An affirmative answer should trigger further questions to assess the patient’s degree of ideation and intent, whether he or she has developed a plan, and the availability and lethality of the method chosen.

Many physicians offer a “no suicide contract” to patients exhibiting suicidality. This involves an agreement that the patient will contact the physician or another health care provider if their suicidal feelings or plans escalate. They acknowledged that although this approach is based on clinical impression, it’s something many of us use, because it just makes us feel better to have this conversation with patients.