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



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).


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


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


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


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.


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.


suicide primary care depression 


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


  1. 1.
    Wisqars. National Center for Injury Prevention and Control. WISQARS (Web-based Injury Statistics Query and Reporting System). Available at: Accessed April 4, 2011. 2011.
  2. 2.
    Claassen CA, Trivedi MH, Shimizu I, Stewart S, Larkin GL, Litovitz T. Epidemiology of nonfatal deliberate self-harm in the United States as described in three medical databases. Suicide Life Threat Behav. 2006;36(2):192–212.PubMedCrossRefGoogle Scholar
  3. 3.
    Kessler RC, Berglund P, Borges G, Nock M, Wang PS. Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990–1992 to 2001–2003. Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990–1992 to 2001–2003. 2005;293(20):2487–95.Google Scholar
  4. 4.
    Safer DJ, Zito JM. Do antidepressants reduce suicide rates? Public Health. 2007;121(4):274–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Glied SA, Frank RG. Better but not best: recent trends in the well-being of the mentally ill. Health Aff (Millwood). 2009;28(3):637–48.CrossRefGoogle Scholar
  6. 6.
    Mojtabai R. Unmet need for treatment of major depression in the United States. Psychiatr Serv. 2009;60(3):297–305.PubMedCrossRefGoogle Scholar
  7. 7.
    Pincus HA, Tanielian TL, Marcus SC, et al. Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties. JAMA. 1998;279(7):526–31.PubMedCrossRefGoogle Scholar
  8. 8.
    Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159(6):909–16.PubMedCrossRefGoogle Scholar
  9. 9.
    Pirkis J, Burgess P. Suicide and recency of health care contacts. A systematic review. Br J Psychiatry. 1998;173:462–74.PubMedCrossRefGoogle Scholar
  10. 10.
    Wissow LS, Larson S, Anderson J, Hadjiisky E. Pediatric residents' responses that discourage discussion of psychosocial problems in primary care. Pediatrics. 2005;115(6):1569–78.PubMedCrossRefGoogle Scholar
  11. 11.
    Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277(8):678–82.PubMedCrossRefGoogle Scholar
  12. 12.
    Kjolseth I, Ekeberg O, Steihaug S. Elderly people who committed suicide–their contact with the health service. What did they expect, and what did they get? Aging Ment Health. 2010;14(8):938–46.PubMedCrossRefGoogle Scholar
  13. 13.
    Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's box. JAMA. 1992;267(23):3157–60.CrossRefGoogle Scholar
  14. 14.
    McCauley J, Yurk RA, Jenckes MW, Ford DE. Inside "Pandora's box": abused women's experiences with clinicians and health services. J Gen Intern Med. 1998;13(8):549–55.PubMedCrossRefGoogle Scholar
  15. 15.
    Tai-Seale M, McGuire T, Colenda C, Rosen D, Cook MA. Two-minute mental health care for elderly patients: inside primary care visits. J Am Geriatr Soc. 2007;55(12):1903–11.PubMedCrossRefGoogle Scholar
  16. 16.
    Schulberg HC, Bruce ML, Lee PW, Williams JW Jr, Dietrich AJ. Preventing suicide in primary care patients: the primary care physician's role. Gen Hosp Psychiatry. 2004;26(5):337–45.PubMedCrossRefGoogle Scholar
  17. 17.
    Bartels SJ, Coakley E, Oxman TE, et al. Suicidal and death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Am J Geriatr Psychiatry. 2002;10(4):417–27.PubMedGoogle Scholar
  18. 18.
    Davidsen AS. 'And then one day he'd shot himself. Then I was really shocked': General practitioners' reaction to patient suicide. Patient Educ Couns. Sep 27 2010.Google Scholar
  19. 19.
    Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Let's not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007;5(5):412–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Beullens J, Rethans JJ, Goedhuys J, Buntinx F. The use of standardized patients in research in general practice. Fam. Pract. 1997;14(1):58–62.PubMedCrossRefGoogle Scholar
  21. 21.
    Vannoy SD, Fancher T, Meltvedt C, Unützer J, Duberstein P, Kravitz RL. Suicide inquiry in primary care: creating context, inquiring, and following up. Ann Fam Med. 2010.Google Scholar
  22. 22.
    Raue PJ, Alexopoulos GS, Bruce ML, Klimstra S, Mulsant BH, Gallo JJ. The systematic assessment of depressed elderly primary care patients. Int J Geriatr Psychiatry. 2001;16(6):560–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Raue PJ, Brown EL, Meyers BS, Schulberg HC, Bruce ML. Does every allusion to possible suicide require the same response? J Fam Pract. 2006;55(7):605–12.PubMedGoogle Scholar
  24. 24.
    Jacobs D. The Harvard Medical School guide to suicide assessment and intervention: Jossey-Bass; 1999.Google Scholar
  25. 25.
    Gerbert B, Caspers N, Bronstone A, Moe J, Abercrombie P. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med. 1999;131(8):578–84.PubMedGoogle Scholar
  26. 26.
    Rhodes KV, Frankel RM, Levinthal N, Prenoveau E, Bailey J, Levinson W. "You're not a victim of domestic violence, are you?" Provider patient communication about domestic violence. Ann Intern Med. 2007;147(9):620–7.PubMedGoogle Scholar
  27. 27.
    Cook MA. Assessment of Doctor-Elderly Patient Encounters, Grant No. R44 AG5737-S2 2002.Google Scholar
  28. 28.
    Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42(5):1871–94.PubMedCrossRefGoogle Scholar
  29. 29.
    Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.CrossRefGoogle Scholar

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

Personalised recommendations