setting, according to Dr. Schulberg. He described a case vignette analysis which found that 91 percent of the physicians presented with case histories considered depression, but suicidal ideation was only considered two percent of the time in relation to the consequences of the depressive disorder. The group discussed how reinforcing the associated medical risks of depression, such as a 6-fold increased rate of myocardial infarctions in a study Dr. Fawcett described, may be a way of engaging general practitioners in mental health screening.

Physicians find it very difficult to ask direct questions about suicide, according to Dr. Schulberg. One study he described found that in only 2 of over 60 completed suicides was there “any indication in the medical records of concern about suicide, and in both of those instances, the physician did not consider the patient to be at significant risk.” Physicians’ inquiry about suicidality varies across specialties, and by the patient’s age and psychiatric history according to Dr. Schulberg. Family physicians consistently make more inquiries about psychosocial wellbeing than do internists and obstetrician/gynecologists, according to Dr. Schulberg. Primary care physicians are more apt to ask patients with a psychiatric history, or who are middle-aged. Once patients have been identified as suicidal, one study Dr. Schulberg described found that “physicians asked about misuse of medications 77 percent of the time, but in only half the instances would they inquire as to whether or not the patient had access to a gun or any other way of taking his life.” Physicians are reticent and non-optimistic in treating older, suicidal patients, as compared to treating older patients for other maladies, according to Dr. Schulberg. Yet once patients of all ages are identified as suicidal, primary care physicians are very likely to refer the patient to mental health services.

When patients were asked about what it was like to talk to your primary care physician, they responded that the primary care physicians were harried and su perficial and really not very interested in what the nature of the problem was that led them to the suicide attempt

Herbert C.Schulberg

Patient behavior impacts assessment and intervention opportunities. Frequency of visits to general practitioners does not distinguish suicidal patients according to a study described by Dr. Schulberg. When examining those with acute mental health needs, therefore at increased risk of suicide, research found that over half “turned to a health provider other than a mental health specialist,” a finding that has been replicated a number of time over the last 20 years. Yet, approximately “less than half [of the patients] informed the primary care physician of their thoughts and plans [for suicide],” according to research Dr. Schulberg described. Other research found that in general, people prefer to talk to a mental health practitioner, rather than a general practitioner about mental health needs.

Patients report feeling “extruded” upon the typical quick referral after disclosing suicidality to their general practitioners, according to Dr. Schulberg. This is important, because experience of rejection may significantly impact on compliance with the mental health services. This is a



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