This Date in UCSF History: Mentioning the Unmentionable

Monday, October 25, 2021

Originally published on October 25, 2007.

Midway through my first year preceptorship, a particularly difficult patient interview taught me the importance of asking patients about depression. Getting a straight history from this patient had been difficult as he repeatedly answered questions with sarcasm and carried himself with a strained sense of cheerfulness.

After presenting the patient history to my preceptor in front of the patient, my preceptor asked if I had inquired about depression. Turning to the patient I then asked if he had ever been depressed. Yes, the patient answered, I have been depressed for many years. Yes, I feel depressed now.

Since that experience, I have made it a priority to ask patients if they have ever been depressed. Even still, I have not yet made it a habit to explore the topic of suicide with patients who report or show signs of depression.

A paper published in the September/ October issue of Annals of family Medicine suggests that most primary care physicians do not consistently inquire about suicide in patients exhibiting depressive symptoms. Mitchell Feldman, MD, MPhil, professor of medicine, Division of General Internal Medicine at UCSF, is lead author on the paper titled “Let’s Not Talk About It: Suicide Inquiry in Primary Care.”

The design of the study involved 152 physicians who consented to see two unannounced standardized patients. Within two months of the physician’s consent, an actress portraying one of six roles presented to the clinic.

The roles involved two clinical conditions (major depression or adjustment disorder) and three medication request types (brand specific, general, or none).

Within two weeks of each standardized patient visit, physicians were asked via fax whether they had suspected that one of their patients was actually a standardized patient. 12.8 percent of physicians reported being suspicious.

Among 298 encounters, suicide was explored only 36 percent of the time. Suicidally was more commonly explored among major depression patients (42 percent) than adjustment disorder patients (30 percent).

With regards to medication requests, physicians were more likely to explore suicide when patients prompted for medication than not, and among those who prompted for medication general requests elicited more exploration than brand specific requests.

Based on data collected in a clinician background questionnaire, exploration was also more common among physicians with personal experience with depression in themselves, in family members, or in close friends.

The questionnaires were completed at least four weeks after the last standardized patient visit. The authors conclude that efforts to encourage patients to request general, as opposed to brand specific, medication for treating depression may improve suicidality screening.

However, they also point out that more research needs to be done to determine the characteristics of individual physicians that make them more likely to explore suicidal ideation among patients with symptoms of depression.

The importance of continued research on this topic is highlighted by studies showing that up to 75 percent of people who commit suicide have seen a primary care physician in the previous 30 days, and studies showing that discussing suicidal ideation with depressed patients does not increase their risk for attempting suicide.