A new article on depression-related suicides in primary care
Leo Sher, M.D.
Profs. Zoltan Rihmer and Xenia Gonda have recently published the research article entitled, “Prevention of depression-related suicides in primary care.” This article was published in Psychiatria Hungarica. Most readers of our web site, www.internetandpsychiatry.com do not have access to articles published in this Journal. However, the Editors of Psychiatria Hungarica have graciously given a permission to publish this Editorial to www.internetandpsychiatry.com Therefore, we are publishing the article, “Prevention of depression-related suicides in primary care” below.
Prevention of depression-related suicides in primary care
Zoltán Rihmer, MD, PhD, DSc, Xenia Gonda, PhD
Summary
Suicide attempt and completed suicide are rare events in the community, but they are quite common among psychiatric patients who contact their GPs before the suicide event. The point prevalence of unipolar major depressive episode in general practice is around ten percent but about half of these cases remain unrecognized, untreated or mistreated. Major depressive episode is the most common current psychiatric diagnosis among suicide victims and attempters (56-87%) and successful acute and log-term treatment of depression significantly reduces the risk of suicidal behaviour even in this high-risk population. As more than half of suicide victims contact their GPs within four weeks before their death, primary care doctors play an important role in suicide prevention. Five large-scale community studies demonstrate that education of GPs and other medical professionals on the diagnosis and appropriate pharmacotherapy of depression, particularly in combination with psycho-social interventions and public education improve the diagnosis and treatment of depression and reduces the rate of completed and attempted suicide in the areas served by trained doctors.
Key-words: Depression, General Practitioners, primary care, suicide, suicide prevention
1. Introduction
Major depressive episodes (both unipolar and bipolar), the most frequent current diagnoses of suicide victims and attempters, are among the most common psychiatric illnesses in the community and in a variety of clinical settings, including primary care practice (Balázs et al, 2003; Berardi et al, 2005; Man et al, 2005; Rihmer and Angst, 2005a, Rihmer, 2007). The lifetime, 1-year and current prevalence rates of unipolar major depression in the general population is in average 12%, 7%, and 4% respectively, and the same figures for minor depression and dysthymic disorder are in the same magnitude (Rihmer and Angst, 2005a; 2005b). About half of patients with unipolar depression have comorbid anxiety disorder(s), and/or substance-use disorders and around one-third of them also have one or more serious medical illness, and comorbid psychiatric and medical conditions decrease the chance of the diagnosis of depression and increase the risk of suicidal behaviour (Davidson and Meltzer-Brody 1999, Wasserman 2001, Hawton and van Heeringen 2000, Rihmer et al. 2002, Rihmer 2005, Rihmer and Angst 2005a).
2. Depressive disorders in primary care practice
Less than half of all depressed patients in the community seek medical help and the majority of the ones who do consult their GPs however, are not adequately diagnosed and treated (Lecribier 1998, Lerrubier and Hergueta 1998, Davidson and Meltzer-Brody 1999, Tylee 1999, Lecrubier 2001, Berardi et al. 2005; Rihmer and Rutz, 2009). While the current prevalence of DSM-III/DSM-IV or ICD-10 major depression in the primary care practice is around 8-10%, many depressed patients are not recognised by their GPs. Moreover the rate of adequate antidepressive pharmacotherapy among diagnosed depressives was less than 20% (Spitzer et al. 1994, Lecrubier 1998, Davidson and Meltzer-Brody 1999, Wittchen et al. 2001, Ansseau et al. 2004, Szádóczky et al. 1997; 2004, Al Windi 2005, Berardi et al. 2005; Torzsa et al, 2009a). The WHO Collaborative Study conducted in 1991 on more than 25.000 primary care patients in 14 countries found that on the whole, approximately 50% of the patients with an ICD-10 diagnosis of major depressive episode were recognised as suffering from some kind of mental disorder by their GPs, but only 15% of major depressives were recognised as having depression, and less than half of them were prescribed antidepressants for their depression (Lecrubier, 1998, 2001, Lecrubier and Hergueta, 1998). However, most recent studies reported much higher rates of recognition and treatment of depression in primary care (62-85%) and 33-50% of them were treated with antidepressants (Wittchen et al. 2001, Lecrubier 2001, Berardi et al. 2005) showing that the situation does appear to be improving.
More than half of depressed patients report painful physical symptoms both in psychiatric and in primary care settings that make the diagnosis of depression more difficult (Garcia-Cebrian et al, 2006). Most patients with depression consult their GPs primarily for somatic reasons, either because of their somatic comorbidity or because of the predominant somatic symptoms of their depression (Davidson and Meltzer-Brody 1999, Tylee 1999, Lecrubier 2001, Tylee and Rihmer 2004). This is quite important, since major depression is frequently associated with chronic physical disorders (cardiovascular diseases, hypertension, stroke, cancer, epilepsy, Parkinson’s disease, HIV infection/AIDS, etc.) which further increase the risk of suicidal behaviour. Several factors, relating to both patients and doctors, are likely to affect the recognition of major depression in primary care.
Patient factors associated with non-recognition of depression include: comorbid psychiatric (anxiety, substance abuse and personality) disorders, comorbid (mostly chronic) medical disorders, low degree of disability, less severe depressions, predominantly somatic symptom-presentation, male gender, younger or older age, and married status (Rihmer and Rutz, 2009). On the other hand, high level disability, lack of comorbid psychiatric and medical disorders, more severe depression, higher number of depressive symptoms, presenting depression predominantly with psychological symptoms (depressed mood, poor concentration, fatigue, psychomotor retardation), middle age-range, female gender and separated or divorced marital status increases the chance of correct identification (Rutz et al. 1995, 1997, Lecrubier 1998, 2001, Tylee 1999, Wittchen et al. 2001, Szádóczky et al. 2004). Unfortunately, the diagnosis and treatment of depression in primary care practice is still far from the optimal (Lecrubier 2001, Wittchen et al. 2001, Berardi et al. 2005; Rihmer and Rutz, 2009).
Physician factors, related to poor recognition of depression are: lack of experience, insufficient or suboptimal knowledge about the symptoms, treatment and good prognosis in treated depression, prejudices about mental illness, lack of postgraduate psychiatric training, insufficient interview-skills, lack of cooperation with psychiatrists, and low level of empathy (Rutz et al. 1997, Tylee 1999, Lecrubier 2001, Wittchen et al. 2001). Specific organisational interventions and postgraduate training programmes improve the recognition and treatment of depression in primary care (Rutz et al. 1997, Appleby et al. 2000, Gilbody et al. 2003, Hegerl et al. 2006, Mann et al. 2005, Szántó et al. 2007). Short screening-instruments, some of them designed specifically for primary care (Davidson and Meltzer-Brody 1999, Lecrubier 2001, Szádóczky et al. 2004) are also helpful, but they do not replace a well-performed and competent clinical interview. Recent findings suggest that history of completed suicide among first or second degree relatives could be a good and simple clinical marker for current and lifetime major depressive episode in primary care patients (Torzsa et al, 2009a).
Clinical studies on suicide in primary care focuses mainly on unipolar major depression and less attention is paid to bipolar disorder, the point prevalence of which is between 1 and 2 percent in the GP practice (Spitzer et al. 1994, Szádóczky et al. 1997, Ansseau et al. 2004). Since the depressive episode of bipolar disorder carries an even higher risk of suicide than unipolar major depression, and because the vast majority of hypomanic and manic patients later also become depressed (Rihmer 2005, Rihmer and Angst 2005b, Akiskal 2007), patients with history of hypomania and mania, particularly in the presence of current depression should be considered as persons at very high risk of suicide and should refer to outpatient psychiatric consultation or, in acute cases they should refer to inpatient psychiatric treatment.
3. Relationship between depression and suicide
Between 10-18 % of adults in different countries of the World report lifetime suicidal ideation and 3-5 % have made at least one suicide attempt lifetime (Kessler et al. 1999, Weissman et al. 1999, Szádóczky et al. 2000; Nock et al, 2008). Suicidal ideation, suicide attempt and completed suicide are three different, but greatly overlapping features. Prior suicide attempt and current major depression are the two best predictors of future suicide, and the vast majority of suicide attempters/completers come from a population of people with current suicidal ideation, particularly in the presence of untreated major depression (Kessler et al. 1999, Rihmer et al. 2002, Goldney et al. 2003). However, depression, suicide attempt and completed suicide are three different, but greatly overlapping categories: about half of suicide victims have at least one previous suicide attempt, and the first suicide attempt significantly increases the risk of completed suicide during the next 10-15 years (Isometsa and Lönnqvist 1998, Hawton and van Heeringen 2000, Wasserman 2001, Suokas et al. 2001, Rihmer et al. 2002, Suominen et al. 2004). Although suicidal behaviour is a relatively rare event in the primary care practice, considering that depression is very common among suicide completers and attempters, depression, particularly in combination with past or current suicidality should be taken very seriously by GPs.
4. Suicide risk factors, clinically detectable in primary care
Suicide is a very complex, multicausal human behaviour with several biological as well as psychosocial and cultural components and it is not the normal response to the levels of stress experienced by most people. On the other hand, however, it is also not the linear consequence of major mental disorders. It is associated with a number of psychiatric-medical (e.g, major mental) disorders, psycho-social (e.g, permanent adverse life situations and acute psycho-social stressors), and demographic (e.g, male gender, old age) suicide risk factors of varying prognostic utility (Rihmer et al. 2002; Akiskal 2007; Rihmer, 2007; Nock et al, 2008). Although the statistical relationship between the different psycho-social and demographic risk factors and suicidal behaviour is well documented, (Rihmer, 2007; Nock et al, 2008) their predictive value is very weak in individual cases. Because suicidal behaviour is quite rare in the absence of current major psychiatric disorders, psychiatric-medical suicide risk factors, particularly current major depression with prior a suicide attempt are the most powerful and clinically explorable predictors of suicidal behaviour, especially in the presence of psycho-social and demographic suicide risk factors (Beautrais et al. 1996, Hawton and van Heeringen 2000, Wasserman 2001, Rihmer et al. 2002, Balázs et al. 2003, Goldney et al. 2003, Tylee and Rihmer 2004, Rihmer 2005; 2007). A cross-national epidemiological survey showed that for lifetime suicide attempts the strongest diagnostic risk factors were mood disorders in high-income countries but impulse control disorders in low- and middle-income countries (Nock et al, 2008). However, studies from different countries of the world consistently show that more than 90 % of suicide victims or attempters have at least one (mainly untreated) major mental disorder, most frequently unipolar or bipolar major depressive episodes (56-87%), substance-use disorders (26-55%) and schizophrenia (6-13%). Comorbid anxiety and personality disorder as well as concomitant serious medical disorders are also frequently present, but they are rarely the only or principal current diagnosis among suicide victims and attempters (Beautrais et al. 1996, Hawton and van Heeringen 2000, Wasserman 2001, Rihmer et al. 2002, Balázs et al. 2003, Rihmer 2005).
In spite of the fact that more than two-thirds of suicide victims and attempters have current major depressive episode (Beautrais et al. 1996, Wasserman 2001, Hawton and van Heeringen 2000, Rihmer et al. 2002, Balázs et al. 2003) and about two-thirds of them contact their GPs within four weeks before the suicidal act (Rihmer et al. 1990, Luoma et al. 2002, Balázs et al. 2003, Fekete et al. 2004) the rate of pharmacotherapy with antidepressants and/or mood stabilisers in depressed suicidal patients is very low: less than 20 % (Rihmer et al. 1990, Marzuk et al. 1996, Henriksson et al. 2001, Balázs et al. 2003).
Given the very high rate of current major mental disorders among people with suicidal behaviour, in the early 1980’s Khuri and Akiskal (1983) considered that much of the putative psycho-social and demographic suicide risk factors were not modifiable in the frame of individual healthcare. Consequently they proposed that suicide prevention should focus on the treatable contributory psychiatric disorders involved in such behaviour (Khuri and Akiskal, 1983, Akiskal 2007).
5. Recognition of the suicidal patient in primary care
Suicidal behaviour in major mood disorder patients occur mostly during major depressive episodes (79-89%), less frequently in the frame of dysphoric (mixed) mania (11-20%), but practically never during euphoric mania and euthymia (0-1%) (Isometsa et al. 1994b, Rihmer 2007). It means that suicidal behaviour in mood disorder patients is a state-dependent phenomenon, indicating the important role of recognition and treatment of depression in suicide prevention (Khuri and Akiskal 1983, Rihmer et al. 2002, Mann et al. 2005). Since up to 66% of suicide victims contact their GPs 4 weeks before their death (Isometsa et al. 1995, Luoma et al. 2002; Rihmer and Rutz, 2009), it is very likely that at these visits the vast majority of the patients are definitely depressed, and most of them have one or more comorbid psychiatric and/or medical disorder. The most characteristic features of suicidal depression are: agitation, severe anxiety, hopelessness, insomnia, appetite and weihgt loss, comorbid substance-use disorders and bipolar depression (i.e., depression with with past hypomania or mania) (Hawton and van Heeringen, 2000; Rihmer, 2007; Nock et al, 2008; Elovainio et al, 2009). Recent psycho-social stressors (Hawton and van Heeringen, 2000; Wasserman, 2001; Mann, 2004; Rihmer, 2007; Nock et al, 2008) and acute alcohol use, even in non-alcoholic depressives (Sher et al, 2009), also increase the current risk of suicidal behaviour. Hewever, depression is often masked by secondary alcoholism, particularly in men, and symptoms of suicidal depressed men is often masked by aggressive, impulsive, and abusive behaviour, and that these men are better known to legal and social welfare agencies than to their GPs (Angst et al, 2002; Rihmer and Rutz, 2009; Rutz et al. 1995, 1997). The role of complex interaction between psychiatric, personality, and psycho-social factors in suicidal behaviour is best explained by the stress-diathesis model for suicidal behaviour (Mann 2004), where the stressors include acute psychiatric disorder and negative life events (“state” component), and the diathesis includes aggressive, impulsive and pessimistic personality features (“trait” component). Both hopelessness/pessimism and aggressivity/impulsivity may be amenable to cognitive/behavioural therapy and pharmacotherapy, like SSRI antidepressants, lithium and other mood stabilizers (Mann 2004; Akiskal, 2007).
As mentioned previously, GP contact is quite common before suicide. Thirty-four to sixty-six percent of suicide victims visit their GPs 4 weeks before their death, and 20-40 % also do so in the last week, respectively (Ismometsa et al. 1995, Luoma et al. 2002; Rihmer and Rutz, 2009) and the rate of GP contact before suicide attempt is in the same magnitude (Fekete et al, 2004). Compared to nonsuicidal patients, suicide victims visit their GPs three times more frequently in the last 4 weeks of their life (Isometsa et al. 1994a, Luoma et al. 2002) and the number of GP visits increases significantly before the suicidal act both among completed suicides and suicide attempters (Michel et al. 1997, Fekete et al. 2004). However, among those with medical contact, the frequency of persons who communicate explicitly their suicidal intention is only around 20%, and it is particularly rare in primary care (11%) and in other (non psychiatric) specialist settings (6%). One study have found that 18% of the suicide victims visited GPs on the last day of their life, but the topic of suicide was discussed in only 21% of these cases (Isometsa et al. 1995). On the other hand, however, it has also been reported that only 3 % of the GPs were interested to inquire about suicidal ideation at least in old-age depressed patients (Wasserman 2001).
To discuss the possibility of suicidal behaviour with the patient and family members as a common but preventable complication of acute severe mental disorders is very important, because asking questions about suicidal ideation and past suicide attempts does not trigger suicide (Hawton and van Heeringen 2000, Gould et al. 2005). This is particularly true if such a discussion is accompanied by some sentences explaining that depressive disorders can be successfully treated, and that suicidal intent will vanish after (or even before) the recovery from depression. This is beneficial, as many patients think they are alone or unique in their suicidal ideas. Leaflets, posters, and fliers left in the waiting room indicating the main symptoms and dangers of depression as well as information on good prognosis of treatment may prompt people to ask for help (Rihmer and Rutz, 2009). Short screening instruments, like the Beck Scale for Suicide Ideation (an interview-rated 19-item scale) and the Beck Hopelessness Scale (a 20-item self-reported questionnaire) are useful in clinical practice for detecting actual suicide risk (Hawton and van Heeringen 2000, Wasserman 2001). Yet, no one screening instrument can replace the optimal doctor-patient relationship, including asking the right questions at the right time, accompanied by a highly professional and empathic atmosphere. Asking simple questions (“what do you think about the future?”, “do you feel that life is not worth living?”, etc.) can easily facilitate further, more deep and honest discussion on the topic of suicide.
Because the risk of suicide is extremely high a few days and weeks after the discharge from inpatient psychiatric departments, particularly in the case of unplanned discharge and in patients with short hospital stay and with a high number of previous hospitalisations (Hawton and van Heeringen 2000, Wasserman 2001, Qin and Nordentoft 2005) GPs should be alert when a patient discharged from the psychiatric clinic seeks help. As a significant part of depressives stop their medication at the fourth week of the treatment (Lin et al, 1995) aftercare of recently discharged depressive patients is essential for improving compliance and to maintain efficacy. The clinical, psycho-social, and demographic features of the acutely suicidal patient in primary care are listed in Table 1.
6. Management and prevention of depression-related suicides in primary care
Although we can not prevent all suicides, the majority of depression-related suicides are preventable, even in primary care. Suicidal behaviour usually does not occur in the very early stages of the depression and this allows enough time to make a precise diagnosis to consult psychiatrists if needed and to start appropriate treatment. Studies show that continuing medical education (including specific depression-training) for GPs improve recognition of depression including detection of current suicidal ideation, and increase treatment of depression (Rutz et al, 1995; 1997, Rihmer et al, 1995; Hegerl et al, 2006; Henriksson and Isacsson 2006; Szántó et al, 2007; Verger et al, 2007), while only a few others found no positive effects (Nutting et al. 2005,). The four most important studies on this field are: The pioneering Gotland Study, performed in the early 80’s in the last century (Rutz et al, 1995; 1997; Rihmer et al, 1995, 1998), the Nuremberg Alliance Against Depression (NAAD) project performed in Germany between 2000 and 2002 (Hegerl et al, 2006), the Swedish Jamtland study performed between 1995 and 2002 (Henriksson and Isacsson 2006) and the Hungarian GP depression-management educational program between 2000 and 2005 implemented in a region of Kiskunhalas where the baseline suicide rate was twice the national average (Szántó et al, 2007).
1/. The results of the Swedish Gotland Study showed that 2 years after the two-days postgraduate educational programme on the diagnosis and treatment of depression for the GPs in 1983 the suicide rate of Gotland decreased by 60%, the prescription of antidepressants increased from 50% to 80% of Swedish average, and the utilization of non-specific medications (benzodiezepines, antipsychotics) decreased by 25% compared to the Swedish average. The number of referrals to psychiatry for depressive disorders decreased by 50% and the inpatient care for depression as well as the number of days on sick leave because of depression also decreased by 75% and 50%, respectively. All these changes were in contrast to the earlier trends on Gotland and/or contemporary trends in the rest of Sweden (Rutz et al, 1995; 1997). Most importantly the rate of depressive suicides among all suicides decreased significantly after the programme (from 42% to 16%).
2/. The Nuremberg Alliance Against Depression, a 2-year intervention program was performed in Nuremberg (440.000 inhabitants) at four levels: a/ training GPs, b/ a public relations campaign, c/ cooperation with community facilitators (teachers, priests, local media) and d/ support for the self-help activities and for high-risk groups (depressed patients, suicide attempters and their relatives). The results showed that compared to control region (Wuerzburg, 290.000 inhabitants) a significant reduction in frequency of all suicidal acts (suicides and suicide attempts combined) was observed in the intervention region during the 2-year intervention period (2002 vs 2000, Nuremberg: 24% reduction, Wuerzburg: 7% increase, p < 0.004). The reduction in all suicidal acts was most pronounced for violent methods. However, concerning only completed suicides there was no significant difference in the decline of suicide rate between the intervention and control region (Hegerl et al, 2006).
3/. Evaluating the effects of continuing medical education programme (8 seminars between 1995 and 2002) for the GPs on depression in Jamtland county, Sweden (136.000 inhabitants) the authors found that compared to pre-intervention period (1970-1994) the mean suicide rate of Jamtland county decreased by 36% in the intervention period (1995-2002) while the mean suicide rate of Sweden decreased “only” bay 30% during the same time. The use of antidepressants in Jamtland county increased from 25% below the Swedish average to the same level. In line with the greater reduction of suicide rate in Jamtland county the use of antidepressants increased by 161% in this county while the same figure for the whole Sweden was “only” 108% (Henriksson and Isacsson, 2006).
4/. As for the Hungarian GP depression-management educational program, in the intervention region (region of Kiskunhalas, 73.000 inhabitants) the 5-year preintervention (1996-2000) and postintervention (2001-2005) mean annual suicide rates per 100.0000 population were 59.7 and 49.9 (16% decrease). In the local control region (Kiskunfélegyháza, 54.000 inhabitants) the same figures were 50.4 and 45.1, respectively (11% decrease). In spite of the fact that this difference is mathematically not significant the difference shows in the expected direction and is in good agreement with the finding that the raise in antidepressant prescription and the rate of antidepressant treated persons increased significantly more in the intervention than in the control region. However, the suicide mortality of subjects seen only by GPs in the last year of their life decreased significantly (by 26%) compared to those who contacted other health-care services (internal medicine, cardiology, rheumatology, psychiatry, pulmonology, etc.) or with no medical cont act at ell. Further, the decrease in annual suicide rate was significantly greater in the intervention region (9.8 per 100.000) compared with the county minus intervention region (6.9 per 100.000) and compared with all of Hungary (4.5 per 100.000) (Szántó et al, 2007; Rihmer and Rutz, 2009).
Although the five major healthcare-based educational programmes, discussed above, were performed in different time-frames and used somewhat different research design the main results show in the same direction indicating that better care of psychiatric (and particularly depressive) patients is one important contributing factor in declining suicide rates of the areas served by trained GPs and other healthcare workers.
However, improved primary care education in isolation, does not have any significant long-term effect, and only complex educational and organisational interventions that incorporate continuous clinician education, an enhanced role of nurses and social workers, as well as high level of integration between primary and secondary (psychiatric) care (consultation-liaison) are beneficial. GP education should be well-focused, quite short and interactive, include written materials, lectures, seminars, video-demonstrations, and small-group discussions (Rutz et al. 1997, Appleby et al. 2000, Gilbody et al. 2003, Mann et al. 2005, Hegerl et al, 2006; Szanto et al. 2007).
Better management of depression requires not only imporved recognition and treatment skills from the doctors, but also good compliance from the patients, since non adherence to antidepressant therapy is one of the most common causes of treatment failure. At least one-third of patients stop taking antidepressants during the first 4 weeks of therapy, and around half of them take them until the end of the third month (Lin et al. 1995). The better side-effect profile and less toxic nature of SSRIs and other new antidepressants, and the recently increasing practice of GPs to prefer these drugs over tricyclic antidepressants is also beneficial for improving the quality of care and reducing the risk of death in the case of overdose (Lin et al. 1995, van Os et al. 2002). Using simple psycho-educational messages (i.e. why, how, and how-long to take antidepressants and what to do in the case of side effects, to optimise the clinical response) both in oral and written form increases the adherence of patients to antidepressant therapy (Lin et al. 1995).
Treatment of depressed patients in primary care should follow international and national guidelines established (van Os et al. 2002). In contrast to recent concerns on the “suicide-provoking potential” of antidepressants, it is evident that antidepressants and mood stabilisers, like lithium, lamotrigine, carbamazepine, valproate, and others treat depression effectively and decrease suicidality markedly among unipolar and bipolar depressives (Yerevanian et al. 2004, Akiskal et al. 2005, Simon et al. 2006; Akiskal 2007; Rihmer 2007; Guzzetta et al, 2007). However, since antidepressant monotherapy, unprotected by mood stabilisers in bipolar depression, sometimes induces agitation, excitement (and rarely also auto- and hetero-aggressive behaviour) in the first few days or weeks of treatment, all depressive patients should be carefully checked for bipolarity and followed closely in the fist 1-3 weeks of the therapy (Akiskal et al. 2005; Aksikal, 2007; Rihmer 2007). Anxiety, agitation or insomnia should always be controlled with concomitant use of high-potency benzodiazepines, which also hasten the clinical response if combined with antidepressants (Furukawa et al. 2001). Regular aftercare with fixed appointments and permanent psychological support are also important, particularly for those patients with prior suicide attempts. This is necessary, since the actual clinical picture immediately after suicide attempt is often misleading, due to the cathartic effect of self-aggression, resulting in a short-lived but sometimes marked improvement of the depression (Jallade et al. 2005). This can also serve as one of the explanations why some healthcare workers misinterpret suicide attempts as manipulative acts.
Acutely suicidal patients usually need inpatient treatment even of involuntary nature. In the case of severe agitation or anxiety prompt anxiolysis with benzodiazepines and close observation is highly recommended. After an open discussion with the patient and relatives, involuntary admission is rarely needed. If acute hospitalisation is not indicated, a close observation by family members and removing possible means of suicide (i.e, guns, drugs, pesticides, car key etc) as well as consultation with a local outpatient psychiatrist is advised. GPs should work in close and permanent collaboration with the local mental health services. Outpatient psychiatric consultation is also helpful in the cases of differential-diagnostic problems, treatment resistance and comorbid substance-use disorder regardless of whether the patient is suicidal or not. If long-term/prophylactic pharmacotherapy is needed (bipolar disorder, recurrent unipolar major depression) the GP may refer the patient to a psychiatrist for optimising the therapy (Hawton and van Heeringen 2000, Wasserman 2001, Tylee and Rihmer 2004). The most frequent reasons of outpatient psychiatric consultation and inpatient admission are listen in the Table 2.
Prevention of depression-related suicidal behaviour in primary care is not an easy task, but it is possible. GPs are the first to meet depressed patients and should be trained in diagnostics and up to date use of antidepressants and non-pharmacologic interventions. Although specific depression-targeted psychotherapies exceed the frame of primary care, psychoeducation and supportive psychotherapy is needed and it is essential to offer this kind of treatment in primary care settings. Regardless, GPs should have knowledge about the identification and treatment of depression and they also should collaborate with psychiatric services.
7. References
Akiskal HS. Targeting suicide prevention to modifiable risk factors: Has bipolar II been overlooked? Acta Psychiat Scand, 2007; 116: 395-402.
Akiskal HS, Benazzi F, Perugi G, Rihmer Z (2005). Agitated “unipolar” depression re-conceptualized as a depressive mixed state: Implications for the antidepressant-suicide controversy. Journal of Affective Disorders, 85, 245-258.
Al Windi A (2005). Depression in the general practice. Nordic Journal of Psychiatry, 59, 272-277.
Angst J, Gamma A, Gastpar M, Lepin J-P, Mendlewicz J, Tylee A (2002). Gender differences in depression. Epidemiological findings from the European DEPRES I and DEPRES II studies. European Archives of Psychiatry and Clinical Neuroscience, 252, 201-209.
Ansseau M, Dierick M, Buntinkx F, Cnockaert P, De Smedt J, Van Den Haute M, Mijnsbrugge DV (2004). High prevalence of mental disorders in primary care. Journal of Affective Disorders, 78, 49-55.
Appleby L, Morriss R, Gask L, et al. (2000). An educational intervention for front-line health professionals in the assessment and management of suicidal patient. The STROM Project. Psychological Medicine, 30, 805-812.
Balázs J, Lecrubier Y, Csiszér N, Koszták J, Bitter I (2003). Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: Importance of the first depressive episode and of bipolar II diagnoses. Journal of Affective Disorders, 76, 113-119.
Beautrais AL, Joyce PR, Mulder RT, Fergusson DM, Deavoll BJ, Ningtingale SK (1996). Prevalence and comorbidityof mental disorders in persons making serious suicide attempts: A case-control study. American Journal of Psychiatry, 153, 1009-1014.
Berardi D, Menchetti M, Cevenini N, Scaini S, Versari M, De Ronchi D (2005). Increased recognition of depression in primary care. Psychotherapy and Psychosomatics 74, 225-230.
Davidson JRT and Meltzer-Brody SE (1999). The underrecognition and undertreatment of depression: What is the breadth and depth of the problem? Journal of Clinical Psychiatry, 60 (Suppl. 7), 4-9.
Elovainio M, Shipley MJ, Ferrie JE, Gimeno D, Vahtera J, Marmot MG, Kivimaki M. Obesity, unexplained weight loss and suicide: The original Whitehall study. J Affect Disord, 2009; 116: 218-221.
Fekete S, Osvath P, Michel K (2004). Contacts with health care facilities prior to suicide attempts. In D De Leo, U Bille-Brahe, A Kerkhof, A Schmidtke, ed. Suicidal Behaviour. Theories and Research Findings, pp. 303-313. Hogrefe and Huber Publishers, Göttingen, Germany.
Furukawa TA, Steiner DL, Young LT (2001). Is antidepressant-benzodiazepine combination therapy clinically useful? A meta-analytic study. Journal of Affective Disorders, 65, 173-177.
Garcia-Cebrian A, Gandhi P, Demyttenaere K, Peveler R. The association of depression and painful physical symptoms – A review of the European literature. Eur Psychiatry, 2006; 21: 379-388.
Gilbody S, Whitty P, Grimshaw J, Thomas R (2003). Educational and organizational interventions to improve the management of depression in primary care. JAMA, 289, 3145-3151.
Goldney RG, Dal Grande E, Fisher LJ, Wilson D (2003). Population attributable risk of major depression for suicidal ideation in a random and representative community sample. Journal of Affective Disorders, 74, 267-272.
.
Gould MS, Marrocco FA, Kleinman M, et al. (2005). Evaluating iatrogenic risk of youth suicide screening programs. A randomized controlled trial. JAMA, 293, 1635-1643.
Guzzetta, F., Tondo, L., Centorrino, F., Baldessarini, R.J. (2007) Lithium treatment reduces suicide risk in recurrent major depressive disorder. J Clin Psychiatry, 68, 380-383.
Hawton K, and van Heeringen K, eds (2000). International Handbook of Suicide and Attempted Suicide. John Wiley and Sons, Chichester.
Hegerl U, Althaus D, Niklewski G, Schmidtke A, Niklewski G. (2006). The alliance against depression: 2-year evaluation of a community-based intervention to reduce suicidality. Psychol Med, 36: 1225-1234.
Henriksson S, Boethius G, Isacsson G (2001). Suicides are seldom prescribed antidepressants: Findings from a prospective prescription database in Jamtland county, Sweden. Acta Psychiatrica Scandinavica, 103, 301-306.
Henriksson S, Isacsson G. (2006) Increased antidepressant use and fewer suicides in Jamtland county, Sweden, after a primary care educational programme on the treatment of depression. Acta Psychiat Scand, 114: 914-920.
Isometsa ET, Aro HM, Henriksson MM, Heikkinen ME, Lönnqvist JK (1994a). Suicide in major depression in different treatment settings. Journal of Clinical Psychiatry, 55, 523-527.
Isometsa ET, Henriksson MM, Aro HM, Lönnqvist JK (1994b). Suicide in bipolar disorder in Finland. American Journal of Psychiatry, 151, 1020-1024.
Isometsa ET, Lönnqvist JK (1998). Suicide attempts preceding completed suicide. British Journal of Psychiatry, 173, 531-533.
Ismometsa ET, Heikkinen ME, Marttunen MJ, Henriksson MM, Aro HM, Lönnqvist JK (1995). The last appointment before suicide: Is suicide intent communicated?
American Journal of Psychiatry, 152, 919-922.
Jallade C, Sarfati Y, Hardy-Baylé MC (2005). Clinical evolution after self-induced or accidental traumatism: A controlled study of the extent and the specificity of suicidal crisis. Journal of Affective Disorders, 85, 283-292.
Kessler RC, Borges G, Walters EE (1999). Prevalence and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56, 617-626.
Khuri R and Akiskal HS (1983). Suicide prevention: The necessity of treating contributory psychiatric disorders. Psychiatric Clinics of North America, 6, 193-207.
Lecrubier Y (1998). Is depression under-recognised and undertreated? International Clinical Psychopharmacology, 13 (suppl. 5), 3-6.
Lecrubier Y (2001). Improved ability to identify symptoms of major depressive disoder (MDD) in general practice. International Journal of Psychiatry in Clinical Practice, 5 (Suppl. 1), 3-10.
Lecrubier Y and Hergueta T (1998). Differences between prescription and consumption of antidepressants and anxiolytics. International Clinical Psychopharmacology, 13 (Suppl. 2), 7-11.
Lin EHB, von Korff M, Katon W, Bush T, Simon GE, Walker E, Robinson P (1995). The role of the primary care physician in patients’ adherence to antidepressant therapy. Medical Care, 33, 67-74.
Luoma JB, Martin CE, Pearson JL (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159, 909-916.
Mann JJ (2004). Searching for triggers of suicidal behavior. American Journal of Psychiatry, 161, 395-397.
Mann JJ, Apter A, Bertolote J, et al. (2005). Suicide prevention strategies. A systematic review. JAMA, 294 2064-2074.
Marzuk PM, Tardiff K, Leon AC, et al. (1996). Use of prescription psychotropic drugs among suicide victims in New York City. American Journal of Psychiatry, 152, 1520-1522.
Michel K, Runeson B, Valach L, Wasserman D (1997). Contacts of suicide attempters with GPs prior to the event: A comparison between Stockholm and Bern. Acta Psychiatrica Scandinavica, 95, 94-99.
Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer A, Beautrais A, Bruffaerts R, Chiu WT, di Girolamo G, Gluzman S, de Graaf R, Gureje Ö, Haro JM, Huang Y, Karam E, Kessler RC, Lepine J-P, Levinson D, Medina-Mora ME, Ono Y, Pasada-Villa J. (2008) Cross-naítional prevalence and risk factors for suicidal ideation, plans and attempts. Brit J Psychiatry, 192: 98-105.
Nutting PA, Dickinson LM, Rubenstein LV, Keely RD, Smith JL, Elliott CE (2005). Improving detection of suicidal ideation among depressed patients in primary care. Annals of Family Medicine, 3, 529-536.
Qin P and Nordentoft M (2005). Suicide risk in relation to psychiatric hospitalization. Archives of General Psychiatry, 62, 427-432.
Rihmer Z, Barsi J, Arató M, Demeter E (1990). Suicide in subtypes of primary major depression. Journal of Affective Disorders 18, 221-225.
Rihmer Z, Rutz W, Pihlgren H (1995). Depression and suicide on Gotland. An intensive study of all suicides before and after a depression-training programme for general practitioners. Journal of Affective Disorders, 35, 147-152.
Rihmer Z, Rutz W, Pihlgren H, Pestality P. 1998. Decreasing tendency of seasonality in suicide may indicate lowering rate of depressive suicides in the population. Psychiatry Res 81: 233-40.
Rihmer Z, Belso N, Kiss K (2002). Strategies for sucide prevention. Current Opinion in Psychiatry, 15, 83-87.
Rihmer Z (2005). Prediction and prevention of suicide in bipolar disorders. Clinical Neuropsychiatry, 2, 48-54.
Rihmer Z and Angst J (2005a). Mood disoders: Epidemiology. In Sadock BJ, Sadock VA, ed. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th edition, pp. 1575-1582. Lipincott Williams and Wilkins, Philadelphia,
Rihmer Z and Angst J (2005b). Epidemiology of bipolar disorder. In Kasper S, Hirschfeld RMA, ed. Handbook of Bipolar Disorder, pp. 21-35. Taylor and Francis, New York.
Rihmer Z, Suicide risk in mood disorders. Curr Opin Psychiat, 2007; 20: 17-22.
Rihmer Z. and Rutz W. Treatment of attempted suicide and suicidal patients in primary care. In. OxfordTextbook of Suicidology and Suicide Prevention, (Eds: Wasserman, D. Wasserman C.), Oxford University Press, New York, 2009, pp: 463-470.
Rutz W, von Knorring L, Pihlgren H, Rihmer Z, Walinder J (1995). Prevention of male suicides: Lessons from Gotland study. Lancet, 345, 524.
Rutz W, Waliner J, Knorring L, Rihmer Z, Pihlgren H (1997). Prevention of depression and suicide by education and medication: Impact on male suicidality. An update from the Gotland study. International Journal of Psychiatry in Clinical Practice, 1, 39-46.
Sher L, Oquendo MA, Richardson-Vejlgaard, Makhija NM, Posner K, Mann JJ, Stanleys BH.(2009). Effect of acute alcohol use on the lethality of szuicide attempts in patients with mood disorders. J Psychiatric Research, 43: 901-905.
Simon GE, Savarino J, Operskalski B, Wang PS (2006). Suicide risk during antidepressant treatment. American Journal of Psychiatry, 163, 41-47.
Spitzer RL, Williams JBW, Kroenke K, et al. (1994). Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 Study. JAMA, 272, 1749-1756.
Suokas J, Suominen K, Isometsa ET, Ostamo A, Lönnqvist J (2001). Long-term risk factors for suicide mortality after attempted suicide – Findings of a 14-year follow-up study. Acta Psychiatrica Scandinavica, 104, 117-121.
Suominen K, Isometsa ET, Suokas J, Haukka J, Achte K, Lönnqvist J (2004). Completed suicide after a suicide attempt: A 37-year follow-up study. American Journal of Psychiatry, 161, 563-564.
Szádóczky E, Rihmer Z, Papp Z, Füredi J (1997). The prevalence of affective and anxiety disorders in primary care practice in Hungary. Journal of Affective Disorders, 43, 239-244.
Szádóczky E, Vitrai J, Rihmer Z, Füredi J (2000). Suicide attempts in the Hungarian adult population. Their relation wtih DIS/DSM-III-R affective and anxiety disorders. European Psychiatry, 15, 343-347.
Szádóczky E, Rózsa S, Zámbori J, Füredi J (2004). Anxiety and mood disorders in primary care practice. International Journal of Psychiatry in Clinical Practice, 8, 77-84.
Szántó K, Kalmar S, Hendin H, Rihmer Z, Mann JJ (2007). A suicide prevention program in a region with a very high suicide rate. Archives of General Psychiatry, 64, 914-20.
Torzsa P, Rihmer Z, Gonda X, Szókontor N, Sebestyén B, Faludi G, Kalabay L (2009a). Family history of suicide: A clinical marker for major depression in primary care practice?
J Affect Disord, 117: 202-204.
Torzsa, P. Székely, A. Bagi, M. Purebl Gy, Kopp M.(2009b) Az “Európai Szövetség a Depresszió Ellen” magyarországi programjának bemutatása. Magyar Családorvosok Lapja, 1: 12-17.
Tylee A (1999). Depression in the community: Physician and patient perspective. Journal of Clinical Psychiatry, 60 (Suppl. 7), 12-16.
Tylee A and Rihmer Z (2004). Suicide and attempted suicide. In Jones R, Britten N, Culpepper L, Gass D, Grol R, Mant D, Silagy C, Ian R, ed. Oxford Textbook of Primary Medical Care, pp. 959-962. McWhinney 2004.
van Os TWDP, van den Brink RHS, Jenner JA, van der Meer K, Tiemens BG, Ormel J (2002). Effects on depression pharmacotherapy of a Dutch general practitioner treating program. Journal of Affective Disorders, 71, 105-111.
Wasserman D ed (2001). Suicide – An unnecessary Death. Martin Dunitz, London.
Weissman MM, Bland RC, Canino GJ, et al. (1999). Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 29, 9-17.
Verger P, Brabis P-A, Kovess V, Lovell A, Sebbah R, Villani P, Paraponaris A, Rouilon F.(2007). Determinants of early identification of suicidal ideation in patients trerated with antidepressants or anxiolytics in general practice: A multilevel analysis. J Affect Disord, 99: 253-257.
Wittchen HU, Höfler M, Meister W (2001). prevalence and recognition of depressive syndromes in German primary care settings: Poorly recognized and treated? International Clinical Psychopharmacology, 16, 121-135.
Yerevaninan BI, Koek RJ, Feusner JD, Hwang S, Mintz J (2004). Antidepressants and suicidal behaviour in unipolar depression. Acta Psychiatrica Scandinavica, 110, 452-458.
Appendix A. Tables.
Table — 1. Most characteristic features of acutely suicidal patients in primary care
| Clinical features (primary suicide risk risk factors) | Psycho-social features (secondary suicide risk factors) | Demographic features (tertiary suicide risk factors) |
|---|---|---|
| Severe depressive episode (agitation, insmonia, anxiety hopelessness, guilt) | Acute psycho-social stressors (loss-events, major financial problems) | Male gender (all ages) Old age (both genders) Young people (males) |
| Acute/chronic alcohol/drug problems | Isolation/divorce, living alone | Same-sex orientation Spring/early summer |
| Severe comorbid medical disorder(s) | living in high buildings | |
| Hopelessness, wish to die, suicide ideas, suicide plan, suicide gestures | Unemployment, permanent adverse life-situatuions | |
| Recent discharge form in–patient psychiatric department (short hospital stay, high number of prior hospitalizations, unplanned discharge) | ||
| Impulsive/aggressive personality features | ||
| Lacking treatment and/or family support |
Table — 2. When to refer primary care patients to psychiatric services?
| Outpatient psychiatric care | Inpatient psychiatric admission |
|---|---|
| Recent suicide attempt/gesture | Current suicidal danger |
| Differential diagnostic problem | Very severe depression (psychotic, catatonic, negativistic features) |
| Treatment resistant depression | |
| Comorbid substance abuse/dependence | Manic or hypomanic episode |
| Noncompliance with the treatment | Acute psychotic states |
| Severe personality disorder | Severe comorbid medical disorder(s) |
| Hypomanic episode | Newly recognized bipolar disorder |