Practice recommendations
- Assess patients with major depression or substance abuse for suicide ideation, as they are at elevated risk for self-harm (B).
- Severity of suicide ideation is associated with suicide risk. Its assessment, therefore, should proceed sequentially from passive to active suicide ideation, to a specific detailed plan, including intention to harm oneself, reasons for living, and impulse control (B).
- Primary care patients at mild to moderate risk for suicide can be effectively treated in primary care settings (B); however, patients at high risk should be referred to mental health specialists given their need for intensive treatments and frequent monitoring (C).
"I think I’d be better off—and my family would be—if I were dead.” This surprising announcement was just made in your office by a lady who is 74 years old and suffers with chronic pain. Are her words an exaggerated expression of frustration and anger, or do they convey a real intention to harm herself? How would you explore her thoughts and feelings? What kind of follow-up is needed?
Risk of suicide must not be thought of as being merely present or absent. The significance of risk, if present, varies along a continuum. Specific elements in a patient’s history can help determine the level of risk, as can the information you glean from a structured interview process that we review in this article.
You are uniquely positioned to assess suicide risk
As a primary care physician, you are often in a better position to assess suicide risk than is a mental health specialist. Any patient with major depression or a substance abuse problem can be at risk for suicide. Accurately identifying suicide ideation can be complex with primary care patients who have severe medical illness, somatic symptoms of depression, pain, disability, and social and environmental adversity.
How prevalent is suicidal ideation in primary care? While most primary care patients do not experience suicide ideation, the rate of such ideation in this population is high compared with general community samples. In a review of 10 studies, any level of suicide ideation among midlife and elderly primary care patients ranged from 1% to 10% depending on the assessment method used,5 with rates up to 54% obtained for patients with depressive disorders.6
Suicidal patients often come to your attention first. Eleven studies15 of completed suicides found that, on average, 23% of victims aged 35 and younger and 58% of victims aged 55 and older visited a general physician in the month preceding suicide. These rates substantially exceed those seen in specialty mental health services. Since older adults and women of all ages see physicians more often than others do, they may particularly benefit from primary care assessment and intervention efforts.15
No data exist on rates of physician contact for suicide victims among ethnic minorities, but their rate may be lower given that minorities use health services at lower levels.16,17
Chart reviews revealed that 60% of patient visits by those who committed suicide included psychiatric components, such as depression or worry.18-20 However, suicidal patients explicitly informed their physician of suicide ideation or plans in only 19% to 54% of visits.18,21,22
Distinct levels of risk. According to the Diagnostic and Statistical Manual for Mental Health, 4th edition (DSM-IV),1 suicide ideation ranges from thoughts that life is not worth living or that one would be better off dead (passive suicide ideation), to thoughts about harming oneself (active suicide ideation), to specific plans for committing suicide. These distinctions are important. Pronounced suicide ideation not only increases the risk for self-harm among patients with major depression,2,3 it may also affect time to treatment response.4
As level of suicide risk increases, so does the need for your attention, to determine at regular intervals whether the level of risk has changed. Even a seemingly flip remark, as portrayed at the start of this article, may signal a desperate state of mind. At minimum, further psychiatric evaluation is warranted, as patients with suicide ideation often have a psychiatric disorder, such as major depression. Patients reporting a suicide plan or intention require immediate emergency room evaluation.
To ask or not to ask?
An older study23 found limited evidence for reliable screening of suicide ideation in general practice. A recent study24 found that physicians can be trained to accurately identify suicide ideation among their depressed patients.
Can asking about suicide provoke a suicide attempt? Some clinicians think so, but we know of no studies investigating this concern.