Brief reportFamily physicians and the risk of suicide in the depressed elderly
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
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