care either through community services or with pharmacotherapy had lower suicide rates.

Psychological autopsy studies reveal that only 6–14 percent of depressed suicide victims were adequately treated and only 8–17 percent of all suicides were under treatment with prescription psychiatric medications. Yet significant opportunities to deliver adequate care exist since over 50–70 percent of those who complete suicide have contact with health services in the days to months before their death. However, suicide risk is difficult to assess. Individuals making serious suicide attempts may knowingly withhold their intentions. Currently, no psychological test, clinical technique, or biological marker is sufficiently sensitive and specific to accurately assess acute prediction of suicide in an individual.

There are significant barriers to receiving effective mental health treatment. About two-thirds of people with diagnosable mental disorders do not receive treatment. The stigma of mental illness deters people who need treatment from seeking it. The fragmented organization of mental health services and the cost of care are among the most frequently cited barriers to mental health treatment. Economic analyses of patterns of use of mental health services clearly indicate that use is sensitive to price: use falls as costs rise, while use increases with better insurance coverage. Physicians are reticent to talk to their patients about suicide; they often do not ask about intent or ideation, and patients often do not spontaneously report it. The goal of suicide treatment in specialty care is to develop and implement a treatment plan, which includes monitoring of medication efficacy and safety, as well as discharge planning. The details of treatment of suicidality, however, are not spelled out in any clinical guidelines. And many physicians are inadequately prepared to address suicide in their practices.

Primary care has become a critical setting for detection of the two most common risk factors for suicide: depression and alcoholism. According the American Medical Association, a diagnostic interview for depression is comparable in sensitivity and specificity to many radiologic and laboratory tests commonly used in medicine. Yet, currently only about 30–50 percent of adults with diagnosable depression are accurately diagnosed by primary care physicians. Treatment of depression in primary care is associated with reduced rates of completed suicide as shown by an ecological study on the Swedish Island of Gotland. Substance use disorders are especially important in suicide among young adults. Substance abuse and mood disorders frequently co-occur, with 51 percent of suicide attempters having both. In the primary care setting, numerous professional groups recommend routine screening for problem drinking in all patients.



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