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Reducing Suicide: A National Imperative
Medical Association council, considerable evidence indicates that a diagnostic interview for depression is comparable in sensitivity and specificity to many radiologic and laboratory tests commonly used in medicine (Preboth, 2000). During depression screening, guidelines explicitly recommend asking patients about suicidal intent and past suicide attempts. When a suicidal patient is identified, primary care physicians should refer them to specialty care and consider hospitalization (Beck et al., 1979; US Preventive Services Task Force, 1996). The role of primary care is likely to expand, however, as a result of recent health care trends and high level public health concern about suicide prevention. The Surgeon General’s National Strategy (PHS, 2001) sets as national objectives screening for depression in federally-supported primary care settings (e.g., Medicare and Medicaid) and the use of such screening as a performance measure for evaluating the quality of managed health care plans.
The expanding role of primary care in detection and treatment of depression stems from at least four major factors. The first is awareness of how frequently depression is encountered in primary care. Depression is one of the most common of all mental and somatic diagnoses (Von Korff et al., 1987). About 6–10 percent of people attending primary care settings have major depression (Katon and Schulberg, 1992). The second is that many people with depression prefer to be treated in primary care or resist referral to specialty care (Cooper-Patrick et al., 1999; Orleans et al., 1985; Williams et al., 1999). Seventy-five percent of those seeking help for depression do so through their primary care physician rather than through a mental health professional (Goldman et al., 1999). One reason may be that they perceive primary care as less stigmatizing than specialty mental health care. The third factor is the advent of new classes of antidepressant medications that are less toxic when taken in overdose, thus making medication management less complex for non-specialists (Hirschfeld and Russell, 1997; US DHHS, 1999). The fourth factor is the trend in cost containment. Managed care generally encourages the receipt of mental health services in primary, rather than specialty, care because of lower costs (Mechanic, 1998). It is thus not surprising that about half of all people with depression and other mental disorders—either by preference or by financing—receive their mental health treatment in primary care (US DHHS, 1999). Primary care physicians handle nearly half of all anti-depressant-related office visits (Pincus et al., 1998).
Only about 30–50 percent of adults with diagnosable depression are accurately diagnosed by primary care physicians (Higgins, 1994; Katon et al., 1992; Wells et al., 1994). Even more startling to suicide prevention are findings about the infrequency of suicide questioning during routine depression evaluation. Only 58 percent of a random sample of 3375 primary