rate actually decreased on the Swedish island of Gotland after the introduction of a primary care educational program to improve depression identification and treatment. This reduction came in spite of investigators’ initial concerns that the suicide rate might increase (Rutz et al., 1989). Furthermore, the vast majority of patients in primary care—both suicidal and nonsuicidal—hold the view that physicians should inquire about emotional health issues on a regular basis or at yearly checkups (Zimmerman et al., 1995).

Another reason for physician reticence comes from the lack of acute predictors for suicide assessment. Most studies have found low sensitivity and specificity of suicide prediction (Goldney, 2000; see Chapter 7; Pokorny, 1993). In a prospective study, long-term risk factors for suicide were unable to provide the means for acute prediction of suicide (Fawcett et al., 1987). Considering the rarity of suicide in primary care—one suicide every 3–5 years—physicians have little incentive to take active steps to become skilled in suicide assessment or treatment (Michel, 2000). Nor do professional guidelines recommend routine screening of asymptomatic patients. Many professional organizations do not have guidelines on suicide assessment. After expressly evaluating the evidence, the US Preventive Services Task Force in 1996 found “insufficient evidence” to recommend routine suicide screening of asymptomatic adults. The Canadian Task Force on Periodic Health Examination came to a similar conclusion in 1994 (Feightner, 1994). But a change in policy may occur with the release in 2001 of the Surgeon General’s National Strategy for Suicide Prevention. This plan encourages development of guidelines for primary care settings. It also sets specific national objectives of screening for suicide risk in federally supported primary care settings (e.g., Medicare and Medicaid) and the use of such screening as a performance measure for managed health care plans.

A final reason cited for physician reticence is lack of clinical training (Bernstein and Feldberg, 1991; Ellis et al., 1998). A majority of primary care physicians are surprised by their patients’ attempted suicide and desire more training (cited in Michel, 2000). More generally, they report insufficient training in dealing with mental health problems (Kane, 1996; Williams et al., 1999). In short, it is generally believed that primary care physicians do not ask about suicide because they feel ill-equipped—in terms of training and skills in suicide assessment and treatment—to handle an affirmative answer.

The United States Surgeon General has been consistent in urging better training of primary care providers to deal with mental health problems (PHS, 2001). More to the point, the Surgeon General sets as a national objective that physicians and physician assistants “should be skilled in talking with patients about the risk for suicide, in providing crisis



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