Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis

摘要

Objective To characterise suicide-risk discussions in depressed primary-care patients. Design Secondary analysis of recordings and self reports by physicians and patients. Descriptive statistics of depression and suicide-related discussion, with qualitative extraction of disclosure, enquiry and physician response. Setting 12 primary-care clinics between July 2003 and March 2005. Participants 48 primary-care physicians and 1776 adult patients. Measures Presence of depression or suicide-related discussions during the encounter; patient and physician demographics; depression symptom severity and suicide ideation as measured by the Patient Health Questionnaire (PHQ9); physician's decision-making style as measured by the Medical Outcomes Study Participatory Decision-Making Scale; support for autonomy as measured by the Health Care Climate Questionnaire; trust in their physician as measured by the Primary Care Assessment Survey; physician response to suicide-related enquiry or disclosure. Results Of the 1776 encounters, 128 involved patients scoring 14 on the PHQ9. These patients were seen by 43 of the 48 physicians. Suicide ideation was endorsed by 59% (n=75). Depression was discussed in 52% of the encounters (n=66). Suicide-related discussion occurred in only 11% (n=13) of encounters. 92% (n=12) of the suicide discussions occurred with patients scoring 2 on PHQ9 item 9. Suicide was discussed in only one encounter with a male. Variation in elicitation and response styles demonstrated preferred and discouraged interviewing strategies. Conclusions Suicide ideation is present in a significant proportion of depressed primary care patients but rarely discussed. Men, who carry the highest risk for suicide, are unlikely to disclose their ideation or be asked about it. Patient-centred communication and positive healthcare climate do not appear to increase the likelihood of suicide related discussion. Physicians should be encouraged to ask about suicide ideation in their depressed patients and, when disclosure occurs, facilitate discussion and develop targeted treatment plans. Article focus Determine frequency of suicide-related discussions in routine primary-care encounters with depressed patients along with demographic predictors. Identify process variables that may or may not influence the likelihood that suicide will be discussed in primary care. Analyse interview style related to enquiring about suicide and responding to patient responses to enquiry as well as unsolicited disclosure. Key messages Suicide is addressed in a small minority of encounters with depressed patients in primary care. Suicide is rarely discussed with depressed male patients who are at high risk for suicide. Physician enquiries related to suicide are often made with patients who have the lowest levels of ideation, and the enquiries themselves are often biased to elicit a denial of ideation.