What predicts suicide attempts in primary care depressive disorders? Psychol Med.Jan.2014

24.01.2014

Detecting and treating depression is a central theme in most suicide prevention strategies. Most of our understanding on risk factors for suicide in depression is based on studies done in psychiatric setting.  Severity of depression,duration of time spent in depression, current suicidal ideation, comorbidty with personality disorders, substance use,physical illness lacking a partner and low perceived social support has been highlighted in many studies as risk factors for suicide attempts.  Most recent systematic review (Hawton et al 2013) identified  previous attempted suicide ,more severe depression ,hopelessness ,male gender , family history of psychiatric disorder, comorbid disorders, including anxiety and misuse of alcohol and drugs as risk factors for completed suicide in depression. However, out of 22 studies  included in this review, only two had primary care patients.

Only 28% of all suicides in UK is classified as ‘patient suicide’ i.e. having any contact with mental health services in the past one year. Though two-thirds of suicides occur outside mental health settings, research is sparse in that area.

Very few studies have  investigated the risk factors for suicide attempt in primary care patients with depression. These patients usually suffer from mild to moderate depression. A group of researchers from Finland (K. Riihimaki, M. Vuorilehto, T. Melartin, J. Haukkaand  and E. Isometsa) report on the risk factors found in the Vantaa Primary Care Depression Study . This is the first prospective  study of primary care patients with depressive disorders ( include Major depressive episode, dysthymia, sub syndromal depression and minor depression)  that used semi- structured interviews to diagnose all Axis I and II disorders. They investigated the role of some psychosocial and socio-economic risk factors, and used life-chart methodology to examine temporal covariation of depression, substance use and suicide attempts. 137 patients ( from a total population of 63400 inhabitants, served by 30 general practitioners with a population-based responsibility) were studied for 5 years.

Results

 10.4%  of the depressive primary care patients attempted suicide during the five year follow-up period. Overall 22.6% attempted suicide before or after study entry. All  patients who had attempted suicide had a life time diagnosis of MDD at study entry.Almost half of the attempts  occurred during periods of concurrent MDE and substance abuse.

Poisoning by drugs (59%) and cutting by knife (27%) were the common methods. The degree of medical severity was  moderate in 45% and  severe in 23%.

At the time of suicide attempts, most (59%) of the patients were not receiving any treatment for their depression.After the attempt, altogether 41%  of attempters received psychiatric care.

Only 5%  of attempters   talked about the attempt to  attending health care personnel in primary care, and even this was long afterwards  the event.

Conclusions: Every tenth patient with depressive disorders in primary care attempts suicide within 5 years. Suicidal acts took place almost exclusively (in 95%) during MDEs, often with concurrent active substance abuse. The attending primary care doctors were rarely aware of these attempts. 

Limitations: Generalisability to different  populations remains unknown.

Comment: It is important to note that most patients with major depression in primary care settings are not getting treatment. Professionals in these settings are usually unaware of the suicidal ideation or attempts of their patients. Absence of communication of suicide intent observed in last appointments preceding suicide revealed in psychological autopsy studies  have resonance here also.

Summary of the article:

Incidence and predictors of suicide attempts among primary-care patients with depressive disorders: a 5-year prospectivestudy.Riihimäki K, Vuorilehto M, Melartin T, Haukka J, Isometsä E. Psychol Med. 2014 Jan;44(2):291-302.

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