One in 10 patients seen in primary care settings meets criteria for major depressive disorder. Depression is particularly common in patients presenting for treatment of a chronic medical condition, with a prevalence of about 30% to 40%. Primary care providers see depressed patients routinely and most are managing these patients with antidepressant pharmacotherapy. Suicidal thinking is a feature of depression and suicide is a potential outcome. Clinicians should therefore be familiar with assessing and managing suicide risk.

Primary care clinicians are better positioned than mental health professionals to identify patients at risk and to intervene to prevent suicide. Clinical contact of depressed patients with primary care providers in the time period preceding a suicide is more common than contact with mental health professions. Three of four suicide victims see a primary care provider in the year before suicide, and nearly half of these patients have contact with their primary care physician in the month before their death, particularly older adults (1). In contrast, only 20% of those who die by suicide see a mental health professional in the month prior to their death (2). Although it is not known whether or not these suicides were preventable, this suggests the clinical encounter immediately before suicide can be an opportunity to identify suicide risk and plan appropriate interventions.

Studies suggest that primary care providers could do a better job at identifying patients at risk for suicide. A recent study examined whether or not suicidal thinking was explored in a group of patients who made
an unannounced visit to a primary care clinic complaining of depressive symptoms and requesting an antidepressant. Fewer than half (42%) of patients were asked about suicidal ideations (3). Another study examined whether or not suicidal thinking was explored by primary care physicians in the last visit prior to suicide in a group of patients who committed suicide within a month of contact. Sixty-two percent of these patients were not asked about suicidal thinking, and in half of these cases, the provider had little knowledge of the patient’s life circumstances (4). Suicidal ideation is common in depressed older adults being treated in primary care settings. One in five patients will report suicidal thoughts during a course of treatment for depression, particularly in those with more severe symptoms (5).

The striking finding that many of those who commit suicide have seen a primary care provider shortly before their death has led to investigations that attempt to profile the type of patient at risk. One study compared differences between older adults who committed suicide within 30 days of visiting a primary care provider with older primary patients who did not commit suicide. Those who committed suicide had more depressive illness, greater physical illness burden, and functional limitations, and were more likely to be prescribed antidepressants, antianxiety agents, and opiate analgesics (6). A similar study investigated the differences between older men and women who committed suicide shortly after a primary care visit. Male suicides outnumbered female by a ratio of 3:1. Men were more likely to be single or widowed than women. Men were more likely to use hanging as a primary suicide method, whereas women tended to overdose on medications, which suggests care should be exercised in prescribing medications that can be lethal in overdose. In both men and women, the primary complaint involved physical, not psychiatric, symptoms (7). Another study found that older adults were more likely to complain of physical symptoms prior to suicide, whereas younger adults were more likely to seek help for psychiatric symptoms (8).

The assessment of suicide risk is not as simple as asking a patient, “Have you been having suicidal thoughts?” Inquiring about suicidal thinking is important, but is only one piece of performing a suicide risk assessment. The assessment also involves an examination of risk factors for suicide balanced against factors protective against suicide. The more suicide risk factors and fewer protective factors, the greater the risk. There is no specific set of risk factors that have been shown to predict whether or not a patient will commit suicide; because suicide is a very rare event, it is nearly impossible to design and carry out a study with that goal. If primary care providers are aware of key risk and protective factors, however, they can use sound clinical judgment to identify at-risk patients and take steps to reduce the likelihood a suicide will occur.