effectiveness in the absence of clear guidelines for what constitutes efficacious treatment. Consequently, the few available studies of suicidal patients focus on whether clinicians in the practice setting (“usual care”) administer appropriate treatment for the associated mental disorder, for which treatment guidelines are available (or for which there is more evidence of treatment efficacy). Studies also focus on process issues such as frequency of treatment.

Most of the available research on barriers to effective treatment pertains to treatment of the mental disorder(s) associated with suicide. The following section covers the relationship between suicide and under-treatment of depression and substance abuse.

Under-Treatment

Depression. Psychological autopsy studies have found that a large percentage of suicide victims with major depression were not receiving treatment or were receiving inadequate treatment. The majority of patients receiving antidepressants were prescribed inadequate doses (Isacsson et al., 1994; Isacsson et al., 1992; Isometsa et al., 1994b; Modestin and Schwarzenbach, 1992). Victims receiving psychotherapy rarely had visits as often as once a week (Isometsa et al., 1994b). These findings also apply to suicide attempters both before as well as after a suicide attempt (Suominen et al., 1998). Patients with depression and a history of past suicide attempts—a group at high risk for suicide—received inadequate pharmacological treatment in the 3 months before hospitalization (Oquendo et al., 1999).

Substance Abuse. Substance abuse is often under-treated in suicidal patients. Although not as well investigated as under-treatment for depression, studies indicate that alcohol dependence is under-treated in the vast majority of patients both before and after a suicide attempt (Suominen et al., 1999). As noted earlier, substance use and mental disorders frequently co-occur in completed (Henriksson et al., 1993) and attempted suicide (Suominen et al., 1996). Co-occurring disorders are best treated by programs that integrate mental health and substance abuse treatment (US DHHS, 1999). A major barrier to integrated treatment is the lack of such specialized programs (US DHHS, 1999).

PATIENT BARRIERS TO TREATMENT

The preceding sections have described the barriers deterring the majority of people with symptoms from seeking mental health care: stigma,



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