Reducing Suicide A National Imperative (2002) / Chapter Skim
Currently Skimming:
9 Barriers to Effective Treatment and Intervention
9 Barriers to Effective Treatment and Intervention
Pages 331-374
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From page 331... ...
of people in the United States who complete suicide have a diagnosable mental disorder, yet only about half of them are diagnosed and treated appropriately (Conwell et al., 1996; Fawcett et al., 1991; Harris and Barraclough, 1997; Isometsa et al., 1994b; Robins et al., 1959~; (2) many are symptomatic for several years before suicide (Fawcett et al., 1991; Shaffer and Craft, 1999~; (3)
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From page 332... ...
About twothirds of people with diagnosable mental disorders do not receive treatment (Kessler et al., 1996; Regier et al., 1993; US DHHS, 1999~. Stigma toward mental illness is pervasive in the United States and many other nations (Bhugra, 1989; Brockington et al., 1993; Corrigan and Penn, 1998~.
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From page 333... ...
It also discourages the public from paying for treatment through health insurance premiums (Hanson, 1998~. Public attitudes toward mental health treatment are somewhat contradictory: while nationally representative surveys find that Americans generally support mental health treatment for people with disorders, the public is less willing to use formal services if they anticipate a mental health problem for themselves (Pescosolido et al., 2000; Swindle et al., 2000~.
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From page 334... ...
Over the past decade, during the growth of managed care, disparities in coverage have led to a 50 percent decrease in the mental health portion of total health care costs paid by employer-based insurance (Hay Group, 1998~. Not surprisingly, insured people with mental disorders in a large United States household survey in 1994 were twice as likely as those without disorders to have reported delays in seeking care and to have reported being unable to obtain needed care (Druss and Rosenheck,1998~.
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From page 335... ...
Linkages between different settings are critical for detection and treatment of mental disorders and suicidality (Mechanic, 1997~. They include linkages between primary care and specialty mental health care; emergency department care and mental health care; substance abuse and mental health care; and, for adolescents, school-based programs with mental health or substance abuse care.
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From page 336... ...
Services research has focused for the past decades in developing better models of care that bridge these different sectors of care to deliver more integrated mental health care. Several successful models have been developed, most notably wraparound services including multisystemic treatment, for children and adolescents with serious emotional problems and assertive community treatment, a form of intensive case management for people with serious mental illness, combined services for people with mental and substance abuse disorders, and management programs for late life depression in primary care settings (US DHHS, 1999~.
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From page 337... ...
Research has been stymied by the dramatic pace of change in the health care marketplace, the difficulty of obtaining proprietary claims data, and the lack of information systems tracking mental health quality or outcome measures (Fraser, 1997; US DHHS, l999~. Most concerns center on potentially poorer quality and outcomes of care from limited access to mental health specialists, reduced length of inpatient care, and reductions in intensity of outpatient mental health services (Mechanic, 1997; Mechanic, 1998~.
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From page 338... ...
Another study, of serious suicide attempters in Florida, found that managed care's criteria for approving admission to hospitals were not predictive of features seen in patients who made such attempts (Hall et al., 1999~. A largely unstudied question is whether reductions in intensity of outpatient services, or in length of stay in inpatient care, contribute to suicide risk.
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From page 339... ...
Depression The detection and treatment of depression by primary care physicians is of great relevance to suicidology. Depression evaluation presents the first opportunity for primary care physicians to ask about suicidal ideation, which is one of several symptoms of major depressive disorder (APA, 1994)
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From page 340... ...
When a suicidal patient is identified, primary care physicians should refer them to specialty care and consider hospitalization (Beck et al., 1979; US Preventive Services Task Force, 1996~. The role of primary care is likely to expand, however, as a result of recent health care trends and high level public health concern about suicide prevention.
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From page 341... ...
Since the vast majority of primary care physicians prefer to treat depression with medication (Williams et al., 1999) , studies often measure inadequate treatment by inadequate dosage or duration of medication, infrequent follow-up, lack of medication adjustment, and/or inadequate conformance to treatment guidelines.
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From page 342... ...
A later section deals with the treatment of substance abuse, with or without a co-occurring mental disorder, because it is reserved for specialty care (US Preventive Services Task Force, 1996~. Primary Care Barriers to Detection of Suicidality It is well established that a large proportion of suicide victims are not detected in primary care in the days before suicide.
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From page 343... ...
. Despite limitations of using case notes to infer what occurred during the final visit, these studies as well as clinical experience point to a major barrier in communication: patients are reluctant to communicate their suicidal intent, and primary care physicians are reluctant to ask (Hirschfeld and Russell, 1997~.
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From page 344... ...
This plan encourages development of guidelines for primary care settings. It also sets specific national objectives of screening for suicide risk in federally supported primary care settings (e.g., Medicare and Medicaid)
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From page 345... ...
Once diagnosed in the ED, suicide attempts are important to treat promptly, to admit to a psychiatric unit, and/or to arrange for effective care after discharge (Buzan and Weissberg, 1992~. Suicide attempters are at risk of re-attempt or completed suicide (Chapter 3~.
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From page 346... ...
The Surgeon General's National Strategy (PHS, 2001) calls for the development and implementation of professional guidelines for suicide assessment as well as individualized policies, procedures, and evaluation programs for treatment in a full range of specialty mental health and substance abuse treatment centers.
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One misdiagnosis that enhances suicide risk relates to bipolar disorder. Patient surveys (N=600)
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From page 348... ...
A psychological autopsy study was conducted in Finland of all suicide victims over a 12-month period whose last appointment occurred 28 days before suicide (N=571~. By interviewing health care professionals, investigators found that, during the last appointment, 39 percent and 30 percent of patients communicated their intent to outpatient and inpatient psychiatric care providers, respectively (Isometsa et al., 1995~.
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From page 349... ...
Patients with depression and a history of past suicide attempts a group at high risk for suicide received inadequate pharmacological treatment in the 3 months before hospitalization (Oquendo et al., 1999~. Substance Abuse.
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From page 350... ...
Another major barrier operating in the treatment setting is that the vast majority of patients who are suicidal often do not spontaneously report their suicidal intent to their clinician. A study, cited earlier, found that only 22 percent of suicide victims communicate their intent to their clinicians (Isometsa et al., 1995~.
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From page 351... ...
Members of the public, for example, perceive suicide in older people as less tragic than suicide in youth (Marks, 1988-1989~. Clinicians, family members, and older adults report that suicidal ideation and depression 5Medicare requires a 50 percent copayment for most outpatient mental health services, as compared to 20 percent copayment for general medical services.
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From page 352... ...
Family physicians attribute their difficulty in detection to the atypical nature of depression's symptoms in older people (Gallo et al., l999~.6 Further complicating the diagnosis is that older people commonly report somatic symptoms, as opposed to mental symptoms. Older men, in particular, are less likely than older women to be detected because they report fewer mood symptoms and crying spells (Unutzer et al., 1999~.
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From page 353... ...
. There are no professional guidelines for screening older people for depression, substance abuse, or suicidality; however, the Surgeon General's National Plan calls for screening as a minimum standard of care for hospice and nursing homes supported by Medicaid and Medicare.
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From page 354... ...
Adolescent suicide attempters typically first access care in emergency departments, but up to half receive no formal treatment after their emergency department visit (Spirito et al., 1989~. Of those receiving care after a visit, non-adherence is exceedingly common.
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From page 355... ...
The American Academy of Pediatrics recommends that pediatricians ask all adolescents about depression, suicidal thoughts, and other suicide risk factors during routine medical history (AAP, 2000~. The American Medical Association also recommends annual screening of adolescents to identify those at risk for suicide (US Preventive Services Task Force, 1996~.
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From page 356... ...
About 23 percent of American Indians and Alaska Natives who report not having IHS coverage lack any other health insurance, compared with 14 percent of whites (Brown et al., 2000~. For suicide victims, however, access to service does not necessarily translate into utilization.
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From page 357... ...
Inmates are often unsafe from random violence, rape, and exploitation (Kupers, 1999~. To the extent that these factors increase the hopelessness of some inmates, they increase risk factors related to suicide and are hard for health professionals to mediate.
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From page 358... ...
Other factors predisposing inmates to suicide include: legal complications such as denial of parole, bad news about "loved ones" at home, and victimization in sexual assault or other trauma. While 73 percent of jails report they have suicide prevention programs (Steadman and Veysey, 1997)
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From page 359... ...
Ethical dilemmas unique to correctional facilities also create barriers to mental health treatment in correctional facilities. The issues of the doctor/patient relationship; the quality, extent and power of patient authority; the process of informed consent and refusal; physician beneficence; the use, misuse, and control and possible abuse of medical technology; and research on human participants, with particular emphasis on especially vulnerable populations including prisoners, are all issues of medical ethics strained in correctional environments (Bell, In press; Dubler and Anno, 1991)
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From page 360... ...
Limitations in the diagnostic and treatment capabilities of primary care physicians also have been noted (e.g., Al-laddou and Malkawi, 1997; Wright et al., 1989~. Among physicians in Tordan, one study found that only 24 percent of the patients with mental disorders were identified (Al-laddou and Malkawi, 1997~.
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From page 361... ...
Professional evidence-based guidelines for suicide risk screening, assessment, and referral need to be developed and implemented into primary health care settings. Screening, treatment, and referral for the major suicide risk factors depression and alcohol abuse disorders should be conducted in primary health care settings.
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From page 362... ...
Culturally appropriate strategies to increase access and utilization of mental health services should be employed. · Lack of adequate insurance coverage for mental health services represents a critical barrier to treatment for mental disorders, including substance use disorders, that increase suicide risk.
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From page 363... ...
A review of the literature. Acta Psychiatrica Scandinavica, 80~1~: 1-12.
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From page 364... ...
1995. Attitudes toward self-determined death: A survey of primary care physicians.
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From page 365... ...
1999. Suicide risk assessment: A review of risk factors for suicide in 100 patients who made severe suicide attempts.
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From page 366... ...
1998. Risk factors for suicidal ideation in psychiatric patients.
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From page 367... ...
1999. Managing depressed and suicidal geriatric patients: Differences among primary care physicians.
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From page 368... ...
1997. On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse.
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2000. Psychiatric aspects of suicidal behavior: Substance abuse.
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From page 370... ...
1995. Demographic predictors of treatment attendance among adolescent suicide attempters.
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1992. Adolescent suicide attempters: Do physicians recognize them?
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From page 372... ...
1996. Mental disorders and comorbidity in attempted suicide.
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From page 373... ...
1999. Primary care physicians' approach to depressive disorders.
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From page 374... ...
"Hope/' is the thing with feathersThat perches in the soulAnd sings the tune without the wordsAnd never stops at allAnd sweetest in the Gale is heardAnd sore must be the stormThat could abash the little Bird That kept so many warmI've heard it in the chillest landAnd on the strangest SeaYet, never, in Extremity, It asked a crumb~f Me EMILY DICKINSON Reprintecl by permission of the publishers and the Trustees of Amherst College from The Poems of Emily Dickinson, Thomas H Johnson, eclitor, Cambridge, Massachusetts: The Belknap Press of Harvarcl University Press, Copyright @)
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