Journal of General Internal Medicine

, Volume 26, Issue 9, pp 1005–1011 | Cite as

Now What Should I Do? Primary Care Physicians’ Responses to Older Adults Expressing Thoughts of Suicide

  • Steven D. Vannoy
  • Ming Tai-Seale
  • Paul Duberstein
  • Laura J. Eaton
  • Mary Ann Cook
Original Research

Abstract

BACKGROUND

Many older adults who die by suicide have had recent contact with a primary care physician. As the risk-assessment and referral process for suicide is not readily comparable to procedures for other high-risk behaviors, it is important to identify areas in need of quality improvement (QI).

OBJECTIVE

Identify patterns in physician-patient communication regarding suicide to inform QI interventions.

DESIGN

Qualitative thematic analysis of video-taped clinical encounters in which suicide was discussed.

PARTICIPANTS

Adult primary care patients (n = 385) 65 years and older and their primary care physicians.

RESULTS

Mental health was discussed in 22% of encounters (n = 85), with suicide content found in less than 2% (n = 6). Three patterns of conversation were characterized: (1) Arguing that “Life’s Not That Bad.” In this scenario, the physician strives to convince the patient that suicide is unwarranted, which results in mutual fatigue and discouragement. (2) “Engaging in Chitchat.” Here the physician addresses psychosocial matters in a seemingly aimless manner with no clear therapeutic goal. This results in a superficial and misleading connection that buries meaningful risk assessment amidst small talk. (3) “Identify, assess, and…?” This pattern is characterized by acknowledging distress, communicating concern, eliciting information, and making treatment suggestions, but lacks clearly articulated treatment planning or structured follow-up.

CONCLUSIONS

The physicians in this sample recognized and implicitly acknowledged suicide risk in their older patients, but all seemed unable to go beyond mere assessment. The absence of clearly articulated treatment plans may reflect a lack of a coherent framework for managing suicide risk, insufficient clinical skills, and availability of mental health specialty support required to address suicide risk effectively. To respond to suicide’s numerous challenges to the primary care delivery system, QI strategies will require changes to physician education and may require enhancing practice support.

KEY WORDS

suicide primary care depression 

Notes

Role of Funders and Data

Funding for this study was provided in part by the National Institute on Aging (AG15737) and the National Institute of Mental Health (MH01935, KL2RR025015, K24MH072712). The design, conduct, data collection, analysis, and interpretation of the results of this study were performed independently of the funders. The funding agencies also played no role in review or approval of the manuscript.

Conflict of Interest Statement

None disclosed

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Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Steven D. Vannoy
    • 1
  • Ming Tai-Seale
    • 2
    • 3
  • Paul Duberstein
    • 4
  • Laura J. Eaton
    • 3
    • 6
  • Mary Ann Cook
    • 5
  1. 1.Department of Psychiatry and Behavioral SciencesUniversity, of WashingtonSeattleUSA
  2. 2.Texas A&M Health Science Center, School of Rural Public HealthCollege StationUSA
  3. 3.Palo Alto Medical Foundation Research InstitutePalo AltoUSA
  4. 4.Center for the Study and Prevention of Suicide, Department of PsychiatryUniversity of Rochester Medical CenterRochesterUSA
  5. 5.JVC Radiology & Medical Analysis LLCSt. LouisUSA
  6. 6.Department of Family and Community MedicineUniversity of California San FranciscoSan FranciscoUSA

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