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Psychosomatic Medicine 65:501-505 (2003)
© 2003 American Psychosomatic Society

ORIGINAL ARTICLE

Major Depression, Physical Illness, and Suicidal Ideation in Primary Care

Renee D. Goodwin, PhD, Kurt Kroenke, MD, Christina W. Hoven, Dr PH and Robert L. Spitzer, MD

From Department of Epidemiology (RDG, CWH), Biometrics Department (RLS), Department of Psychiatry (RLS, CWH); College of Physicians and Surgeons, Columbia University, New York, NY; and the Regenstrief Institute; Indiana University School of Medicine (KK), Indianapolis, IN.

Address reprint requests to: R. D. Goodwin, 1043 Riverside Dr., Unit 43, New York, NY 10032. Email: rdg66{at}columbia.edu

Received for publication August 22, 2002; revision received October 17, 2002.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: To determine the association between major depression and suicidal ideation and the role of physical illness in this link among primary care patients.

METHOD: More than 3,000 randomly selected primary care patients at eight sites across the United States completed the PRIME-MD PHQ, a screen for mental disorders for use in primary care. Physicians independently diagnosed physical illnesses. Multiple logistic regression analyses were used to determine the relationship between PRIME-MD depression, physical illness, and suicidal ideation.

RESULTS: Pulmonary disease was associated with an increased likelihood of suicidal ideation, even among patients without major depression [odds ratio = 1.9 (1.04, 3.4)]. There was evidence of statistical interaction between pulmonary disease and depression in increasing the odds of suicidal ideation. Specifically, patients with pulmonary disease without depression, those with depression without pulmonary disease, and patients with both pulmonary disease and depression had significantly increased odds of suicidal ideation with odd ratios of 1.9 (1.04, 3.4), 7.4 (5.6, 9.7), and 9.6 (5.1, 18.0), respectively.

CONCLUSIONS: These data suggest that some physical disorders may be associated with increased suicidal ideation in primary care and may also play a role in the relationship between depression and suicidal ideation among primary care patients. Primary care physicians may wish to engage in an in-depth evaluation of psychiatric problems, especially current suicidal ideation, among patients with specific ongoing physical illnesses.

Key Words: depression, • suicidal ideation, • primary care, • physical illness, • pulmonary disease, • comorbidity.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Suicidal ideation is common and associated with functional impairment, psychiatric comorbidity, increased health service use and subjective distress among primary care patients (1–4). Despite these correlations, suicidal ideation remains infrequently detected by primary care physicians (5). Moreover, the rate of suicidal behavior and suicide completions following primary care visits is significantly greater than expected by chance (6, 7). It is well known that major depression, which is common in primary care, is an important risk factor for suicidal ideation in primary care settings (7, 8). Major depression, however, is not the sole condition associated with suicidal ideation. Other common mental disorders, such as anxiety disorders and substance use disorders have also been shown to play a significant role in the increased odds of suicidal ideation among primary care patients, along with being female, perception of poor health, and psychiatric comorbidity (1–4, 9, 10).

Data from previous studies suggest that some forms of physical illnesses may be associated with increased rates of depression and suicidal ideation (11). Previous studies have shown an association between physical illness and depression, and higher than expected prevalence of suicidal ideation among patients with severe physical illness in clinical and community samples (11, 12). For instance, cancer is associated with an increased prevalence of suicidal ideation in specialty patient populations (13). Another recent study found an association between asthma and suicidal ideation among medical inpatients (14). Previous studies have not investigated the relationship between physical illness and suicidal ideation among patients in primary care outpatient samples, despite the prevalence of suicidal ideation in these populations. Moreover, although previous data suggest that depression is more common among those with, compared with those without, physical illness in primary care, no previous study has examined the relationship between the co-occurrence of physical illness and depression in the risk of suicidal ideation among primary care patients.

The goal of the current study was to determine the relationship between depression, physical illness, and suicidal ideation among primary care patients. On the basis of previous findings, we hypothesized that physical illness would be associated with an increased likelihood of suicidal ideation among adult primary care patients. We also predicted that the co-occurrence of depression and physical illness would be associated with an even greater odds of suicidal ideation compared with that associated with either or neither.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Sites and Selection of Subjects
All patients (N = 3890; age 18 years or older) presenting for visits with their physician at the five internal medicine and three family practice sites were invited to participate in the study from May 1997 to November 1998. There were 190 who declined to participate, 266 who started but did not complete the study questionnaire, and 434 whose questionnaires were not entered into the data set because more than one page was not completed or there were inadequate data to rule in or out one or more of the mental disorder diagnoses derived from the questionnaire. This resulted in the 3000 cases reported here (71.1% response rate overall, with 1578 family practice, and 1422 general internal medicine patients). All sites used one of two subject selection methods to minimize sampling bias: selection of either consecutive patients for a given clinic session or every ninth patient until the intended quota for that session was achieved.

Assessment
For all subjects, current major depressive disorder, panic attacks, and alcohol use disorder were assessed with the PRIME-MD Patient Health Questionnaire (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), a screening instrument that uses diagnostic algorithms to generate diagnoses of common mental disorders (15). The diagnostic validity of this instrument is comparable to the original clinician-administered PRIME-MD (16). Suicidal ideation was measured with the question, "Have you had thoughts that you would be better off dead or of hurting yourself in some way for at least several days in the last two weeks?" At each site, using the identical procedure, the physician recorded current physical disorders with a checklist that included: diabetes, pulmonary disease, cancer, cardiac disease, liver disease, kidney disease, hypertension, and arthritis); after evaluating each patient but before reviewing the PHQ. All procedures were approved by the IRB committees of each institution before the study. If a patient was deemed actively suicidal, he or she was given appropriate treatment.

Analytic Strategy
First, Pearson’s {chi}2 tests were used to determine differences in sociodemographic characteristics, current mental disorders, and physical illness between those with and without current suicidal ideation, and with and without major depression. All tests were two sided and significance was set at 0.05. Second, the relationship between each physical illness diagnosed and odds of suicidal ideation was determined using multivariate logistic regression analyses. Next, the relationship between the co-occurrence of depression and physical illness (any illness and specific illnesses) was investigated using multiple logistic regression analyses to determine the independent effects of specific physical disorders, with and without depression, and the likelihood of suicidal ideation. An interaction term was included in the final model for the association between depression and physical illnesses that were independently associated with suicidal ideation.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Suicidal Ideation
Patients with suicidal ideation were more likely to be male, younger, separated, divorced, or never married and with less education, compared with those without suicidal ideation (Table 1). Major depression, generalized anxiety disorder (GAD), and alcohol use disorders were significantly more common among those with, compared with those without, suicidal ideation. Pulmonary disease was more common and hypertension was less common among patients with suicidal ideation, compared with those without suicidal ideation.


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  		TABLE 1. Sociodemographic Characteristics, Mental, and Physical Disorders Among Primary Care Patients With and Without Suicidal Ideation
 
Major Depression
Major depression was significantly more common among female patients who were separated or divorced (data not shown). There were no differences in age, race, or education between those who were and were not depressed. Major depression was associated with significantly higher levels of GAD, alcohol use disorders, and suicidal ideation, compared with those without major depression. Patients with major depression were significantly more likely to have liver disease (2.6% vs. 0.9%, x = 10.6, df = 1, p = .001), pulmonary disease (22.0% vs. 14.8%, x = 7.8, df = 1, p = .005), and diabetes (11.5% vs. 7.2%, x = 10.2, df = 1, p = .001), compared with those who were not depressed.

Association Between Physical Illness and Suicidal Ideation in Primary Care
Pulmonary disease was associated with a statistically significant increased likelihood of suicidal ideation (Table 2). Hypertension was associated with a decreased likelihood of suicidal ideation, yet this association was no longer statistically significant after adjusting for differences in mental disorders. The association between pulmonary disease and suicidal ideation persisted after adjusting for differences in sociodemographic characteristics and mental disorders, and showed evidence of statistical interaction (p < .0001). Specifically, the suicide ideation rate was 6.3% with neither disorder, 11.0% with pulmonary disease without major depression, 9.5% with major depression without pulmonary disease, and 12.0% with both pulmonary disease and depression. Patients with pulmonary disease without depression were 1.7 (1.04, 3.4) times more likely to have suicidal ideation, those with depression without pulmonary disease were 7.4 (5.6, 9.7) times more likely, and patients with both pulmonary disease and depression were 9.6 (5.1, 18.0) times more likely to have suicidal ideation. Being female and unmarried was also associated with a significantly increased likelihood of suicidal ideation, as were major depression, GAD, and alcohol use disorders. In contrast, higher level of formal education was associated with decreased odds of suicidal ideation.


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  		TABLE 2. Association Between Hypertension and Pulmonary Disease and Odds of Suicidal Ideation Among Primary Care Patients
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Primary care patients with pulmonary disease who are depressed are significantly more likely to experience suicidal ideation, compared with those with either, or neither, of these disorders. This relationship was not evident among those with other physical disorders. Furthermore, pulmonary disease was associated with an increased likelihood of suicidal ideation, which persisted after adjusting for depression and other common mental disorders, although these factors did contribute to the strength of the association. Our analyses also showed evidence of statistical interaction between depression and pulmonary disease in the likelihood of suicidal ideation.

The mechanism of the association between pulmonary disease, major depression, and suicidal ideation is not known. It may be that the pain and physical suffering or the prospects of a more limited lifestyle associated with specific physical illnesses such as asthma and chronic obstructive pulmonary disease is severe enough that this leads to thoughts that life is not worth living. It could also be that suicidal ideation is associated with an increased likelihood that one will have exacerbated, or poorer control over, ongoing pulmonary disease, leading to more frequent physician visits, thereby increasing this association in primary care patients. Although this is a plausible explanation, other reports have shown an increased likelihood of suicidal ideation and suicide behavior associated with lung disease in unselected community-based samples (14), which decreases the chance that this association is simply a result of sampling bias. These data are also consistent with several studies showing the high prevalence of major depression and functional impairment in pulmonary disease (17–21). Alternatively, it could be that some medications used to treat some physical diseases (eg, steroid-based medications used to treat asthma) may be associated with increased depressive and anxiety symptoms at a subclinical level which could contribute to suicidal ideation.

Alternatively, it may be that there are common factors related to both pulmonary disease and suicidal ideation, which independently predict their co-occurrence. These could be genetic or environmental. In this instance, perhaps some pulmonary diseases (eg, emphysema, chronic obstructive pulmonary disease) are associated with other behaviors (eg, cigarette smoking, excessive alcohol consumption) (22) that often occur among individuals with depressive symptoms (23, 24) as well as other more severe mental disorders, which may contribute to this association. Moreover, recent data suggest a potential physiological basis for how pulmonary disease may increase the risk for neuropsychological symptoms, which could be linked to depression (25, 26). Future research is needed to determine the nature of this link.

The strengths of this study include the use of physician diagnoses of physical disorders and of a multisite, geographically diverse sample of primary care outpatients not selected for either physical illness or mental disorder. Several study limitations should be noted. First, our investigation of the relationship between physical illness and suicidal ideation is limited to those eight physical illnesses that were diagnosed by primary care physicians on the encounter forms. Second, we had only information on the presence or absence of physical disorders rather than their severity, and the latter may be an important factor in the likelihood of suicidal ideation. Third, the low prevalence of some physical disorders (such as cancer) limited power of the study to determine a relationship with suicidal ideation. Fourth, the lack of information on the sequence of onset of these events and the lack of data on suicide plans or attempts limit any potential interpretations about the possible causal chain of events that may influence these outcomes.

Although the mechanisms of these relations remain unclear, these results may prompt clinicians to consider physical illnesses, particularly pulmonary disease, as possible risk indicators in their assessment of risk of suicide ideation among patients in primary care. If these results are confirmed in future studies, it may be worthwhile to investigate the possible utility of more directly inquiring about mental health problems among individuals who present with these medical illnesses, especially among those with known mental disorders. Furthermore, future studies that investigate whether and to what degree the treatment of depression is associated with improvement in physical health problems, as well as the reverse, and the extent to which mental health care affects the risk of suicide behavior also merit attention. For instance, including physical health status as an outcome variable in studies that examine the efficacy and effectiveness of improvement in quality of care interventions for mental disorders in primary care may yield important data (27). Because suicidal ideation has been identified among the strongest predictors of suicide behavior (28), there may be considerable benefit from early detection and intervention among those at risk. Future studies that investigate whether the use of interventions aimed at improving treatment of depression in primary care (29) have a positive effect on the likelihood of suicidal ideation among those with specific physical illness in primary care may be useful as a next step in understanding the mechanism of these associations.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Welch SS. A review of the literature on the epidemiology of parasuicide in the general population. Psychiatr Serv 2001; 52: 368–375.[Abstract/Free Full Text]
  2. King RA, Schwab-Stone M, Flisher AJ, Greenwald S, Kramer RA, Goodman SH, Lahey BB, Shaffer D, Gould MS. Psychosocial and risk behavior correlates of youth suicide attempts and suicidal ideation. J Am Acad Child Adolesc Psychiatry 2001; 40: 837–846.[CrossRef][Medline]
  3. Leon AC, Olfson M, Broadhead WE, Barrett JE, Blacklow RS, Keller MB, Higgins ES, Weissman MM. Prevalence of mental disorders in primary care. Implications for screening. Arch Fam Med 1995; 4: 857–861.[Abstract/Free Full Text]
  4. Lish JD, Zimmerman M, Farber NJ, Lush DT, Kuzma MA, Plescia G. Suicide screening in a primary care setting at a veterans affairs medical center. Psychosomatics 1996; 37: 413–424.[Abstract/Free Full Text]
  5. Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW. Primary health care providers’ recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry 1988; 10: 317–321.[CrossRef][Medline]
  6. Hyden LC. Care utilization and the incidence of suicide: suicide victims’ contacts with primary health care and psychiatry in six psychiatric districts in the County of Stockholm from 1979 to 1990. Acta Psychiatr Scand 1996; 93: 442–6.[Medline]
  7. Goldney RD, Wilson D, Dal Grande E, Fisher LJ, McFarlane AC. Suicidal ideation in a random community sample: attributable risk due to depression and psychosocial and traumatic events. Aust NZ J Psychiatry 2000; 34: 98–106.[CrossRef][Medline]
  8. Rost K, Zhang M, Fortney J, Smith J, Coyne J, Smith GR Jr. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry 1998; 20: 12–20.[CrossRef][Medline]
  9. Olfson M, Shea S, Feder A, Fuentes M, Nomura Y, Gameroff M, Weissman MM. Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice. Arch Fam Med 200; 2000: 9: 876–883.[Abstract/Free Full Text]
  10. Lin EHB, Von Korff M, Wagner EH. Identifying suicide potential in primary care. J Gen Int Med 1989; 4: 1–6.[Medline]
  11. Stenager EN, Stenager E. Physical illness and suicidal behavior.In Hawton K, van Heuringen K, editors. The international handbook of suicide and attempted suicide. New York: Wiley, 2000.
  12. Hendin H. Suicide, assisted suicide, and medical illness. J Clin Psychiatry 1999; 60 (Suppl 2): 46–50.
  13. Gupta MA, Gupta AC. Depression and suicidal ideation in dermatology patients with acne, aloecia areata, atopic dermatitis, and psoriasis. Br J Dermatology 1998; 139: 846–850.[CrossRef][Medline]
  14. Druss B, Pincus H. Suicidal ideation and suicide attempts in general medical illnesses. Arch Intern Med 2000; 160: 1522–1526.[Abstract/Free Full Text]
  15. Spitzer RL, Kroenke K, Williams JBW, and the Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study. JAMA 1999; 282: 1737–1744.[Abstract/Free Full Text]
  16. Spitzer RL, Kroenke K, Williams JBW, and the PHQ Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD. JAMA 1999; 282: 1737–1744.
  17. Kelly TM, Soloff PH, Lynch KG, Haas GL, Mann JJ. Recent life events, social adjustment, and suicide attempts in patients with major depression and borderline personality disorder. J Pers Disord 2000; 14: 316–326.[Medline]
  18. Borson S, Glaypoole K, McDonald GJ. Depression and chronic obstructive pulmonary disease: treatment trials. Clin Neuropsychiatry 1998; 3: 115–130.
  19. Felker B, Katon W, Hedrick SC, Rasmusse J, McKnight K, McDonnell MB, Fihn SD. The association between depressive symptoms and health status in patients with chronic pulmonary disease. Gen Hosp Psychiatry 2001; 23: 56–61.[CrossRef][Medline]
  20. Aydin IO, Ulusahin A. Depression, anxiety comorbidity, and disability in tuberculosis and chronic obstructive pulmonary disease patients: Applicability of the GHQ-12. Gen Hosp Psychiatry 2001; 23: 77–83.[CrossRef][Medline]
  21. Light RW, Merrill EJ, Despars JA, Gordon GH, Mutalipassi LR. Prevalence of depression and anxiety in patients with COPD: relationship to functional capacity. Chest 1985; 87: 35–8.[Abstract/Free Full Text]
  22. Viegi G, Scognamiglio A, Baldacci S, Pistelli F, Carrozzi L. Epidemiology of chronic obstructive pulmonary disease (COPD). Respiration 2001; 68: 4–19.[CrossRef][Medline]
  23. Glassman AH. Psychiatry and cigarettes. Arch Gen Psychiatry 1998; 55: 692–3.[Free Full Text]
  24. Compton WM3rd, Cottler LB, Phelps DL, Ben Abdallah A, Spitznagel EL. Psychiatric disorders among drug dependent subjects: are they primary or secondary? Am J Addict 2000; 9: 126–134.[CrossRef][Medline]
  25. Stuss DT, Peterkin I, Guzman DA, Troyer AK. Chronic obstructive pulmonary disease: effects of hypoxia on neurological and neuropsychological measures. J Clin Exp Neuropsychol 1997; 19: 515–524.[Medline]
  26. Grant I, Heaton RK, McSweeny AJ, Adams KM, Timms R. Neuropsychologic findings in chronic obstructive pulmonary disease. Arch Intern Med 1982; 142: 1470–6.[Abstract/Free Full Text]
  27. Unutzer J, Rubenstein L, Katon WJ, Tang L, Duan N, Lagomasino IT, Wells KB. Two-year effects of quality improvement programs on medication management for depression. Arch Gen Psychiatry 2001; 58: 935–942.[Abstract/Free Full Text]
  28. Nielsen B, Wang AG, Bille-Brahe U. Attempted suicide in Denmark. IV: a five-year follow-up. Acta Psychiatr Scand 1990; 81: 250–4.[Medline]
  29. Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, Unutzer J, Miranda J, Carney MF, Rubenstein LV. Impact of dissemination of quality improvement programs for depression in primary care: a randomized clinical trial. JAMA 2000; 283: 212–220.[Abstract/Free Full Text]



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