Brief report
Family physicians and the risk of suicide in the depressed elderly

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Abstract

Background: Depression is the most frequent psychiatric disorder in the elderly. It is the reason for most suicides in this age group. Method: We performed a representative survey in primary care. Two written case vignettes were presented to 170 family physicians in face-to-face interviews which took place in their practices. The case vignettes described either (Case 1) a mildly depressed otherwise healthy old patient or a severely depressed patient (Case 2) with somatic comorbidity. Afterwards the interviewers asked standardized open questions. The physicians were not let into the mental health focus of the study. Results: The response rate was 77.6%. Depression was considered for primary or differential diagnosis by 91.2% of the physicians in Case 1 and by 70% in Case 2 (X2-test; p<0.01). For further anamnesis, only 2.4% of the physicians were interested in suicidal ideation of the patient. When directly asked at the end of the interview, 76.9% of the physicians said they would talk about suicide. Those who would not, thought that the patient would communicate suicidal intent himself/herself, or they feared to induce suicide by asking directly. Conclusion: Thinking of suicidality and its prevention is not uppermost in the physicians' mind. Therefore, and also with regard to the relatively high rate of depression recognition, we conclude that educational means should not only focus on the recognition and screening of depression, but also on the management—`how to talk about…'—of complex problems like suicide in the elderly, in order to change suicide rates.

Introduction

Recent studies in the US revealed increasing suicide rates in the elderly in recent years (Diekstra and Gulbinat, 1993, Centers for Disease Control and Prevention, 1996). Psychiatric illness accounts for about 90% of all suicides, with depression making up much more than 50% especially in the elderly (Henriksson et al., 1993, Henriksson et al., 1995, Conwell et al., 1996). Recent evidence reveals that early recognition and treatment of the underlying psychiatric disorder is the most important method of suicide prevention (Isacsson et al., 1996, Rutz et al., 1989, Rutz et al., 1992, Rihmer et al., 1995, Ahrens et al., 1995). Different guidelines recommend routine screening and evaluation of suicide risk in high risk groups (American Medical Association, 1994, Canadian Task Force on the Periodic Health Examination, 1994).

In the elderly, the recognition and treatment of depression is of major importance because it is a frequent disorder (Beekman et al., 1995) and can be treated as successful as in younger age groups (Katona, 1995, Lebowitz et al., 1997). However, more than for younger ages, it goes under-recognized and undertreated (Lebowitz et al., 1997, NIH Consensus Development Panel on Depression in Late Life, 1992). Since most of the elderly exclusively visit their family physicians, these hold the key position to better recognition and management. Two thirds of all suicides visited their family physician within the month preceding the suicide (Lloyd and Jenkins, 1995, Cattell and Jolley, 1995). However, only one fifth of those who would commit suicide within the following 4 weeks had discussed suicide during their last appointment, according to a Finnish study (Isometsa et al., 1995). In old age, some patient factors make detection and treatment of depression and suicidality even more difficult (NIH Consensus Development Panel on Depression in Late Life, 1992, Gallo et al., 1994, Lyness et al., 1995). In addition different attitudes of the physicians and the community with regard to suicide in old compared to young patients must be taken into account (Duberstein et al., 1995).

There is some evidence that gender differences on the part of the patients as well as on the part of the physicians may be influencing this situation. Duberstein et al. (1995)found that female physicians “hold attitudes toward suicide that are different from male physicians and, perhaps, from other women”. In the Gotland study the rate of female depressive suicides decreased dramatically after the training program, while the proportion of male depressive suicides was almost unchanged (Rihmer et al., 1995). Finally, Isometsa et al. (1994)found significant sex differences in current and previous treatment of major depressed patients who later died of suicide.

With a two-step design the following study reveals information about the willingness of family physicians to elicit a history of suicidal ideation in their elderly depressed patients.

Section snippets

The case vignettes

We designed written sample case histories. The severity of the depression and the gender of the patient were the main factors which were experimentally varied.

Case 1 describes a patient free of other diseases with a mild depression. The symptoms have been described to be typical of old age depression (Ernst and Angst, 1995, Brodaty et al., 1991).

Case 2 describes a patient with moderate to severe depression with the same social characteristics as the patient in Case 1. The severity is underlined

Results

In the investigation area 239 physicians work in private practices according to the list of the chamber of physicians. A total of 20 doctors had to be excluded as they did not practise any more (n=6) or they were not primary care physicians (11). From the remaining physicians (n=219), 77.6% (125 general practitioners and 45 primary care internists) took part in the study. In detail, the group consisted of 131 males and 39 females, with a mean age of 47.04 years, who had been running their

Discussion

The method we used is well known in epidemiological research as a tool to measure physicians' competence, attitudes and also actual behaviour (Duberstein et al., 1995, Jones et al., 1990, Holt and Mazzucca, 1992, Yoder et al., 1990). We have discussed the advantages and problems of this method previously in publications of an earlier study of our group (Stoppe et al., 1994). An advantage with regard to the questions of this study is that a standardised patient, which was regarded by 88% of the

References (34)

  • Centers for Disease Control and Prevention, 1996. Suicides among Older Persons, United States, 1980–1992, MMWR (Morb....
  • J.S Cohen et al.

    Attitudes towards assisted suicide and euthanasia among physicians in Washington State

    N. Engl. J. Med.

    (1994)
  • Y Conwell et al.

    Relationship of age and axis I diagnoses in victims of completed suicide: A psychological autopsy study

    Am. J. Psychiatry

    (1996)
  • R.F.W Diekstra et al.

    The epidemiology of suicidal behaviour: A review of three continents

    Wld. Hlth. Statis. Quart.

    (1993)
  • P.R Duberstein et al.

    Attitudes toward self-determined death: A survey of primary care physicians

    J. Am. Geriatr. Soc.

    (1995)
  • C Ernst et al.

    Depression in old age. Is there a real decrease in prevalence? A review

    Eur. Arch. Psychiatry Clin. Neurosci.

    (1995)
  • J.J Gallo et al.

    Age differences in the symptoms of depression: A latent trait analysis

    J. Gerontol.

    (1994)
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