• Understand the issues related to antidepressant management and suicidality.
Target Audience: Primary care physicians and psychiatrists.
CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.
This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: October 25, 2007.
Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.
To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by December 1, 2009 to be eligible for credit. Release date: December 1, 2007. Termination date: December 31, 2009. The estimated time to complete all three articles and the posttest is 3 hours.
Dr. Posner is director of the Suicide Classification Center at Columbia University, assistant professor in the Division of Child & Adolescent Psychiatry at Columbia University College of Physicians & Surgeons, and research scientist at New York State Psychiatric Institute. in New York City. Dr. Melvin is research scientist at the New York State Psychiatric Institute. Dr. Stanley is director of the Suicide Intervention Center at the New York State Psychiatric Institute/Columbia University College of Physicians & Surgeons.
Disclosure: Dr. Posner has received funding from the Food and Drug Administration to develop and implement the suicidality classification system used in their child antidepressant safety analyses. This system was subsequently used in the adult antidepressant safety analyses. As part of an effort to help execute the FDA suicidality classification mandates, Dr. Posner has had and will have research support from Abbott, Bristol-Myers Squibb, Cephalon, Eli Lilly, GlaxoSmithKline, Johnson and Johnson, Merck, Novartis, Organon, Pfizer, sanofi-aventis, Schwarz Pharma, Shire, Vivus, and Wyeth Research. Dr. Melvin reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Stanley receives grant support from the American Foundation for Suicide Prevention, the National Institute of Mental Health, and the National Institute on Alcohol Abuse and Alcoholism.
Please direct all correspondence to: Barbara Stanley, PhD, Division of Molecular Imaging, New York State Psychiatric Institute, Unit 42, 1051 Riverside Dr, New York, NY 10032; Tel: 212-543-5918; Fax: 212-543-6946; E-mail: email@example.com.
Suicide is a leading cause of death and a public health priority. In an attempt to reduce suicide rates, efforts have focused on detection and management of suicidal patients in primary care settings, given that an estimated 45% of suicide victims see their physician in the month prior to their death. Previous research suggests that limitations exist in primary care physicians’ (PCPs’) assessment and treatment of suicidal risk. Training programs addressing the detection of suicidal patients and management of suicidal risk in primary care settings have demonstrated significant improvement in practice. Hence, treatments are available to help PCPs assist with suicide prevention. Recent safety warnings about suicidal ideation and behavior associated with youths and young adult antidepressant treatment have led to sharp declines in prescribing, particularly by PCPs. Concern now exists about under-treatment of depression and the subsequent impact on suicide rates. This article reviews recent literature and provides an overview of suicide risk factors and assessment of suicide risk. The importance of assessing and managing suicidal ideation and behavior and risk factors is highlighted.
Suicide remains a leading cause of mortality, with elderly males at greatest risk.1 Training general medical professionals in the detection and management of suicide risk is a core component of national suicide prevention efforts.2 A review of studies found that on average 45% of individuals who commit suicide had contact with their primary care physician (PCP) in the month prior to suicide and 77% had contact in the previous year,3 placing PCPs in a unique position to prevent suicide. In addition, PCPs also regularly see patients with psychiatric disorders who are at risk of suicide. Olfson and colleagues4 reported that of those attending general medical care in the United States, 18.9% had major depressive disorder (MDD), 7.9% met criteria for substance abuse, and 7.1% experienced suicidal ideation. These three factors are major risks for suicide and suicide attempts. Epidemiologic studies have shown that the majority of suicide attempters will die on their first attempt.5 Given this, individuals who complete suicide on their first attempt are probably less likely to have been engaged by mental health professionals for specialist care but more likely to have been seen in the primary care setting. Moreover, a minority of suicide completers had contact with mental health services in the month prior to their suicide3 and almost 75% of those seeking help for depression will see their PCP rather than a mental health professional.6 Thus, PCPs are uniquely situated to play a critically important role in the prevention of suicide. This may be particularly the case in the at-risk population of elderly men, who may seek care for medical problems,7 providing the PCP with an opportunity to assess suicide risk.
A physician’s ability to assess, monitor, and treat suicide risk is dependent on his or her training, knowledge, skills, and attitudes. Previous studies have identified limitations in PCPs’ suicidal risk management skill and barriers that impede their practice.6,8,9 Gaps in suicide and depression training have been detected in primary care academic programs.10 However, with skills training, improved PCP management of suicidality has been demonstrated. The importance of assessment, monitoring, and treatment of suicidality in a primary care setting is discussed along with an overview of the current state of knowledge.
Assessment and Monitoring
Previous studies of suicide completers have demonstrated the need for routine suicide risk assessment in primary care. For example, in a retrospective review of the final primary care appointment prior to suicide, only two of 61 cases had a comment noted about suicide risk,11 potentially suggesting the need for more systematic practice in the assessment of suicide risk. In a retrospective review of completed suicide cases, Isometsa and colleagues12 found that 19% of PCPs knew about the suicidal intentions of their patients compared with 59% of psychiatric practitioners, perhaps highlighting that suicidality is not typically inquired about in general practice. However, assessment of psychiatric issues, including suicidality in primary care, is complicated by physician time pressure and competing needs to assess presenting medical issues.6 As previously mentioned, approximately 50% of suicide completers visit their PCP in the month prior to completing suicide. However, some demographic groups are less likely to be seen, such as males <35 years of age.3 Detecting those at risk may also be challenging because, while suicides may be seen before their death, it is usually for stated reasons quite unrelated to mental health or risk factors for suicide. However, Appleby and colleagues11 found 64% of 61 suicide completers reported psychological complaints at their visits to their general practitioner in the three months prior to suicide. The importance of improved detection is not diminished by suicide being a relatively rare event in primary care13 as some risk factors such as depressive disorders4 are quite common. Further risk assessment can detect and potentially prevent the more frequent suicide attempts, which are of significance on their own and are a cause of burden on the healthcare system.
The importance of suicide risk assessment in primary care and the challenges for PCPs in conducting this clinical task have prompted investigations into improved practices. Evidence suggests that significant improvements in PCP suicide assessment practices can be detected following the implementation of training programs.14,15 Within the Skills Training on Risk Management (STORM) project, PCPs and other professionals demonstrated a significant improvement following a 6-hour training course on the assessment and management of suicide risk.14 The focus of assessment training was on suicide risk, mental state, and psychosocial problems. Nutting and colleagues15 found that 41% of patients seen within programs designed to improve quality of depression care were identified with suicidal ideation compared with 21% within a usual care group.
Suicide risk factors are important for a PCP to consider when forming an opinion about suicide risk. Two of the strongest and most important risk factors for suicide are past suicidal behavior and ideation16,17 as well as MDD.18,19 Other psychiatric disorders known to raise risk include alcohol and substance use disorders, schizophrenia, bipolar disorder during depressive or mixed phase, and anxiety disorders.12,19,20 The psychological trait of hopelessness is also known to increase risk.21 Being male quadruples risk and those ≥65 years of age are in the age range typically at greatest risk.1 Those who have experienced sexual abuse22 or have a family history of suicide and/or sexual abuse are also at elevated risk.23 In addition to psychiatric and demographic factors, some chronic illnesses such as epilepsy,24 AIDS,25 multiple sclerosis,26 stroke,27 and myocardial infarction28 raise risk of suicide. Chronic illness has been found to be a greater risk factor in older men than older women.29 These risk factors should be determined in the first appointment with a patient when taking his or her history, along with the family history of mental health.
There is often reluctance on the part of physicians to ask about mental health issues, particularly suicidality. In conducting a risk assessment, physicians should not hesitate to ask the patient about both suicidal ideation and behavior. Gould and colleagues30 dispelled the clinical myth that asked if suicidality has iatrogenic effects, clearly demonstrating that asking does not cause distress or suicidal thinking. A risk assessment needs to include questions about suicidal ideation (eg, wishes to die, thoughts about committing suicide, any plans for suicide, and “intent” to act on such thoughts) and behavior (eg, preparations for a suicide attempt, past suicidal behavior) as well as risk factors previously described. If a patient reports a suicidal plan, any suicidal intent, and/or access to suicidal method (eg, gun), risk is likely elevated. An assessment of suicide risk is a clinical opinion valid for that point in time which the practitioner is required to reasonably act upon according to the level of risk that is present to ensure the safety of the patient (eg, schedule a further appointment for treatment or refer to a mental health professional).
Patients identified as being at risk of becoming suicidal or those who have a level of suicidal ideation or behavior judged appropriate for management in the primary care setting should be monitored for risk at regular intervals. It is important to remember that suicide risk should not be assumed to be stable over time. Schulberg and colleagues31 reported on a clinical trial in which patients with uncomplicated depression, including some with suicidal ideation, were monitored and managed within a primary care setting over a 6- or 12-month time frame. At a simple level, the trial demonstrated that PCPs could successfully monitor depressed patients with suicidal ideation over a sustained period, but it was also found that suicidal ideation largely declined or remained stable throughout the trial. The impact of monitoring suicidality was demonstrated recently in a study of subjects with borderline personality disorder.32 Participants received monitoring of their suicidal symptoms for 1 year and made 80% fewer attempts compared with the previous year.
The use of screening instruments can be a helpful technique to assess suicidal risk. Items that measure suicidal ideation and behavior are usually contained within measures of depression. Recommended depression measures include the Patient Health Questionnaire33 and the Beck Depression Inventory for Primary Care,34 both of which have demonstrated psychometric properties in primary care. For a specific measure designed to assess and track suicidal ideation and behavior (eg, suicide attempts, wish to die, thoughts of suicide, plan and intent) the Columbia-Suicide Severity Rating Scale (C-SSRS) is recommended as a helpful tool. The C-SSRS is a brief, low-burden questionnaire administered by the clinician.35
Screening for prominent suicide risk factors of depressive36 and alcohol use disorders37-39 can be effectively performed in primary care settings and leads to an improved rate of detection. Detection of these disorders provides an opportunity for the implementation of treatment intervention or referral that may be useful in reducing risk factors for suicidality. Psychometrically sound measures to screen for alcohol use disorders and hazardous drinking include the four-item CAGE questionnaire40,41 and the 10-item Alcohol Use Disorder Identification Test (AUDIT). Abbreviated versions of the AUDIT with similar psychometric properties42,43 such as five-item AUDIT-PC44 may be more practical in primary care settings.
In recent years, treatment programs for depression with suicidal ideation specific to the general practice setting have been developed and demonstrated to be superior to usual care. Treatments typically involve a physician training component, antidepressant treatment, as well as an adjunctive counseling component provided by another practice staff member. Bruce and colleagues45 demonstrated that a depression and suicidal ideation management program comprising treatment guidelines (psychopharmacology, interpersonal psychotherapy), physician education, and care managers who monitored treatment and in some cases provided therapy, was superior to usual care in reducing suicidal ideation and depression in older patients with depression. Unützer and colleagues46 compared a collaborative care treatment comprising antidepressant medication plus a course of problem-solving treatment provided by a psychologist or registered nurse to treatment as usual in a sample of elderly depressed patients with or without suicidality. Significantly greater declines in suicidal ideation were evident in the collaborative care group compared to the treatment as usual group.
Non-mental health professionals, including PCPs, trained in the STORM project showed significant improvement in their overall ability to manage suicidality, with specific gains in managing suicidal intent, removal of lethal means, and arrangement of appropriate support.14 Comparison of suicide rates in the district in which training was conducted in the years pre- and post-training did not differ.47 This is not surprising given only 39% of the district’s practitioners were trained, the rarity of suicide, and the tendency for suicide rates to be influenced by multiple factors.
In addition to the specifically developed treatments for suicidal depression, treatment of depression may also reduce risk of suicidality. In a review of effective primary care treatment strategies, Gilbody and colleagues48 found that collaborative care between a PCP and psychiatrist or psychologist was associated with improved treatment outcome and lower treatment cost for those with MDD. Models have been developed to enable best practice care of depression in primary care. Oxman and colleagues49 describe a three-component model that comprises education for clinicians and office staff about skills and procedures; care management, the focus of which is the use of telephone calls to educate and monitor progress and treatment compliance; and mental health interface, which includes involvement of a consulting psychiatrist who supervises clinicians and is available for consultation and referral.
Antidepressants are an effective treatment for depressive disorders in primary care settings.50 Ensuring that patients treated with antidepressants are receiving an adequate dose is an important treatment consideration as evidence points to the widespread practice of inadequate dosing.51 Evidence of inadequate dosing has been found in patients who completed suicide while in treatment in primary care11 as well as in depressed patients in community care.52 The Agency for Health Care Policy and Research Practice Guidelines provides guidelines for treatment of adult depression in primary care.53
Increasing selective serotonin reuptake inhibitor (SSRI) prescription rates have been associated with a significant decrease in suicide rates in many countries,54-58 and across the lifespan, and represent a reversal of the increasing suicide trend that preceded the introduction of SSRIs. In a large sample of treatment-seeking US veterans with MDD, Gibbons and colleagues59 demonstrated that risk of suicide attempt was reduced with antidepressant treatment. For example, risk of suicide attempt almost halved (221/100,000 to 123/100,000 participants) following the SSRI commencement, adding further support to the robustness of this relationship. In addition, completed suicide has been clearly associated with a lack of treatment or treatment non-compliance.60 Toxicology studies typically demonstrate that antidepressants are very rarely present in suicide victims at time of death.61,62
In recent years the Food and Drug Administration has analyzed the relationship between antidepressants and suicidality compared with placebo63 and released warnings about an increased risk of suicidal ideation and behavior initially in children and adolescents and subsequently in young adults up to 25 years of age.64 However, these conclusions were reached with studies not designed to measure suicidality, which limits the causal interpretations that can be drawn. Also included in this warning is acknowledgement of the role that depressive and other psychiatric disorders play in increasing risk of suicide. While the FDA aimed to educate prescribers and the general public of the possible risks of antidepressants to allow informed treatment decisions, an unintended consequence appears to have occurred. Prescription rates of antidepressants to youths have declined strikingly since the release of the warning,65,66 resulting in concern about even greater under-treatment of youth depression. Libby and colleagues65 estimated a 58% reduction in prescription fills compared with projected trends following the implementation of FDA warnings. Prescription by PCPs has declined markedly while psychiatrist prescription has inclined,65,66 indicating PCP hesitancy to prescribe. A further consequence of potential great harm has been a decline in diagnosis of youth depression and a decline in treatment of adult depression.65 Of particular concern, the first evidence of the consequences of these declines in prescription have started to manifest with a 49% increase in suicide recorded in the Netherlands (between 2003 and 2005) and a 14% increase recorded in the US (between 2003 and 2004), coinciding with an approximate 22% decline in prescriptions in both countries following the warnings.67 These findings may not be unexpected given the clear inverse relationship between SSRI prescription and suicide rate. These findings stress the importance of the management of depressive disorders in the prevention of suicide. The Texas Children’s Medication Algorithm Project provides treatment guidelines for antidepressant prescribing for children and adolescents.68
In addition to addressing depression, support exists for the use of brief behavioral interventions for alcohol problems in primary care settings, such as hazardous and harmful drinking69-71 and alcohol misuse.72 These cost-effective treatments73,74 typically include feedback on personal risk; advice; and self-help information on changing drinking behavior, goal setting, referral for further assistance, and ongoing monitoring.38,72 A meta-analysis found that brief interventions have a clear effect in men at reducing alcohol consumption but not in women.71 Specialized programs with demonstrated efficacy also exist for elderly populations.75
Primary care provides a unique opportunity for identification of those at risk for suicide and for the prevention of suicidal behavior. PCPs can serve at the front line in suicide prevention. Identification and treatment of conditions known to increase risk for suicide, particularly depression and alcohol use disorders, may help to avert suicidal crises. Furthermore, serious and chronic medical illness, managed often in the primary care setting, increases suicide risk. While some specialized training is needed, PCPs can be effectively trained in suicide assessment, risk management, and treatment strategies in an efficient manner. PP
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