one month of death, the rate is 34–38 percent of completed suicides (Pirkis and Burgess, 1998). The frequency of contacts with primary care also increases in the month before death of young suicide victims (<35 years old) (Appleby et al., 1996). These findings are widely interpreted as suggesting that patients are motivated to seek help but are reluctant to bring up suicide as the reason during an office visit (Hirschfeld and Russell, 1997; Michel, 2000). Yet people with suicidal thoughts usually tell their physicians if they are asked (Delong and Robins, 1961).
Communication of suicidal intent is an interactive process. It depends on the patient’s willingness to communicate, as well as the clinician’s ability to listen, recognize, and ask questions about intentions. During the final contact with primary care, there is a striking breakdown in communication: physicians often do not ask about suicidal intent or ideation, and patients often do not spontaneously report it. A review of medical records of 61 completed suicides (<35 years) in Manchester, United Kingdom, found almost total absence of documentation of suicide risk by the general practitioner (Appleby et al., 1996). Suicide risk was commented upon in the medical record in only one case. Yet the physicians deemed that 64 percent of the patients had psychological concerns as the principal reason for the visit. A similar study of suicide deaths in Scottish adults (>16 years) found that only 3.3 percent of records indicated that patients expressed suicide ideation or communications at the time of the final consultation4 (Matthews et al., 1994). The figures are somewhat higher in a study from Finland in which 19 percent of suicide completers with depression communicated their intent to medical providers (Isometsa et al., 1994c). Despite limitations of using case notes to infer what occurred during the final visit, these studies—as well as clinical experience—point to a major barrier in communication: patients are reluctant to communicate their suicidal intent, and primary care physicians are reluctant to ask (Hirschfeld and Russell, 1997).
The failure of physicians to detect suicidality was described in a now classic paper as an “error of omission” (Murphy, 1975). Numerous interrelated reasons are proffered to explain physicians’ reticence to ask patients about suicide, yet there has been little systematic research.
One of the most common explanations for physicians’ reticence stems from their concern that asking patients about suicide will trigger suicidal behavior (Michel, 2000). Clinical experience, however, suggests this concern to be unwarranted: “There is universal agreement that asking questions about suicidal ideation does not trigger suicidal behavior…” (Michel, 2000:665). There is also indirect research support for this statement. The suicide