Middle-aged men are at high risk of suicide. While about half of those who kill themselves visit a primary care clinician (PCC) shortly before death, in current practice, few spontaneously disclose their thoughts of suicide during the visits, and PCCs seldom inquire about such thoughts. In a randomized controlled trial, we examined the effect of a tailored interactive computer program designed to encourage middle-aged men’s discussion of suicide with PCCs.
We recruited men 35–74 years old reporting recent (within 4 weeks) active suicide thoughts from the panels of 42 PCCs (the unit of randomization) in eight offices within a single California health system. In the office before a visit, men viewed the intervention corresponding to their PCC’s random group assignment: Men and Providers Preventing Suicide (MAPS) (20 PCCs), providing tailored multimedia promoting discussion of suicide thoughts, or control (22 PCCs), composed of a sleep hygiene video plus brief non-tailored text encouraging discussion of suicide thoughts. Logistic regressions, adjusting for patient nesting within physicians, examined MAPS’ effect on patient-reported suicide discussion in the subsequent office visit.
Sixteen of the randomized PCCs had no patients enroll in the trial. From the panels of the remaining 26 PCCs (12 MAPS, 14 control), 48 men (MAPS 21, control 27) were enrolled (a mean of 1.8 (range 1–5) per PCC), with a mean age of 55.9 years (SD 11.4). Suicide discussion was more likely among MAPS patients (15/21 [65%]) than controls (8/27 [35%]). Logistic regression showed men viewing MAPS were more likely than controls to discuss suicide with their PCC (OR 5.91, 95% CI 1.59–21.94; P = 0.008; nesting-adjusted predicted effect 71% vs. 30%).
In addressing barriers to discussing suicide, the tailored MAPS program activated middle-aged men with active suicide thoughts to engage with PCCs around this customarily taboo topic.
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Suicide. Facts at a glance. Atlanta, GA: National Center for Injury Prevention and Control, Division of Violence Prevention, Centers for Disease Control and Prevention; 2015.
Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999-2014. NCHS Data Brief. 2016:1–8.
10 leading causes of death by age group, United States - 2017. U.S. Centers for Disease Control and Prevention. 2019; https://www.cdc.gov/injury/wisqars/leadingcauses.html
Shepard DS, Gurewich D, Lwin AK, Reed GA, Jr., Silverman MM. Suicide and Suicidal Attempts in the United States: Costs and Policy Implications. Suicide Life Threat Behav. 2016;46:352–362.
Injury Prevention & Control: Data & Statistics (WISQARS). U.S. Centers for Disease Control and Prevention. 2016; http://www.cdc.gov/injury/wisqars/index.html. Accessed 11 March 2020.
Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29:870–877.
Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294:563–570.
Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63:757–766.
Motto JA, Bostrom AG. A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv. 2001;52:828–833.
du Roscoat E, Beck F. Efficient interventions on suicide prevention: a literature review. Rev Epidemiol Sante Publique. 2013;61:363–374.
Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617–626.
Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med. 2002;136:302–311.
Yip PS, Caine E, Yousuf S, Chang SS, Wu KC, Chen YY. Means restriction for suicide prevention. Lancet. 2012;379:2393–2399.
Simon RI. Suicide risk assessment: gateway to treatment and management. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing textbook of suicide assessment and management, 2nd Washington, DC: American Psychiatric Publishing; 2012.
Clinical Care and Intervention Task Force, National Action Alliance for Suicide Prevention. Suicide care in systems framework. Washington, DC: NAASP; 2011.
Office of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 national strategy for suicide prevention: goals and objectives for action. Washington, DC: U.S. Department of Health and Human Services; 2012.
ten Have M, de Graaf R, van Dorsselaer S, et al. Incidence and course of suicidal ideation and suicide attempts in the general population. Can J Psychiatry. 2009;54:824–833.
Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med. 2003;33:395–405.
McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-risk management for the busy primary care physician. Mayo Clin Proc. 2011;86:792–800.
Hawton K, Houston K, Haw C, Townsend E, Harriss L. Comorbidity of axis I and axis II disorders in patients who attempted suicide. Am J Psychiatry. 2003;160:1494–1500.
Milner A, Sveticic J, De Leo D. Suicide in the absence of mental disorder? A review of psychological autopsy studies across countries. Int J Soc Psychiatry. 2013;59:545–554.
Heikkinen M, Aro H, Lonnqvist J. Recent life events, social support and suicide. Acta Psychiatr Scand Suppl. 1994;377:65–72.
Olfson M, Weissman MM, Leon AC, Sheehan DV, Farber L. Suicidal ideation in primary care. J Gen Intern Med. 1996;11:447–453.
Rudd MD, Berman AL, Joiner TE, Jr., et al. Warning signs for suicide: theory, research, and clinical applications. Suicide Life Threat Behav. 2006;36:255–262.
Conner KR, Duberstein PR, Conwell Y, Seidlitz L, Caine ED. Psychological vulnerability to completed suicide: a review of empirical studies. Suicide Life Threat Behav. 2001;31:367–385.
Nock MK, Borges G, Bromet EJ, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192:98–105.
Zimmerman M, Lish JD, Lush DT, Farber NJ, Plescia G, Kuzma MA. Suicidal ideation among urban medical outpatients. J Gen Intern Med. 1995;10:573–576.
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;5:412–418.
Nutting PA, Dickinson LM, Rubenstein LV, Keeley RD, Smith JL, Elliott CE. Improving detection of suicidal ideation among depressed patients in primary care. Ann Fam Med. 2005;3:529–536.
Vannoy SD, Robins LS. Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis. BMJ Open. 2011;1:e000198.
O'Loughlin RE, Duberstein PR, Veazie PJ, et al. Role of the gender-linked norm of toughness in the decision to engage in treatment for depression. Psychiatr Serv. 2011;62:740–746.
Rochlen AB, Paterniti DA, Epstein RM, Duberstein P, Willeford L, Kravitz RL. Barriers in diagnosing and treating men with depression: a focus group report. Am J Mens Health. 2010;4:167–175.
Reynders A, Kerkhof AJ, Molenberghs G, Van Audenhove C. Help-seeking, stigma and attitudes of people with and without a suicidal past. A comparison between a low and a high suicide rate country. J Affect Disord. 2015;178:5–11.
Kravitz RL, Paterniti DA, Epstein RM, et al. Relational barriers to depression help-seeking in primary care. Patient Educ Couns. 2011;82:207–213.
Jerant A, Duberstein P, Cipri C, Bullard B, Stone D, Paterniti D. Stakeholder views regarding a planned primary care office-based interactive multimedia suicide prevention tool. Patient Educ Couns. 2019;102:332–339
Rost K, Nutting P, Smith J, Coyne JC, Cooper-Patrick L, Rubenstein L. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9:150–154.
Almeida OP, Pirkis J, Kerse N, et al. A randomized trial to reduce the prevalence of depression and self-harm behavior in older primary care patients. Ann Fam Med. 2012;10:347–356.
Shah R, Franks P, Jerant A, et al. The effect of targeted and tailored patient depression engagement interventions on patient-physician discussion of suicidal thoughts: a randomized control trial. J Gen Intern Med. 2014;29:1148–1154.
Kravitz RL, Franks P, Feldman MD, et al. Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial JAMA. 2013;310:1818–1828.
Nock MK, Hwang I, Sampson NA, Kessler RC. Mental disorders, comorbidity and suicidal behavior: results from the National Comorbidity Survey Replication. Mol Psychiatry. 2010;15:868–876.
Hunt T, Wilson CJ, Caputi P, Woodward A, Wilson I. Signs of current suicidality in men: A systematic review. PLoS One. 2017;12:e0174675.
Beck AT, Brown GK, Steer RA, Dahlsgaard KK, Grisham JR. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide Life Threat Behav. 1999;29:1–9.
Schulz KF, Grimes DA. Generation of allocation sequences in randomised trials: chance, not choice. Lancet. 2002;359:515–519.
Pisani AR, Cross WF, Watts A, Conner K. Evaluation of the Commitment to Living (CTL) curriculum: a 3-hour training for mental health professionals to address suicide risk. Crisis. 2012;33:30–38.
Pressman RS. Software Engineering: A Practitioner’s Approach, 6th New York: McGraw-Hill; 2005.
Kreuter M, Farrell D, Olevitch L, Brennan L. Tailoring Health Messages: Customizing Communication With Computer Technology. Mahwah: Lawrence Erlbaum Associates; 2000.
Noar SM, Benac CN, Harris MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull. 2007;133:673–693.
Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013;32:207–214.
Sacks RM, Greene J, Hibbard JH, Overton V. How well do patient activation scores predict depression outcomes one year later? J Affect Disord. 2014;169:1–6.
Jerant A, To P, Franks P. The Effects of Tailoring Knowledge Acquisition on Colorectal Cancer Screening Self-Efficacy. J Health Commun. 2014;In press.
Jerant A, Sohler N, Fiscella K, Franks B, Franks P. Tailored interactive multimedia computer programs to reduce health disparities: opportunities and challenges. Patient Educ Couns. 2011;85:323–330.
Medical practice pulse report: patient perspectives on American health care. Press Ganey Associates, Inc. 2009; http://www.pressganey.com/Documents_secure/Medical%20Practices/White%20Papers/Keep_Me_Waiting.pdf?viewFile. Accessed 11 March 2020.
Peterson C, Stunkard AJ. Personal control and health promotion. Soc Sci Med. 1989;28:819–828.
Miller SM. Monitoring versus blunting styles of coping with cancer influence the information patients want and need about their disease. Implications for cancer screening and management. Cancer. 1995;76:167–177.
Epstein A. Common Sleeping Problems (video). New York: HealthiNation; 2011.
Beck AT, Brown GK, Steer RA. Psychometric characteristics of the Scale for Suicide Ideation with psychiatric outpatients. Behav Res Ther. 1997;35:1039–1046.
Linehan MM, Comtois KA, Brown MZ, Heard HL, Wagner A. Suicide Attempt Self-Injury Interview (SASII): development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury. Psychol Assess. 2006;18:303–312.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613.
Prins A, Bovin MJ, Smolenski DJ, et al. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and evaluation within a veteran primary care sample. J Gen Intern Med. 2016;31:1206–1211.
Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158:1789–1795.
We are indebted to the primary care offices, PCCs, and patients who participated in the trial. We are also grateful to the following individuals: Peach Dounias, BS, Sherry Hao, BA, Lauren Walker, MSW, and Zachary Weiss, BA, who facilitated the patient recruitment and participation; Simon Dvorak, BA, Charles Turner, PhD, and Robert Burnett, MA, who programmed the MAPS and control interventions; the actors who performed in videos incorporated in MAPS, overseen, and trained by Lynn Baker-Nauman, MA; and the analysts at the University of California Davis Clinical and Translational Science Center, for the administrative support in conducting the trial.
This work was supported by cooperative agreement U01CE002664 (Jerant, Duberstein) from the National Center for Injury Prevention and Control, U.S. Centers for Disease Control and Prevention (CDC). Additional funding was provided by the UCD Behavioral Health Center of Excellence (Jerant) and the Department of Family and Community Medicine (Jerant). The CDC participated in the design and conduct of the study. Neither the CDC nor the other funders had a role in the collection, management, analysis, or interpretation of the data or in the decision to submit the manuscript for publication.
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Jerant, A., Duberstein, P., Kravitz, R.L. et al. Tailored Activation of Middle-Aged Men to Promote Discussion of Recent Active Suicide Thoughts: a Randomized Controlled Trial. J GEN INTERN MED 35, 2050–2058 (2020). https://doi.org/10.1007/s11606-020-05769-3