Patient Engagement for Suicide Prevention

You can't manage what you can't measure is a truism in quality improvement. In mental health, it goes even further: You can't manage what you won't even talk about. Although lots of barriers have fallen in the realm of acceptable topics for conversation between doctors and patients - we no longer avoid saying "cancer" like the word itself was the disease - suicide is still a particularly difficult topic for providers to broach. No doubt training the doctors to deal with this sticky area head on can help, but it takes two to tango, and physicians hate to initiate a difficult discussion as much as anyone else.

So, Ruby Shah, Richard Kravitz and the good folks at UC Davis went at the problem from the other end. They used patient engagement techniques - a tailored interactive media program shown in the waiting room - to activate the patient to discuss their symptoms (both emotional and physical) including thoughts of self-harm, and the possibility that those symptoms were due to depression. Among patients with mild depression, there was little impact, perhaps because there was little need. But among patients with moderate to severe depression, the probability that suicide would at least be discussed went from 40% to 58%. 

Is this enough to make a difference? Talking about the issue is only the first step. Did it result in appropriate action? Kravitz and company already reported in JAMA that the engagement approach increased treatment (or referral for treatment) from 16% to 26%. So, the intervention works in the sense that it sometimes stimulates the necessary discussion and appropriate treatment. However, the depression scores 12 weeks later were not better in the engagement group and were even a bit worse. Increased prescribing for non-depressed patients raises the possibility that the engagement program actually made things worse for some patients.

This study was excellent science, but not a clear cut success for patient care. The tailored messaging had an impact on behavior and resulted in treatment changes. However, some of those treatment changes could have made things worse, not better. Twelve weeks later, there was little evidence that the patients felt better - probably because depression is hard to treat, especially with medications.

Shah R, Franks P, Jerant A, Feldman M, Duberstein P, Y Garcia EF, Hinton L,
Strohecker L, Kravitz RL. The Effect of Targeted and Tailored Patient Depression 
Engagement Interventions on Patient-Physician Discussion of Suicidal Thoughts: A 
Randomized Control Trial. J Gen Intern Med. 2014 Apr 8. [Epub ahead of print]
PubMed PMID: 24710994.

Kravitz RL, Franks P, Feldman MD, et al. Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care: A Randomized Trial. JAMA. 2013;310(17):1818-1828. doi:10.1001/jama.2013.280038