Older patients who are contemplating suicide are three times more likely to consult a family physician in the month before death than comparable patients who do not have such thoughts. Although suicide may occur only once every five years in an individual practice, the number of older patients at risk of self-harm may be significant. Pfaff and Almeida studied older patients who were consulting 54 family physicians in Australia and assessed the prevalence of severe depression and suicidal ideation.
The participating family physicians were randomly selected based on postal codes in Western Australia. Each physician was asked to enroll up to 15 consecutive patients older than 60 years. The patients were asked to complete a self-report questionnaire while waiting to meet with the physician. The questionnaire covered demographic information; use of alcohol, tobacco, and medications; and information about depressive symptoms and suicidal thoughts using two standardized scales (i.e., Depressive Symptom Inventory Suicidality Subscale [DSI-SS] and Center for Epidemiological Studies Depression Scale [CES-D]). A nurse or receptionist collected each questionnaire before the physician examined the patient. Each physician was unaware of whether or not the patient had participated in the study. After each consultation, the physician completed a brief questionnaire about the reason for the consultation, the patient’s medical problems and medications, and the physician’s perception of depressive symptoms or suicidal ideation.
Of 1,433 eligible patients, 1,061 completed questionnaires. The average age was 72.2 years and about one half (57 percent) were women. Patients who declined to participate were older than participants, but the two groups did not differ in use of medications, use of psychotropic drugs, psychologic complaints, or physician assessment of depression. Although only 5.1 percent of participants presented with psychological symptoms, 23.8 percent had scores indicating clinically significant depression, and 5.8 percent acknowledged current suicidal ideation. More than one half (59.6 percent) of patients presenting with psychological complaints scored above the cutoff for clinical depression compared with 21.8 percent of those presenting with medical complaints. Of all participants, 5.5 percent had DSI-SS scores indicating significant current suicidal ideation. Comparing these with other patients, the researchers found they were more likely to smoke, perceive their health as poor, use a sleep medication, report depression, and present with psychological symptoms. In multivariate analysis, current depression, a history of suicide attempts, and a CES-D score of 16 or more were strongly associated with suicidal ideation.
The authors conclude that regardless of the presenting complaint, approximately one fourth of older patients presenting to family physicians could be clinically depressed, and 5 percent could be at significant risk of suicide. They recommend that older patients who show any signs of depression should be asked about psychological symptoms, including suicide risk.