Preventing Suicide among Depressed Patients in Primary Care Practice

Suicide prevention is an important task in primary care practice [1]. Most suicide victims contact a primary care physician within a month before their death [1], and 1% to 10% of primary care patients report suicidal ideation, which highly suggests that suicide risk evaluation and management of suicidality are inherent to primary care practice [2].

Studies have shown that most suicide ideators, attempters, and completers suffer from one or more psychiatric illness [3]. However, about 50% of individuals who complete suicide have never been treated for a psychiatric disorder [3]. Despite the increasing efforts to improve detection and treatment of psychiatric disorders in primary care, depression and other psychiatric disorders are under-recognized and under-treated in this setting [1]. Improving physician's knowledge about mental disorders associated with a high risk for suicidal behaviour, implementing screening procedures, and improving suicide risk evaluation are all important components of suicide prevention [1].

Screening aims to recognize at-risk individuals and direct them to treatment [1]. Primary care physicians have been recommended to focus primarily on patients experiencing depression [2]. Indeed, major depression carries as much as a 20-fold increase in lifetime risk of suicide [4]. Studies investigating suicidality in response to primary care physician education programs, mostly targeting depression identification and treatment, have often reported considerable declines in suicide rates [1]. However, the idea that all depressed patients are at high risk for suicide has recently been challenged [5]. Vuorilehto et al.[5] studied patients with depressive disorders treated in a primary care clinic in a Finnish city. The authors showed that non-fatal suicidal behaviour clustered almost completely in subjects with moderate to severe major depressive disorder, psychiatric co-morbidity with personality disorders, and a history of psychiatric care, and suggested that prevention of suicidal behaviour in primary care should focus more on high-risk subgroups of depressed patients. Schulberg et al.[2] reported that among primary care subjects with an uncomplicated depression, about 90% had no risk or a low risk of self-harm based on the presence and nature of suicidal ideation. Moreover, almost all patients initially classified as having no risk or low risk level for suicidality continued at these levels at 3 and 6 months of follow-up. These converging results, if replicated, may have profound impact in suicide prevention in primary care. All patients with depression should be screened for suicidal ideation. However, primary care physicians should concentrate their prevention efforts for suicidal behaviour on depressed patients who belong to high-risk subgroups. Psychiatrists should educate primary care physicians about the role of psychiatric co-morbidity in suicidal behaviour. Future investigations are required to further delineate high-risk subgroups of depressed subjects for whom interventions may be more specifically targeted in primary care practice.