0
December 14, 1994, Vol 272, No. 22 >
ARTICLE | December 14, 1994

Identifying Suicidal Ideation in General Medical Patients FREE

Lisa Cooper-Patrick, MD, MPH; Rosa M. Crum, MD, MHS; Daniel E. Ford, MD, MPH
[+] Author Affiliations

Presented in part at the Mid-Atlantic Regional Conference of the Society of General Internal Medicine, Philadelphia, Pa, March 5, 1993, and at the Seventh Annual National Institute of Mental Health International Research Conference on Primary Care Mental Health Research, McLean, Va, September 20, 1993.

Reprint requests to Welch Center for Prevention, Epidemiology, and Clinical Research, 2024 E Monument St, Suite 2-600, Baltimore, MD 21205-2223 (Dr Cooper-Patrick).


JAMA. 1994;272(22):1757-1762. doi:10.1001/jama.1994.03520220051030
Text Size: A A A
Published online
Article
References

Objectives.  —To describe characteristics of general medical patients with suicidal ideation and to develop an efficient clinical strategy for identifying these patients.

Design.  —Cross-sectional analysis of data without intervention.

Setting.  —A representative sample of community respondents interviewed as part of the National Institute of Mental Health Epidemiologic Catchment Area surveys.

Subjects.  —A total of 6041 individuals who reported receiving care in general medical settings in the 6 months preceding the baseline interview.

Main Outcome Measure.  —Suicidal ideation within the year preceding the baseline interview.

Results.  —A total of 154 patients (2.6%) had experienced suicidal thoughts within the previous year. In multivariate analyses, the following sociodemographic factors were significantly associated with having suicidal ideation: being white (odds ratio [OR], 2.8; P<.001) relative to African American, separated or divorced (OR, 1.8; P=.03) relative to married, and aged 18 to 30 years (OR, 2.3; P=.02) or aged 31 to 50 years (OR, 2.1; P=.03) relative to those older than 65 years. Gender, educational level, and socioeconomic status were not statistically associated with suicidal ideation. Psychiatric disorders significantly associated with suicidal ideation were major depression (OR, 10.3; P<.001), panic disorder (OR, 5.2; P<.001), alcohol disorder (OR, 2.0; P=.04), and phobic disorder (OR, 1.6; P=.02) within the previous year. However, only 34% of respondents with suicidal ideation met criteria for major depression. With the aid of stepwise logistic regression, a four-item screening questionnaire, the Suicidal Ideation Screening Questionnaire, was developed to predict patients with suicidal ideation. Likelihood ratios for suicidal ideation increased from 0.21 to 32.8 with more positive responses to questions concerning symptoms of hopelessness, guilt, depressed mood, and sleep disturbances.

Conclusions.  —If the results from the four-item screen are reproduced in a clinical setting, general medical patients with a high likelihood for suicidal ideation may be identified with a brief screening questionnaire. This screen would have greater sensitivity than would be achieved by assessing suicidal ideation only in those patients who meet criteria for a distinct psychiatric disorder.(JAMA. 1994;272:1757-1762)

REFERENCES

1 +
Healthy People 2000 . Washington, DC: US Dept of Health and Human Services; 1990;. US Dept of Health and Human Services publication PHS 91-50213
2 +
Vital Statistics of the United States, II: Mortality, Part A, 1988 . Hyattsville, Md: National Center for Health Statistics; 1990;. US Dept of Health and Human Services publication PHS 90-1102.
3 +
Beck A, Kovacs M, Weissman M.  Assessment of suicidal ideation: the scale for suicide ideation. J Consult Clin Psychol . 1979;;47:559-563.
4 +
Bonner R, Rich A.  Toward a predictive model of suicidal ideation and behavior: some preliminary data in college students. Suicide Life Threat Behav . 1987;;17:50-63.
5 +
Guze SB, Robins E.  Suicide and primary affective disorders. Br J Psychiatry . 1970;;117:437-448.
6 +
Motto JA.  The psychopathology of suicide: a clinical model approach. Am J Psychiatry . 1979;;136: 516-520.
7 +
Carlson GA, Rich CL, Grayson P, Fowler RC.  Secular trends in psychiatric diagnoses of suicide victims. J Affect Disord . 1991;;21:127-132.
8 +
Rich CL, Runeson BS.  Similarities in diagnostic comorbidity between suicide among young people in Sweden and the United States. Acta Psychiatr Scand . 1992;;86:335-339.
9 +
Runeson B, Beskow J.  Borderline personality disorder in young Swedish suicides. J Nerv Ment Dis . 1991;;179:153-156.
10 +
Moscicki EK, O'Carroll P, Rae DS, Locke BZ, Roy A, Regier D.  Suicide attempts in the Epidemiologic Catchment Area study. Yale J Biol Med . 1988;;9:51-69.
11 +
Weissman MM, Klerman GL, Markowitz JS, Ouellette R.  Suicidal ideation and suicide attempts in panic disorder and attacks. N Engl J Med . 1989;; 321:1209-1214.
12 +
Petronis KR, Samuels JF, Moscicki EK, Anthony JC.  An epidemiologic investigation of potential risk factors for suicide attempts. Soc Psychiatry Psychiatr Epidemiol . 1990;;25:193-199.
13 +
Hesselbrock M, Hesselbrock B, Syzmanski K, Weidenman M.  Suicide attempts and alcoholism. J Stud Alcohol . 1988;;49:436-442.
14 +
Moscicki EK.  Epidemiologic surveys as tools for studying suicidal behavior: a review. Suicide Life Threat Behav . 1989;;19:131-146.
15 +
Paykel ES, Myers JK, Lindenthal JJ, Tanner J.  Suicidal feelings in the general population: a prevalence study. Br J Psychiatry . 1974;;124:460-469.
16 +
Garrison CZ, McKeown RE, Valois RF, Vincent ML.  Aggression, substance use, and suicidal behaviors in high school students. Am J Public Health . 1993;;83:179-184.
17 +
Rich A, Bonner R.  Concurrent validity of a stress-vulnerability model of suicidal ideation and behavior: a follow-up study. Suicide Life Threat Behav . 1987;;17:265-270.
18 +
Robins E, Gassner S, Kayes J, Wilkinson R Jr, Murphy G.  The communication of suicide intent: a study of 134 consecutive cases of successful (completed) suicide. Am J Psychiatry . 1959;;115:724-733.
19 +
Murphy GE.  The physician's responsibility for suicide, I: an error of commission. Ann Intern Med . 1975;;83:301-304.
20 +
Murphy GE.  The physician's responsibility for suicide, II: errors of omission. Ann Intern Med . 1975;;83:305-309.
21 +
Diekstra RFW, van Egmond M.  Suicide and attempted suicide in general practice, 1979-1985. Acta Psychiatr Scand . 1989;;79:268-275.
22 +
Lin EHB, Von Korff M, Wagner EH.  Identifying suicide potential in primary care. J Gen Intern Med . 1989;;4:1-6.
23 +
Johnson J, Weissman M, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community. JAMA . 1992;; 267:1478-1483.
24 +
Katon W.  The epidemiology of depression in medical care. Int J Psychiatry Med . 1987;;17:93-112.
25 +
Blacker C, Clare A.  Depressive disorder in primary care. Br J Psychiatry . 1987;;150:737-751.
26 +
Manning WG, Wells KB.  The effects of psychological distress and psychological well-being on use of medical services. Med Care . 1992;;30:541-553.
27 +
Goldberg R.  Depression in primary care: DSM-III diagnoses and other depressive syndromes. J Gen Intern Med . 1988;;3:491-497.
28 +
Kessler L, Burns B, Shapiro S, et al.  Psychiatric diagnoses of medical service users: evidence from the Epidemiologic Catchment Area program. Am J Public Health . 1987;;77:18-24.
29 +
Eaton WW, Kessler LG, eds. Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program . Orlando, Fla: Academic Press Inc; 1985;.
30 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition . Washington, DC: American Psychiatric Association; 1980;.
31 +
Robins LN, Helzer JE, Croughan J, Ratcliff KS.  National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry . 1981;;38:381-389.
32 +
Sackett DL, Haynes RB, Guyatt GH, Tugwell P, eds. Clinical Epidemiology: A Basic Science for Clinical Medicine . Boston, Mass: Little Brown & Co Inc; 1991;:119-139.
33 +
Koopman PAR.  Confidence intervals for the ratio of two binomial proportions. Biometrics . 1984;; 40:513-517.
34 +
Rich AR, Kirkpatrick-Smith J, Bonner RL, Jans F.  Gender differences in the psychosocial correlates of suicidal ideation among adolescents. Suicide Life Threat Behav . 1992;;22:364-373.
35 +
Kienhorst CWM, DeWilde EJ, Van Den Bout J, Diekstra RFW, Wolter WHG.  Characteristics of suicide attempters in a population-based sample of Dutch adolescents. Br J Psychiatry . 1990;;156:243-248.
36 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994;.
37 +
Beck AT, Brown G, Steer RA.  Prediction of eventual suicide in psychiatric inpatients by clinical ratings of hopelessness. J Consult Clin Psychol . 1989;;57:308-310.
38 +
Holden RR, Mendonca JD, Serin RC.  Suicide, hopelessness, and social desirability: a test of an interactive model. J Consult Clin Psychology . 1989;; 57:500-504.
39 +
Hamdi E, Amin Y, Mattar T.  Clinical correlates of intent in attempted suicide. Acta Psychiatr Scand . 1991;;83:406-411.
40 +
Wetzel KD, Margulies T, Davis R, Karam E.  Hopelessness, depression, and suicide intent. J Clin Psychiatry . 1980;;41:159-160.
41 +
Bonner R, Rich A.  A prospective investigation of suicidal ideation in college students: a test of a model. Suicide Life Threat Behav . 1988;;18:245-258.
42 +
Murphy GE.  The physician's role in suicide prevention.  In: Roy A, ed. Suicide . Baltimore, Md: Williams & Wilkins; 1986;:171-179.
43 +
Delong WB, Robins E.  The communication of suicidal intent prior to psychiatric hospitalization: a study of 87 patients. Am J Psychiatry . 1961;;117: 695-705.
44 +
Seager CP.  Suicide in neurosis and personality disorder.  In: Roy A, ed. Suicide . Baltimore, Md: Williams & Wilkins; 1986;:113-121.
45 +
Henriksson MM, Aro HM, Martunnen MJ, et al.  Mental disorders and comorbidity in suicide. Am J Psychiatry . 1993;;15:935-940.
46 +
Whitlock FA.  Suicide and physical illness.  In: Roy A, ed. Suicide . Baltimore, Md: Williams & Wilkins; 1986;:151-174.
47 +
Barraclough B, Bunch J, Nelson B, Sainsbury P.  A hundred cases of suicide: clinical aspects. Br J Psychiatry . 1974;;125:355-373.
48 +
Barraclough B.  A medical approach to suicide prevention. Soc Sci Med . 1972;;6:661-671.
49 +
Regier D, Goldberg I, Taube C.  The defacto US Mental Health Services System. Arch Gen Psychiatry . 1978;;35:685-693.
50 +
Kessler LG, Cleary PD, Burke JD.  Psychiatric disorders in primary care: results of a follow-up study. Arch Gen Psychiatry . 1985;;42:583-587.
51 +
Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW.  Primary health care providers' recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry . 1988;;10:317-321.
52 +
Perez-Stable EJ, Miranda J, Munoz R, Ying Y.  Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med . 1990;;150: 1083-1088.
53 +
Ormel J, van den Brink W, Koeter MWJ, et al.  Recognition, management and outcome of psychological disorders in primary care: a naturalistic follow-up study. Psychol Med . 1990;;20:909-923.
54 +
Coombs D, Miller HL, Alarcon A, Herlihy C, Lee JM, Morrison DP.  Presuicide attempt communications between parasuicides and consulted caregivers. Suicide Life Threat Behav . 1992;;22:289-302.
55 +
Buzan RD, Weissberg MP.  Suicide: risk factors and prevention in medical practice. Annu Rev Med . 1992;;43:37-46.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Healthy People 2000 . Washington, DC: US Dept of Health and Human Services; 1990;. US Dept of Health and Human Services publication PHS 91-50213
2 +
Vital Statistics of the United States, II: Mortality, Part A, 1988 . Hyattsville, Md: National Center for Health Statistics; 1990;. US Dept of Health and Human Services publication PHS 90-1102.
3 +
Beck A, Kovacs M, Weissman M.  Assessment of suicidal ideation: the scale for suicide ideation. J Consult Clin Psychol . 1979;;47:559-563.
4 +
Bonner R, Rich A.  Toward a predictive model of suicidal ideation and behavior: some preliminary data in college students. Suicide Life Threat Behav . 1987;;17:50-63.
5 +
Guze SB, Robins E.  Suicide and primary affective disorders. Br J Psychiatry . 1970;;117:437-448.
6 +
Motto JA.  The psychopathology of suicide: a clinical model approach. Am J Psychiatry . 1979;;136: 516-520.
7 +
Carlson GA, Rich CL, Grayson P, Fowler RC.  Secular trends in psychiatric diagnoses of suicide victims. J Affect Disord . 1991;;21:127-132.
8 +
Rich CL, Runeson BS.  Similarities in diagnostic comorbidity between suicide among young people in Sweden and the United States. Acta Psychiatr Scand . 1992;;86:335-339.
9 +
Runeson B, Beskow J.  Borderline personality disorder in young Swedish suicides. J Nerv Ment Dis . 1991;;179:153-156.
10 +
Moscicki EK, O'Carroll P, Rae DS, Locke BZ, Roy A, Regier D.  Suicide attempts in the Epidemiologic Catchment Area study. Yale J Biol Med . 1988;;9:51-69.
11 +
Weissman MM, Klerman GL, Markowitz JS, Ouellette R.  Suicidal ideation and suicide attempts in panic disorder and attacks. N Engl J Med . 1989;; 321:1209-1214.
12 +
Petronis KR, Samuels JF, Moscicki EK, Anthony JC.  An epidemiologic investigation of potential risk factors for suicide attempts. Soc Psychiatry Psychiatr Epidemiol . 1990;;25:193-199.
13 +
Hesselbrock M, Hesselbrock B, Syzmanski K, Weidenman M.  Suicide attempts and alcoholism. J Stud Alcohol . 1988;;49:436-442.
14 +
Moscicki EK.  Epidemiologic surveys as tools for studying suicidal behavior: a review. Suicide Life Threat Behav . 1989;;19:131-146.
15 +
Paykel ES, Myers JK, Lindenthal JJ, Tanner J.  Suicidal feelings in the general population: a prevalence study. Br J Psychiatry . 1974;;124:460-469.
16 +
Garrison CZ, McKeown RE, Valois RF, Vincent ML.  Aggression, substance use, and suicidal behaviors in high school students. Am J Public Health . 1993;;83:179-184.
17 +
Rich A, Bonner R.  Concurrent validity of a stress-vulnerability model of suicidal ideation and behavior: a follow-up study. Suicide Life Threat Behav . 1987;;17:265-270.
18 +
Robins E, Gassner S, Kayes J, Wilkinson R Jr, Murphy G.  The communication of suicide intent: a study of 134 consecutive cases of successful (completed) suicide. Am J Psychiatry . 1959;;115:724-733.
19 +
Murphy GE.  The physician's responsibility for suicide, I: an error of commission. Ann Intern Med . 1975;;83:301-304.
20 +
Murphy GE.  The physician's responsibility for suicide, II: errors of omission. Ann Intern Med . 1975;;83:305-309.
21 +
Diekstra RFW, van Egmond M.  Suicide and attempted suicide in general practice, 1979-1985. Acta Psychiatr Scand . 1989;;79:268-275.
22 +
Lin EHB, Von Korff M, Wagner EH.  Identifying suicide potential in primary care. J Gen Intern Med . 1989;;4:1-6.
23 +
Johnson J, Weissman M, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community. JAMA . 1992;; 267:1478-1483.
24 +
Katon W.  The epidemiology of depression in medical care. Int J Psychiatry Med . 1987;;17:93-112.
25 +
Blacker C, Clare A.  Depressive disorder in primary care. Br J Psychiatry . 1987;;150:737-751.
26 +
Manning WG, Wells KB.  The effects of psychological distress and psychological well-being on use of medical services. Med Care . 1992;;30:541-553.
27 +
Goldberg R.  Depression in primary care: DSM-III diagnoses and other depressive syndromes. J Gen Intern Med . 1988;;3:491-497.
28 +
Kessler L, Burns B, Shapiro S, et al.  Psychiatric diagnoses of medical service users: evidence from the Epidemiologic Catchment Area program. Am J Public Health . 1987;;77:18-24.
29 +
Eaton WW, Kessler LG, eds. Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program . Orlando, Fla: Academic Press Inc; 1985;.
30 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition . Washington, DC: American Psychiatric Association; 1980;.
31 +
Robins LN, Helzer JE, Croughan J, Ratcliff KS.  National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psychiatry . 1981;;38:381-389.
32 +
Sackett DL, Haynes RB, Guyatt GH, Tugwell P, eds. Clinical Epidemiology: A Basic Science for Clinical Medicine . Boston, Mass: Little Brown & Co Inc; 1991;:119-139.
33 +
Koopman PAR.  Confidence intervals for the ratio of two binomial proportions. Biometrics . 1984;; 40:513-517.
34 +
Rich AR, Kirkpatrick-Smith J, Bonner RL, Jans F.  Gender differences in the psychosocial correlates of suicidal ideation among adolescents. Suicide Life Threat Behav . 1992;;22:364-373.
35 +
Kienhorst CWM, DeWilde EJ, Van Den Bout J, Diekstra RFW, Wolter WHG.  Characteristics of suicide attempters in a population-based sample of Dutch adolescents. Br J Psychiatry . 1990;;156:243-248.
36 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Association; 1994;.
37 +
Beck AT, Brown G, Steer RA.  Prediction of eventual suicide in psychiatric inpatients by clinical ratings of hopelessness. J Consult Clin Psychol . 1989;;57:308-310.
38 +
Holden RR, Mendonca JD, Serin RC.  Suicide, hopelessness, and social desirability: a test of an interactive model. J Consult Clin Psychology . 1989;; 57:500-504.
39 +
Hamdi E, Amin Y, Mattar T.  Clinical correlates of intent in attempted suicide. Acta Psychiatr Scand . 1991;;83:406-411.
40 +
Wetzel KD, Margulies T, Davis R, Karam E.  Hopelessness, depression, and suicide intent. J Clin Psychiatry . 1980;;41:159-160.
41 +
Bonner R, Rich A.  A prospective investigation of suicidal ideation in college students: a test of a model. Suicide Life Threat Behav . 1988;;18:245-258.
42 +
Murphy GE.  The physician's role in suicide prevention.  In: Roy A, ed. Suicide . Baltimore, Md: Williams & Wilkins; 1986;:171-179.
43 +
Delong WB, Robins E.  The communication of suicidal intent prior to psychiatric hospitalization: a study of 87 patients. Am J Psychiatry . 1961;;117: 695-705.
44 +
Seager CP.  Suicide in neurosis and personality disorder.  In: Roy A, ed. Suicide . Baltimore, Md: Williams & Wilkins; 1986;:113-121.
45 +
Henriksson MM, Aro HM, Martunnen MJ, et al.  Mental disorders and comorbidity in suicide. Am J Psychiatry . 1993;;15:935-940.
46 +
Whitlock FA.  Suicide and physical illness.  In: Roy A, ed. Suicide . Baltimore, Md: Williams & Wilkins; 1986;:151-174.
47 +
Barraclough B, Bunch J, Nelson B, Sainsbury P.  A hundred cases of suicide: clinical aspects. Br J Psychiatry . 1974;;125:355-373.
48 +
Barraclough B.  A medical approach to suicide prevention. Soc Sci Med . 1972;;6:661-671.
49 +
Regier D, Goldberg I, Taube C.  The defacto US Mental Health Services System. Arch Gen Psychiatry . 1978;;35:685-693.
50 +
Kessler LG, Cleary PD, Burke JD.  Psychiatric disorders in primary care: results of a follow-up study. Arch Gen Psychiatry . 1985;;42:583-587.
51 +
Borus JF, Howes MJ, Devins NP, Rosenberg R, Livingston WW.  Primary health care providers' recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry . 1988;;10:317-321.
52 +
Perez-Stable EJ, Miranda J, Munoz R, Ying Y.  Depression in medical outpatients: underrecognition and misdiagnosis. Arch Intern Med . 1990;;150: 1083-1088.
53 +
Ormel J, van den Brink W, Koeter MWJ, et al.  Recognition, management and outcome of psychological disorders in primary care: a naturalistic follow-up study. Psychol Med . 1990;;20:909-923.
54 +
Coombs D, Miller HL, Alarcon A, Herlihy C, Lee JM, Morrison DP.  Presuicide attempt communications between parasuicides and consulted caregivers. Suicide Life Threat Behav . 1992;;22:289-302.
55 +
Buzan RD, Weissberg MP.  Suicide: risk factors and prevention in medical practice. Annu Rev Med . 1992;;43:37-46.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems