| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
LETTERS TO THE EDITOR |
Juvenile Protective Association and University of Illinois at Chicago, Chicago, Illinois, Ludwig-Maximilians-Universitat Munchen, University of Pennsylvania
A recent article by Goodwin et al. (1) in Psychosomatic Medicine addressed an important, clinically relevant question: suicidal ideation and its correlates among primary care patients. However, their effort was seriously limited from the start by an assessment of ideation with a single, nonspecific, and compound item, leaving the investigators and readers to draw disorienting clinical implications from its bivariate and multivariate associations. Specifically, Goodwin et al. (1) and, in an accompanying editorial, Rollman and Shear (2), were left pondering 2 odd findings: a) hypertension was negatively related to suicidal ideation in a bivariate association, and b) pulmonary disease, but none of 6 other important health problems, was related to suicidal ideation in bivariate and multivariate associations.
The measure of suicidal ideation used was a single item taken from the Patient Health Questionnaire (3): "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?" In a primary care context, this item taps a full range of functional, medical, and psychosocial complaints and self-concerns quite removed from the likelihood that patients are at serious risk of taking their own lives. Problems with the item are aggravated when it is considered separate from a diagnosis of depression or substance abuse. While some of the issues tapped by such an item might otherwise go unaddressed in a primary care visit, there are more fruitful ways of identifying them than labeling such disparate concerns suicidal ideation. The ready slide from acceptance of the label of suicidal ideation into addressing these complaints and concerns as mental issues, or, worse, the management of them with the presumption of suicidality, would be, at best, premature and alienating to patients.
The high prevalence (9%) of endorsement of the item should have raised concerns about the item’s limitations. Given the results obtained, we must either revise the well-supported impression that suicidal risk is relatively low among such a predominately middle-aged sample (4) or concede that this item is too nonspecific to serve its intended purpose.
In the absence of additional data, we are left to speculate what might prompt patients’ endorsement of thinking that they would be better off dead. Without a more specific context, endorsement of the first clause, "better off dead," might well reflect unaddressed pain or the burden and functional impairment associated with symptoms such as fatigue and dyspnea (hence, the association with pulmonary disease). We cannot be sure how much the second half of the item, "hurting yourself in some way," separately contributes to the frequency with which this item was endorsed. However, in this clinical context, frequent endorsement could well reflect a confession of nonadherence or unhealthy lifestyle rather than suicidal intent.
Statistical analyses available in the article are less illuminating than they might have been. Expressions of the likelihood that patients with various medical conditions also suffered from major depression would have been more informative than the converse probabilities that patients with major depression had these other health conditions. To explicate any clinical implications of the data, simple statistics presenting the association of chronic health conditions with suicidal ideation in the absence of major depression would have been an informative supplement to multivariate analyses. Namely, among how many patients (and then, which patients) does suicidal ideation occur in the absence of major depression? Data reported in the text indicate that the association between the suicidal ideation item and major depression dwarf any of the associations between suicidal ideation and physical health conditions. Furthermore, any interpretation of statistical results involving major depression need to be tempered by recognition of limitations of the self-report data on which the diagnosis was based.
If the proffered clinical implications of these data were taken seriously, primary care physicians would be encouraged to have a heightened suspicion of risk for suicide among their patients in the absence of major depression. Routine inquiry modeled after the authors’ ideation item would yield very few patients who had clinically significant risk of suicide and many more patients who did not have any risk, resulting in many patients identified as at risk, few of whom who actually were contemplating suicide. This misdirection of resources is especially problematic given that there still does not exist an established effective treatment for acute suicidal ideation except as part of a general management of mental illness. Conventional approaches to the treatment of acute suicidality, such as contracting, are not very effective (5). As well, any effective intervention is likely to be resource-intensive and to depend on accurate identification. As it stands, the vital needs in suicide research are a) the development of effective interventions and b) the refinement of tools for identifying people at risk of suicide attempts. Broadening the definition of suicidal ideation addresses neither need and may interfere with both.
Whether coming from researchers or clinicians, reliance on vague general inquiries about putative suicidal ideation may reflect the concern that directly asking about suicidal ideation, desires, or plans may upset patients or increase distress. In our experience with diverse populations (6,7), we have found that simple, direct questions about active suicidal plans or intentions work well and do not cause undue distress. Such precision is especially important in working with children, elderly people, and people with medical comorbidities, who are likely to misunderstand vague generalities. For example, in 1 study, 8-year-old children were asked about "wanting to kill yourself" (7), with no negative outcomes. In their call for more specific nomenclature in suicidology, O’Carroll et al. (8) lamented "because the term ‘attempted suicide’ potentially means so many different things, it runs the risk of meaning almost nothing at all" (8, p 238). Even more concern is appropriate for the term suicidal ideation. As a field, we are in danger of defining and assessing it so loosely that we will be unable to distinguish the few genuinely suicidal people from the many who are not.
More generally, researchers need to be sensitive to the unintended effects of their suggestions that primary care physicians should be giving greater attention to clinical issues they are allegedly missing. Recommendations that primary care physicians pursue presumed clinical indicators whose prevalence dictates high rates of false-positives and negligible true-positives are at best likely to be met with skepticism and more likely will ultimately result in clinical cynicism about the value of any such research-based opinion.
Primary care physicians are already having enough difficulty translating the available practice guidelines into improved clinical outcomes for depression. Greater success in addressing highly prevalent and treatable depression among their patients would do much more to reduce the risk of suicide among these patients than aggressively pursuing the highly ambiguous risk associated with endorsement of the item the authors claim represents suicidal ideation.
REFERENCES
Columbia University, New York, New York
Regenstrief Institute at Indiana, University School of Medicine, Indianapolis, Indiana
Thompson et al. identify a valid limitation regarding our article—namely, that the single Patient Health Questionnaire (PHQ) item screening for suicidal ideation (SI) is in fact a compound question asking about not only active thoughts of self-harm but also passive thoughts about whether life is worth living. A principal aim of the PHQ developers was to create a diagnostic measure that was both valid and brief to enhance its utility in clinical practice. This required collapsing related depression symptoms into the same item; this was true not only for the SI item but also for individual items about increased or decreased sleep, increased or decreased appetite or weight, and psychomotor agitation or retardation. A positive response to such compound items requires further probing by the clinician. Regarding the SI item, an initial follow-up question should clarify whether the patient is experiencing passive thoughts about death vs. active thoughts about self-harm. If the latter, further questioning about suicidal plans, past attempts, and suicidal risk factors is warranted.
In short, it is not simple endorsement of the PHQ SI item but rather follow-up questions to this item that identify true suicidal ideation. In this respect, however, the PHQ is not alone; inability to define and detect suicide risk is a recognized shortcoming of current diagnostic measures (1). Incidentally, the 9% endorsement rate of this PHQ item was not unique to our sample but has also been verified in general population samples (2).
The fact that we denoted positive responses to the question about thoughts of death or self-harm as "suicidal ideation" certainly overestimates the prevalence of active suicidality in our population. On the other hand, this compound item can be used as a marker of intense mental distress: its endorsement indicates either risk for self-harm or, at the least, uncertainty about whether life is worth living. The fact that pulmonary patients appear especially prone to experience these feelings suggests that pulmonary disorders may have particularly devastating psychological consequences. The added finding that pulmonary disease nearly doubles the likelihood of experiencing passive or active thoughts about death even after controlling for depression and other potential confounders further strengthens the association. It is also consistent with other data showing linkages between lung disease and asthma and suicidal ideation, suicide attempts, and completion among adults in primary care patients (3) and in the community (4,5). In short, we agree that depression screening in patients with comorbid medical disorders should take primacy over merely inquiring about SI, and that endorsement of our compound question should trigger explicit inquiry about actual suicidal ideation and plans.
REFERENCES
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
