Psychiatry and Primary CareRecent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Jürgen Unutzer, M.D., will publish informative research articles that address primary care-psychiatric issues.Mental health care for adults with suicide ideation☆
Introduction
Suicide is a leading cause of death in the United States and many industrialized nations [1]. It was the 11th leading cause of death overall and the 8th leading cause of death among men in the United States in 2001 [2]. Recent reports from diverse federal agencies have recommended the development and implementation of evidence-based programs to prevent suicide [3], [4], [5]. In such efforts, suicide ideation is often viewed as a key predictor of suicidal behavior, making it a key target for suicide prevention efforts [1], [6]. In a longitudinal community survey, persons who reported suicidal behavior at baseline were found to be more likely to report attempts at follow-up [6]. Some have argued, however, that suicide ideation may not be a useful indicator for instituting preventive efforts since the majority of those with ideation do not attempt or complete suicide [7], [8].
Prior studies suggest that the majority of patients with suicide ideation or who complete suicide suffer from one or more psychiatric conditions, especially major depressive disorder and alcohol abuse [1], [9], [10], [11]. Nonetheless, about 50% of individuals who complete suicide have not been treated for a psychiatric disorder [1]. The literature on the effectiveness of treatments for preventing completed suicide is under-developed [10]: antidepressant medications have not been shown to reduce suicide rates [1], but lithium may be effective across a range of affective disorders, including unipolar depression [1], [12], [13]; cognitive-behavioral therapy can reduce short-term risk of recurrence of suicide attempts [14]. Epidemiologic studies have reached various conclusions about whether suicide rates have lowered with increased antidepressant use for the population as a whole [1], [11], [15].
Kessler et al. [11] found that a substantial proportion of individuals who reported suicide-related thoughts and behaviors received no treatment for emotional problems in the previous 12 months. Studies of mental health services indicate that persons who do not perceive a need for care are unlikely to use services [16], [17]. Mojtabai et al. [18] found that suicidal thoughts and behaviors were strongly associated with perceived need; conversely, 5% of individuals with psychiatric disorders who did not perceive a need for help reported suicide ideation, plans or attempts during the past year. Detailed data on clinical services received in a nationally representative sample of persons with suicide ideation, with and without perceived need for care, have not been available, and recent studies have called for such information [11].
The current study builds on this literature by providing national estimates of perceived unmet need and use of mental health and substance abuse services and clinical treatments among persons with suicide ideation. We focus on individuals who also have probable common psychiatric disorders or substance abuse problems, or perceived need for help in the same year. We provide estimates of use for persons without suicide ideation as a reference point, anticipating higher rates of treatments among persons with suicide ideation. We expected moderate to low rates of use of clinical or potentially therapeutic services among persons with suicide ideation, even among those with probable psychiatric disorders.
Section snippets
Data
We use data from the second wave of Healthcare for Communities (HCC), part of the Robert Wood Johnson Foundation's Health Tracking Initiative. The survey, conducted during 2000–2001, is a stratified probability sample of participants in the Community Tracking Study (CTS) [19], which includes a sequence of random telephone surveys focusing on health services use and health insurance coverage.
Healthcare for Communities used CTS data to oversample individuals with family income below $20,000,
Suicide ideation
Suicide ideation was measured by a positive response to the question: “During the past 12 months, have you ever felt so low you thought about committing suicide?”
Sociodemographic and health status
Survey questions assessed age, gender, marital status, education, insurance status (insured or uninsured) and race/ethnic identification [white (non-Hispanic), black (non-Hispanic), Hispanic or other race].
Probable clinical need
We used the short-form version of the Composite International Diagnostic Interview (CIDI) that applies diagnostic criteria from the
Results
The percentage of respondents who reported suicide ideation in the past year was 3.6% (95% CI 2.96–4.26). The characteristics of respondents with and without suicide ideation are presented in Table 1. Age (being middle aged or younger), being unmarried and having lower educational status were significantly associated with increased reports of suicide ideation. Gender, ethnicity and insurance status were not significantly associated with suicide ideation.
Persons with suicide ideation in the last
Discussion
Similar to the findings of Kessler et al. [11] we found that nearly 3.6% of the US adult population in households with telephones reported having thoughts of suicide at least once in a 12-month period. Consistent with previous studies, suicide ideation was more common among younger adults, unmarried persons and those with lower levels of education [15]. About three-quarters of persons with suicide ideation had a probable psychiatric disorder or substance abuse problem, and just over half (56%)
Acknowledgments
This research was supported by grants from The Robert Wood Johnson Foundation, Grant #038273; and the National Institute of Mental Health, Grant #P30 MH068639.
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Work for this paper was completed at the Health Services Research Center of the UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior in Los Angeles, CA.