The failure of suicide prevention in primary care: family and GP perspectives - a qualitative study

Background Although Primary care is crucial for suicide prevention, clinicians tend to report completed suicides in their care as non-preventable. We aimed to examine systemic inadequacies in suicide prevention from the perspectives of bereaved family members and GPs.Methods Qualitative study of 72 relatives or close friends bereaved by suicide and 19 General Practitioners who have experienced the suicide of patients.Results Relatives highlight failures in detecting symptoms and behavioral changes and the inability of GPs to understand the needs of patients and their social contexts. A perceived overreliance on anti-depressant treatment is a major source of criticism by family members. GPs tend to lack confidence in the recognition and management of suicidal patients, and report structural inadequacies in service provision.Conclusions Mental health and primary care services must find innovative and ethical ways to involve families in the decision-making process for patients at risk of suicide

Depressive symptoms and suicide in 56,000 older Chinese: a Hong Kong cohort study

Objective: To examine dose-response associations between depressive symptoms and suicide and modification effects of sex, age and health status in older Chinese. Methods: We used the Chinese version of the 15-item Geriatric Depression Scale (GDS) to measure depressive symptoms (GDS score ≥ 8) and Cox regression to examine association with suicide mortality in a population-based cohort of 55,946 individuals, aged 65 years or above, enrolled from July 1998 to December 2000 at one of 18 Elderly Health Centres of Hong Kong Department of Health. The cohort was followed up for suicide mortality till 31 March 2009 (mean follow-up 8.7 years). Results: Depressive symptoms were associated with suicide in men [hazard ratio (HR) 2.03, 95% confidence interval (CI) 0.96-4.29] and women (HR = 2.36, 95% CI 1.31-4.24) after adjusting for age, education, monthly expenditure, smoking, alcohol drinking, physical activity, body mass index, health status, and self-rated health. There was no threshold for GDS score and suicide in either sex. Age, sex and health status did not modify the association. Conclusions: Depressive symptoms predict higher suicide risk in older Chinese in a dose-response pattern. These associations were not attenuated by adjustment for health status, suggesting that depressive symptoms in older people are likely to be an independent causal factor for suicide. The GDS score showed no threshold in predicting suicide risk, suggesting that older people with low GDS scores deserve further attention and those with very high scores need urgent intervention. © 2011 The Author(s).published_or_final_versionSpringer Open Choice, 21 Feb 201

Acupuncture and counselling for depression in primary care : a randomised controlled trial

Background: Depression is a significant cause of morbidity. Many patients have communicated an interest in nonpharmacological therapies to their general practitioners. Systematic reviews of acupuncture and counselling for depression in primary care have identified limited evidence. The aim of this study was to evaluate acupuncture versus usual care and counselling versus usual care for patients who continue to experience depression in primary care. Methods and Findings: In a randomised controlled trial, 755 patients with depression (Beck Depression Inventory BDI-II score $20) were recruited from 27 primary care practices in the North of England. Patients were randomised to one of three arms using a ratio of 2:2:1 to acupuncture (302), counselling (302), and usual care alone (151). The primary outcome was the difference in mean Patient Health Questionnaire (PHQ-9) scores at 3 months with secondary analyses over 12 months follow-up. Analysis was by intention-to-treat. PHQ-9 data were available for 614 patients at 3 months and 572 patients at 12 months. Patients attended a mean of ten sessions for acupuncture and nine sessions for counselling. Compared to usual care, there was a statistically significant reduction in mean PHQ-9 depression scores at 3 months for acupuncture (22.46, 95% CI 23.72 to 21.21) and counselling (21.73, 95% CI 23.00 to 20.45), and over 12 months for acupuncture (21.55, 95% CI 22.41 to 20.70) and counselling (21.50, 95% CI 22.43 to 20.58). Differences between acupuncture and counselling were not significant. In terms of limitations, the trial was not designed to separate out specific from non-specific effects. No serious treatment-related adverse events were reported. Conclusions: In this randomised controlled trial of acupuncture and counselling for patients presenting with depression, after having consulted their general practitioner in primary care, both interventions were associated with significantly reduced depression at 3 months when compared to usual care alone

Characteristics, Management, and Depression Outcomes of Primary Care Patients Who Endorse Thoughts of Death or Suicide on the PHQ-9

BACKGROUND: With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts. OBJECTIVE: To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program. DESIGN: Observational analysis of data collected from a patient registry. PARTICIPANTS: Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP). INTERVENTIONS: MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review. MAIN MEASURES: The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score < 10). KEY RESULTS: SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001). CONCLUSIONS: Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up

Tendência da mortalidade por suicídio na população brasileira e idosa, 1980-2006

OBJETIVO: Descrever a mortalidade por suicídio no Brasil, com destaque para a população idosa. MÉTODOS: Análise temporal e estudo de tendência por regressão polinomial de suicídios na população acima de dez anos no Brasil e no Estado do Rio de Janeiro de 1980 a 2006. Os dados foram extraídos do Sistema de Informações sobre Mortalidade e as taxas, calculadas segundo sexo e faixa etária, considerando-se a população residente fornecida pelo Datasus por 100 mil habitantes. Para os anos de 1980 a 1995, utilizou-se a nona revisão da Classificação Internacional de Doenças e Problemas Relacionados à Saúde, e para 1996 a 2006, a décima revisão. RESULTADOS: Crescimento significativo foi observado nas taxas de suicídio na população brasileira e no Rio de Janeiro (5,7 e 3,1 para cada 100 mil habitantes, respectivamente) em 2006. Esse incremento ocorreu pelo aumento dos suicídios na população masculina em todas as idades. A curva crescente aconteceu principalmente entre homens maiores de 60 anos. O incremento não foi estatisticamente significativo entre homens e houve decréscimo entre mulheres no Rio de Janeiro. Os principais meios de suicídio utilizados pelos homens foram enforcamento, sufocação, estrangulamento e armas de fogo. Para as mulheres, o enforcamento também ocupou a primeira posição, seguido pela ingestão de substâncias, atiramento ao fogo e precipitação de altura. A elevada taxa de indefinição dos meios ressaltou problemas na qualidade dos dados. CONCLUSÕES: Suicídios são eventos significantes na população masculina, sobretudo entre homens idosos, ao longo do tempo. No Rio de Janeiro, as taxas entre homens idosos também são maiores, mas não estatisticamente significantes. Segundo a Organização Mundial da Saúde e o Ministério da Saúde, o suicídio é passível de prevenção e existem cuidados preconizados para cada grupo etário