{'fraction_non_alphanumeric': 0.027379679144385025, 'fraction_numerical': 0.013775401069518717, 'mean_word_length': 5.324675324675325, 'pattern_counts': {'":': 0, '<': 2, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 1, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Let’s Not Talk About It: Suicide Inquiry in Primary Care

PURPOSE The purpose of this study was to ascertain physician characteristics associated with exploring suicidality in patients with depressive symptoms and the influence of patient antidepressant requests. METHODS Primary care physicians were randomly recruited from 4 sites in northern California and Rochester, NY; 152 physicians participated (53%–61% of those approached). Standardized patients portraying 2 conditions (major depression and adjustment disorder) and 3 antidepressant request types (brand specific, general, or none) made unannounced visits to these physicians between May 2003 and May 2004. We examined factors associated with physician exploration of suicidality. RESULTS Suicide was explored in 36% of 298 encounters. Exploration was more common when the patient portrayed major depression (vs adjustment disorder) (P = .03), with an antidepressant request (vs no request) (P=.02), in academic settings (P <.01), and among physicians with personal experience with depression (P <.01). The random effects logistic model revealed a significant physician variance component with ρ = 0.57 (95% confidence interval, 0.45–0.68) indicating that there were additional, unspecified physician factors determining the tendency to explore suicide risk. These factors are unrelated to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confidence in treating depression. CONCLUSIONS When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality. Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help. Research is needed to further elucidate physician characteristics associated with the assessment of suicidality.


INTRODUCTION
Suicide is a leading cause of death and potential life-years lost worldwide. 1 Most people who die by suicide have a treatable mental disorder, usually depression, but few have seen a mental health specialist. 2,3 Although many patients are reluctant to seek and actively engage in mental health treatment, up to 75% of those who complete suicide have seen a primary care clinician in the previous 30 days. [4][5][6][7] The primary care setting thus presents an excellent venue for detection of and early intervention for suicide risk. 8,9 Suicide ideation, defi ned as the presence of passive or active thoughts about a premature end of life, is present in 2% to 7% of all primary care patients. 10,11 Suicide ideation confers risk for suicide as well as morbidity and all-cause mortality. [12][13][14][15][16][17][18] In spite of ample opportunity for detection and intervention, presuicidal patients seldom alert physicians to their plans, and studies have found low rates of inquiry and detection of patients' suicidal thoughts by primary care practitioners. 8,15,19 Remarkably little is known about the factors that infl uence whether primary care physicians broach the topic of suicide. The lack of data on suicide risk is especially SUICIDE INQUIRY striking considering how much has been written about the detection of depression in the primary care setting. [20][21][22][23] To determine whether physician characteristics, patient symptoms, and patient behavior infl uence whether physicians explore the topic of suicide with their patients, we conducted secondary analyses of data collected in a randomized trial that examined actual clinical behavior of physicians in the context of patient requests for treatment. Specifi cally, we examined the following questions: (1) What physician demographic and clinical characteristics enhance the likelihood that they will broach the topic of suicide to patients with depressive symptoms? (2) Are physicians more likely to inquire about suicide when patients have more severe symptoms of depression? (3) Do patient requests for antidepressants affect physician inquiries about suicide?

Design Overview
The study was approved by the institutional review boards at all participating institutions, and details have been presented elsewhere. 24 Standardized patients were trained to portray 6 roles, involving 2 clinical conditions (major depression or adjustment disorder) and 3 medication request types (brand specifi c, general, or none). Participating physicians gave advanced consent to see 2 unannounced standardized patients and have the visits covertly audio recorded by the patient; physicians were randomized to see both roles with 2 of the request types. Visits took place between May 2003 and May 2004. After each visit, the standardized patients completed a reporting form on the questions asked by the physician. Physicians completed a clinician background questionnaire at the conclusion of the study.

Physicians
Internists and family physicians were recruited from 4 sites: (1) a primary care network in the Sacramento, Calif, area; (2) a group-model health maintenance organization, also in the Sacramento area; (3) a physician network in the San Francisco, Calif, Bay Area; and (4) a physician network in the Rochester, NY, area. A total of 152 physicians participated in the study; 6 physicians saw only 1 standardized patient. Participation rates by site ranged from 53% to 61%. The age and sex distributions of participating physicians were similar to those of nonparticipating physicians.

Standardized Patient Roles and Visits
A total of 18 actresses portrayed the 2 standardized patient roles. Role 1 was a 48-year-old divorced white woman with major depression of moderate severity and wrist pain consistent with carpal tunnel syndrome. Role 2 was a 45-year-old divorced white woman with adjustment disorder with depressed mood and low back pain. Role outlines were revised iteratively until they were judged by a consensus of investigators and advisors to be clinically credible and manageable within the context of a 15-to 20-minute, new-to-physician, "acute" visit. Standardized patients were required to portray the role details with 95% accuracy, maintain affective fi delity (agreed-on levels of depressed mood and anxiety), and demonstrate competence in completing the reporting form. By design, there were 3 antidepressant request conditions: (1) a request for Paxil (paroxetine), (2) a request for "medication that might help," and (3) no specifi c request. In the analyses reported here, the fi rst 2 request conditions were collapsed into 1 category, called "prompt." The third condition was labeled "no prompt." Immediately following the visit, standardized patients listened to the audio recording and completed the reporting form, including questions on the physician's depression history taking. An independent judge listened to 36 randomly selected audio recordings; overall agreement between the standardized patient and the independent judge was 92% (mean κ, 0.82). Within 2 weeks of a standardized patient visit, physicians were asked via facsimile whether, during the prior 2 weeks, they had been defi nitely or probably suspicious that 1 of their patients was actually a standardized patient; 12.8% of physicians reported being suspicious. At least 2 months separated both the time from consent to the fi rst visit and the time from the fi rst to the second visit.

Standardized Patient Reporting Form Questions
This study focused on the items on the standardized patient reporting form pertaining to history taking for depression symptoms. Items were derived from published recommendations and the advice of the study's clinical advisory panel. 25 One item inquired whether the physician asked the standardized patient about thoughts of wanting to be dead, of engaging in selfharm, or of committing suicide (yes/no). This variable was the main outcome of the study and is referred to as exploration.

Clinician Background Questionnaire
We asked physicians about their age, sex, race (white or not), medical specialty (family medicine or internal medicine), and practice setting (solo or group, academic medical setting or not). Based on Bandura's Social Cognitive Theory, 26 we asked 8 questions pertaining to their level of confi dence in treating depres-

SUICIDE INQUIRY
sion, each rated on a 4-point Likert scale (Cronbach α = 0.76; mean, 3.0; SD, 0.41; range, 1.75-4.0), and 9 items about perceived barriers to treating depressed patients, each rated on a 3-point Likert scale (Cronbach α = 0.75; mean, 2.0; SD, 0.45; range, 1.00-2.88), to indicate the extent to which different factors limited optimal depression care. Finally, based on research suggesting that personal experience may inform clinical decision making, 27 we asked whether physicians had personal experience with depression in themselves, in family members, or in close friends. Physicians completed the questionnaire at least 4 weeks after the last standardized patient visit. The physicians' practices were compensated to make up for lost revenue but were not paid to complete the questionnaire.

Audiotape Analysis
Encounters were analyzed using the Measure of Patient-Centred Communication (MPCC). 28 We felt that the MPCC score would serve as a proxy for physician communication style that would predict the likelihood of exploring suicidality in their patients. The MPCC has shown adequate reliability (interrater reliability reported as 0.80-0.83) and validity, and has an established relationship with patient trust and patient perceptions of their physicians' communication behavior. [28][29][30] The MPCC measures 3 aspects (or components) of physician communication and is unique in that it is theoretically linked to a model of patientcentered communication. For component 1 (exploring both the disease and the illness experience), the coder notes patient statements about symptoms, ideas, expectations, feelings, and the effect of the symptoms on functioning. Component 2 (understanding the whole person) measures the degree to which the physician explores family, social, and occupational issues. Component 3 (fi nding common ground) measures the degree to which the physician arrives at a common understanding with the patient about the nature of the problem and its management. We trained 2 coders to score the recordings using the MPCC; 10% of recordings were scored by both coders. The total MPCC score represents the mean of the 3 component scores. Observed scores ranged from 0.12 (least patient centered) to 0.81 (most patient centered), with a mean of 0.51 (SD, 0.88). Our reliability data as well as means and standard deviations of the scores were virtually identical to those reported by the developers. 28

Statistical Analysis
Analyses were performed with STATA version 9.2 (Stata Corp, College Station, Tex). The main outcome of interest in these analyses was whether the physician explored the topic of suicide with the standardized patient (exploration), as assessed from the standardized patient reporting form. In addition to examining the bivariate relationships between exploration and other variables, we used logistic mixed models to examine the relationships between exploration and characteristics of patients and physicians including the MPCC score. Patient characteristics included mood disorder (major depression vs adjustment disorder) and prompting (any medication request vs none). Physician factors included demographics, study site (San Francisco, Calif; Sacramento, Calif; Rochester, NY), practice setting (solo vs group; academic vs nonacademic), confidence in treating depressed patients, perceived barriers to treating depressed patients, and personal experience with depression (vs none).
Analyses were conducted with each standardized patient-physician encounter as an observation. Random intercept, mixed effects regression analyses evaluated both standardized patients and physicians as random effects and other covariates as fi xed effects. Assessment of the physician random effect (or variance component) allowed calculation of the consistency with which physicians explored suicide in the encounters. We report that consistency as the proportion of total variance contributed by the physician variance component (ρ, or the intraclass correlation coeffi cient). 31 Results were considered statistically signifi cant if the P value was .05 or less. Analyses excluding encounters wherein the physician suspected the patient was a standardized patient were similar to those reported here and are not presented.

RESULTS
Suicide was explored in 36% of the 298 encounters. Table 1 shows the relationships between exploration about suicidality and each of the measured characteristics. Exploration was more common when the standardized patient role was major depression (vs adjustment disorder) and when the standardized patient used a prompt (vs none). In the depression scenario, the rate of question asking about suicidality was at least 10% higher for both request conditions (brand specifi c and general) compared with the no request condition (data not shown). In addition, the increased exploration in the depression scenario was more pronounced with a general request than with a brand-specifi c request.
Exploration was also more common in academic settings and among physicians with a personal experience with depression (whether in themselves, family members, or close friends). There was no relationship between individual standardized patients (n = 18) and the likelihood of exploring suicide (details not shown, P = .25).

SUICIDE INQUIRY
When only the standardized patient role and request variables were entered into a random effects logistic model with exploration as the dependent variable, we observed a signifi cant physician variance com-ponent (ρ = 0.57; 95% confi dence interval, 0.45-0.68). When physician characteristics and MPCC score were also entered into the model, the effects for role, prompt, academic setting, and personal experience with depression continued to be signifi cant ( Table 2). The ρ value dropped slightly to 0.53 (95% confi dence interval, 0.40-0.67).
In none of the logistic regression models were standardized patient random effects signifi cant, suggesting that role fi delity was well standardized across the 18 standardized patients.

DISCUSSION
This secondary analysis of a randomized trial of standardized patient visits to primary care practices examined specifi c physician and patient characteristics that may predict whether physicians are likely to inquire about suicide in their patients with depression. We found that, overall, primary care physicians inquired about suicide in less than one half of the standardized patients with depression and in even fewer of those with adjustment disorder. In the depression scenario, standardized patient requests for medication significantly increased physicians' inquiries about suicide. This fi nding was especially true when general requests were made; the effects of brand-name requests on inquiry about suicide were less powerful. There was signifi cant physician variance in this behavior with a large effect size (ρ), suggesting that physicians have a characteristic style that infl uences whether they explore suicide. This fi nding is impressive, given that the ρ value for primary care physician activities is generally reported to range from 0 to 0.3 and is usually less than 0.1. 32 Even after controlling for potential confounders, the ρ value remained large, indicating that there are additional, albeit unspecifi ed, physician factors that determine the tendency to explore suicide risk. These factors are probably related to unmeasured attitudes, traits, or knowledge. Our analyses suggest that suicide inquiries are not related to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confidence in treating depression. Some physicians might avoid bringing up the issue of suicide because of fears that broaching the topic might heighten patients' suicidal feelings. 33 Others could be concerned about offending the patient or are themselves made uncomfortable by the prospect of inquiring about a behavior that was once considered a sin by many religious authorities and a crime in many legal jurisdictions worldwide. Prior work on primary care physicians' response to domestic violence invoked the image of opening Pandora's box to explain why they avoided screening for domestic violence. 34 Physicians reported a fear of offending their patients and concern that they had insuffi cient expertise to intervene appropriately if the patient screened positive-so they avoided the topic altogether. For some physicians, suicide may represent another of the thorny issues in Pandora's box, raising many of the same fears and concerns of inadequate expertise and insuffi cient time in a busy practice. Interestingly, although there was no association between physicians' personal experiences with domestic violence and their proclivities to screen, we found that physicians' personal experience with depression was signifi cantly associated with exploration (adjusted odds ratio = 3.11; P = .03). 34 Perhaps those who have had personal experience with depression are less judgmental, more attuned to the suffering it entails, more aware of the mortality risk, and less likely to be infl uenced by societal stigmatization of mental illness and suicide.
We found patient-related factors were also a signifi cant predictor of physician suicidal assessment. Physicians were more likely to ask about suicide when the standardized patient role was major depression (vs adjustment disorder with depressed mood). This fi nding is reassuring because patients with more depressive symptoms are more likely to attempt and complete suicide. 2 Physicians also were more likely to ask about suicide when the standardized patient requested antidepressant treatment (vs no request). This was especially true when general requests were made; the effects of brand-name requests on inquiry about suicide were less powerful. This fi nding suggests that patient requests or prompts may in essence give the physician permission to ask about a topic such as suicide that otherwise might be avoided by both physician and patient. In fact, it is interesting to note that the patient request in this study had a similar effect size to a clinical intervention to improve detection of suicidal ideation in primary care described in a recent study. 35 Overall, physicians asked about suicide only 27% of the time in the unprompted condition. This fi nding is similar to the control group rate of detection of 20.5% in a recent study. 35 Surprisingly, there are few studies that would help inform effective interventions to address this problem. A recent study from France found that telephone follow-up after a suicide attempt reduced repeated attempts over 1 year, 36 and collaborative care has been shown to reduce suicide ideation in primary care patients. 8 These studies suggest that system-level interventions similar to what has been found to improve outcomes for depressed primary care patients may also improve outcomes for suicidal patients. To date, routine screening for suicide has not been universally advocated, but it seems evident that inquiries about suicide may be the most important questions that primary care physicians ask of patients with depressive symptoms. 1,8,37 Our study suggests that one approach to improving the rate of physician recognition of suicidal thinking in depressed patients is through advertising or public service messaging ("social marketing") that prompts patients to ask for help in treating depression without encouraging them to request specifi c antidepressant medications. Patient prompts for treatment would not be effective, however, if we did not improve the ability of physicians to respond appropriately to these prompts. Earlier research has suggested that interventions aimed at changing specifi c physician behavior in depression care are more likely to lead to primary care physician behavior change and improved patient outcomes than more comprehensive interventions aimed, for example, at improving physician monitoring of depression treatment response. 38 This study has a number of limitations. First, we established that there are signifi cant individual differences between physicians in their propensity to broach the topic of suicide, but the study design did not allow us to identify the specifi c traits, attitudes, or personal experiences that account for these differences. More research is needed. Second, although the use of standardized patients has a number of potential methodologic advantages, we cannot know whether the observed physician behavior would hold true with real patients in other practice settings. 24 It is reassuring that standardized patient factors were not signifi cant in determining whether physicians broached the topic of suicide. Third, a considerable limitation is that the standardized patients in this study were middle-aged women making fi rst visits to a new physician. The estimated rate of exploring suicide risk in this sample may not accurately represent physicians' overall rate of exploration or formal screening. 39 Rates of exploration or screening may be higher or lower as a function of patient age, sex, or race, or length of the physician-patient relationship. Given that suicide rates peak in women in their mid 40s, our focus on depressed middle-aged women is a strength. Fourth, although we can provide a reasonable estimate of whether physicians explored the topic of suicide with these patients, we have no data on the quality of these discussions or whether the discussions could be considered formal suicide screens. The numbers provided here are undoubtedly upper-bound estimates of the rate of suicide screening conducted with depressed middle-aged women in the community. Fifth, although our study concludes that physicians have a characteristic style that infl uences whether they explore suicide, we are unable to clearly identify the specifi c physician factors that determine this behavior. Finally, the data on suicide exploration were derived entirely from standardized patient report. Although these reports were made immediately after the visit with the physician and thus should not be subject to memory decay, we do not have data on their validity.
In summary, this study examined the factors that infl uence whether physicians broach the topic of suicide with distressed patients in primary care. The fi nding that patient requests for medication led to higher rates of exploration speaks to the potential value of disease awareness campaigns, mental health literacy programs, and patient activation programs. [40][41][42] Our data also suggest that research is needed to better elucidate the characteristics of physicians associated with the assessment and reporting of suicide ideation in patients with symptoms of depression. Ideally, these studies would be conducted in conjunction with research on how characteristics of patients and health care settings infl uence physician assessments. More translational research is needed to inform the design and implementation of interventions aimed at suicide prevention and other improved outcomes for depressed patients.