Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis

Objective: To characterise suicide-risk discussions in depressed primary-care patients. Design: Secondary analysis of recordings and self reports by physicians and patients. Descriptive statistics of depression and suicide-related discussion, with qualitative extraction of disclosure, enquiry and physician response. Setting: 12 primary-care clinics between July 2003 and March 2005. Participants: 48 primary-care physicians and 1776 adult patients. Measures: Presence of depression or suicide-related discussions during the encounter; patient and physician demographics; depression symptom severity and suicide ideation as measured by the Patient Health Questionnaire (PHQ9); physician’s decision-making style as measured by the Medical Outcomes Study Participatory Decision-Making Scale; support for autonomy as measured by the Health Care Climate Questionnaire; trust in their physician as measured by the Primary Care Assessment Survey; physician response to suicide-related enquiry or disclosure. Results: Of the 1776 encounters, 128 involved patients scoring \u3e14 on the PHQ9. These patients were seen by 43 of the 48 physicians. Suicide ideation was endorsed by 59% (n1⁄475). Depression was discussed in 52% of the encounters (n1⁄466). Suicide-related discussion occurred in only 11% (n1⁄413) of encounters. 92% (n1⁄412) of the suicide discussions occurred with patients scoring \u3c2 on PHQ9 item 9. Suicide was discussed in only one encounter with a male. Variation in elicitation and response styles demonstrated preferred and discouraged interviewing strategies. Conclusions: Suicide ideation is present in a significant proportion of depressed primary care patients but rarely discussed. Men, who carry the highest risk for suicide, are unlikely to disclose their ideation or be asked about it. Patient-centred communication and positive healthcare climate do not appear to increase the likelihood of suicide related discussion. Physicians should be encouraged to ask about suicide ideation in their depressed patients and, when disclosure occurs, facilitate discussion and develop targeted treatment plans

What Factors Determine Disclosure of Suicide Ideation in Adults 60 and Older to a Treatment Provider?

Correlates of patient disclosure of suicide ideation to a primary care or mental health provider were identified. Secondary analyses of IMPACT trial data were conducted. Of the 107 patients 60 years of age or older who endorsed thoughts of ending their life at least a little bit during the past month, 53 indicated they had disclosed these thoughts to a mental health or primary care provider during this period. Multiple logistic regression was used to identify predictors of disclosure to a provider. Significant predictors included poorer quality of life and prior mental health specialty treatment. Among participants endorsing thoughts of suicide, the likelihood of disclosing these thoughts to a provider was 2.96 times higher if they had a prior history of mental health specialty treatment and 1.56 times higher for every one-unit decrease in quality of life. Variation in disclosure of thoughts of suicide to a mental health or primary care provider depends, in part, on patient characteristics. Although the provision of evidence-based suicide risk assessment and guidelines could minimize unwanted variation and enhance disclosure, efforts to routinize the process of suicide risk assessment should also consider effective ways to lessen potential unintended consequences

Evaluation of an Anger Therapy Intervention for Incarcerated Adult Males

ABSTRACT An anger therapy intervention was developed for incarcerated adult males. The therapy was an extension of cognitive-behavioral approaches, incorporating principles and practices drawn from Buddhist psychology. Adult males from a Midwestern low-security prison were randomly assigned to ei- ther a treatment group (n = 16) or a waiting list control group (n = 15). Following a 10-session intervention, treated participants exhibited significant reduction in anger relative to those in the control group. Greater reductions in anger for the therapy group was mediated (p = .07), by greater reduction in egotism relative to the control group. Contrary to predictions, anger reduction was not mediated by increases in empathy. Implications for designing and delivering interventions in prison settings are discussed. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2004 by The Haworth Press, Inc. All rights reserved.

Making an IMPACT on late-life depression. Partnering with primary care providers can double the effect of treatment

Few depressed older adults seek help from psychiatrists. Those who receive mental health treatment most likely do so in pri- mary care settings. Yet primary care physicians (PCPs) often are ill-equipped to effectively treat depression while managing older patients’ numerous acute and chronic medical conditions. If depressed older patients won’t go to a psychiatrist, why not bring the psychiatrist to the patients? This article describes a clinically tested approach called project IMPACT that links psy- chiatrists to primary care teams and dramatically improves depression treatment in older adults

Current Practices of Suicide Risk Management Protocols in Research

Abstract. Background: Participant safety is an important concern in mental-health-oriented research. Investigators conducting studies in the United States that include potentially suicidal individuals are often required to develop written suicide risk management (SRM) protocols. But little is known about these protocols. It is possible that such protocols could serve as templates for suicide risk management in clinical settings. Aims: To elucidate common (best) practices from mental health intervention researchers. Methods: We conducted a systematic descriptive analysis of written SRM protocols. A convenience sample of studies funded by the United States’ National Institute of Mental Health in 2005 were scanned to discover projects in which investigators were likely to identify and take responsibility for suicide risk in their participant pool. Qualitative methodology was used to create a checklist of tasks perceived to be operationally significant for insuring the safety of suicidal participants. The checklist was applied to all protocols to determine the variability of patient safety tasks across protocols. Results: We identified 45 candidate studies, whereof 38 investigators were contacted, resulting in the review of 21 SRM protocols. Three main categories emerged: overview, entry/exit, and process. Overall, 19 specific tasks were identified. Task frequency varied from 7% to 95% across protocols. Conclusions: The SRM checklist provides a framework for comparing the content of SRM protocols. This checklist may assist in developing SRM protocols in a wide range of settings. Developing guidelines and standard methodologies is an important step to further development of suicide prevention strategies. More research is necessary to determine the impact of SRM protocols on participant safety

Activity scheduling as a core component of effective care management for late-life depression

Background: Activity scheduling is an established component of evidenced-based treatment for late-life depression in primary care. We examined participant records from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial to identify activity scheduling strategies used in the context of successful depression care management (CM), associations of activity scheduling with self-reported activity engagement, and depression outcomes. Methods: This study used observational mixed methods analysis of 4335 CM session notes from 597 participants in the intervention arm of the IMPACT trial. Grounded theory was used to identify 17 distinct activity categories from CM notes. Logistic regression was used to evaluate associations between activity scheduling, activity engagement, and depression outcomes at 12 months. All relevant institutional review boards approved the research protocol. Results: Seventeen distinct activity categories were generated. Most patients worked on at least one social and one solitary activity during their course of treatment. Common activity categories included physical activity (32%), medication management (22%), active–non-physical (19%), and passive (14%) activities. We found significant, positive associations between activity scheduling, self-reported engagement in activities at 12 months, and depression outcomes at 12 months. Conclusion: Older primary care patients in CM for depression worked on a wide range of activities. Consistent with depression theory that has placed emphasis on social activities, the data indicate a benefit for intentional social engagement versus passive social and solitary activities. Care managers should encourage patients to balance instrumental activities (e.g., attending to medical problems) with social activities targeting direct interpersonal engagement. Copyright # 2012 John Wiley & Sons, Ltd

Effectiveness of Problem-Solving Therapy for Older, Primary Care Patients With Depression: Results From the IMPACT Project

Purpose: We compared a primary-care-based psy- chotherapy, that is, problem-solving therapy for primary care (PST-PC), to community-based psycho- therapy in treating late-life major depression and dys- thymia. Design and Methods: The data here are from the IMPACT study, which compared collabora- tive care within a primary care clinic to care as usual in the treatment of 1,801 primary care patients, 60 years of age or older, with major depression or dysthymia. This study is a secondary data analysis (n = 433) of participants who received either PST-PC (by means of collaborative care) or community-based psychotherapy (by means of usual care). Results: Older adults who received PST-PC had more de- pression-free days at both 12 and between 12 and 24months(b=47.5,p,.001;b=47.0,p, .001), and they had fewer depressive symptoms and better functioning at 12 months (bdep = 0.36, p , .001; bfunc = 0.94, p , .001), than those who received community-based psychotherapy. We found no differences at 24 months. Implications: Results suggest that PST-PC as delivered in primary care settings is an effective method for treating late-life depression