Steven D. Vannoy

Let’s Not Talk About It: Suicide Inquiry in Primary Care

PURPOSE The purpose of this study was to ascertain physician characteristics associated with exploring suicidality in patients with depressive symptoms and the influence of patient antidepressant requests. METHODS Primary care physicians were randomly recruited from 4 sites in northern California and Rochester, NY; 152 physicians participated (53%–61% of those approached). Standardized patients portraying 2 conditions (major depression and adjustment disorder) and 3 antidepressant request types (brand specific, general, or none) made unannounced visits to these physicians between May 2003 and May 2004. We examined factors associated with physician exploration of suicidality. RESULTS Suicide was explored in 36% of 298 encounters. Exploration was more common when the patient portrayed major depression (vs adjustment disorder) (P = .03), with an antidepressant request (vs no request) (P=.02), in academic settings (P <.01), and among physicians with personal experience with depression (P <.01). The random effects logistic model revealed a significant physician variance component with ρ = 0.57 (95% confidence interval, 0.45–0.68) indicating that there were additional, unspecified physician factors determining the tendency to explore suicide risk. These factors are unrelated to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confidence in treating depression. CONCLUSIONS When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality. Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help. Research is needed to further elucidate physician characteristics associated with the assessment of suicidality.

Hopelessness and suicidal ideation in Iraq and Afghanistan war veterans reporting subthreshold and threshold posttraumatic stress disorder

We examined hopelessness and suicidal ideation in association with subthreshold and threshold posttraumatic stress disorder (PTSD) in a sample of Iraq and Afghanistan War Veterans (U.S., N = 275) assessed within a specialty VA postdeployment health clinic. Veterans completed paper-and-pencil questionnaires at intake. The military version of the PTSD Checklist was used to determine PTSD levels (No PTSD; subthreshold PTSD; PTSD), and endorsement of hopelessness or suicidal ideation were used as markers of elevated suicide risk. Veterans were also asked if they received mental health treatment in the prior 6 months. Veterans reporting subthreshold PTSD were 3 times more likely to endorse these markers of elevated suicide risk relative to the Veterans without PTSD. We found no significant differences in likelihood of endorsing hopelessness or suicidal ideation comparing subthreshold and threshold PTSD groups, although the subthreshold PTSD group was less likely to report prior mental health treatment. Clinicians should be attentive to suicide risk in returned Veterans reporting both subthreshold and threshold PTSD.

DOES PTSD MODERATE THE RELATIONSHIP BETWEEN SOCIAL SUPPORT AND SUICIDE RISK IN IRAQ AND AFGHANISTAN WAR VETERANS SEEKING MENTAL HEALTH TREATMENT

Objective: This study examined posttraumatic stress disorder (PTSD) as a potential moderating variable in the relationship between social support and elevated suicide risk in a sample of treatment‐seeking Iraq and Afghanistan War Veterans. Method: As part of routine care, self‐reported marital status, satisfaction with social networks, PTSD, and recent suicidality were assessed in Veterans (N=431) referred for mental health services at a large Veteran Affairs Medical Center. Logistic regression analyses were conducted using this cross‐sectional data sample to test predictions of diminished influence of social support on suicide risk in Veterans reporting PTSD. Results: Thirteen percent of Veterans were classified as being at elevated risk for suicide. Married Veterans were less likely to be at elevated suicide risk relative to unmarried Veterans and Veterans reporting greater satisfaction with their social networks were less likely to be at elevated risk relative to Veterans reporting lower satisfaction. Satisfaction with social networks was protective for suicide risk in PTSD and non‐PTSD cases, but was significantly less protective for veterans reporting PTSD. Conclusions: Veterans who are married and Veterans who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. However, the presence of PTSD may diminish the protective influence of social networks among treatment‐seeking Veterans. Depression and Anxiety, 2010. Published 2010 Wiley‐Liss, Inc.

The effect of camera geometry on singles flux, scatter fraction and trues and randoms sensitivity for cylindrical 3D PET-a simulation study

Preliminary results of an assessment of the effects of changing the axial field of view (AFOV) and detector ring diameter (DRD) of a cylindrical PET tomograph on count rate performance are presented. The assessment was made using Monte Carlo simulations of an anthropomorphic phantom based on the Zubal phantom. This phantom was modified to include cylinders approximating arms and legs, and was sequentially stepped through the AFOV to simulate a whole-body scan covering an axial region of interest of 1 m. DRD was varied from /spl sim/60 cm to /spl sim/108 cm, and AFOV was varied from 10 cm to 60 cm. A simple activity distribution and dead time model was assumed to allow the calculation of noise-equivalent count (NEC) rates for a situation similar to that of a typical 18F-FDG study. Both the scatter fraction and singles flux were found to be strongly dependent on DRD, but only weakly dependent on AFOV when the latter was greater than /spl sim/25 cm. Trues and randoms sensitivity were strongly dependent on AFOV, and randoms sensitivity was also strongly dependent on DRD. Scatter and singles flux do not appear to be limiting factors for extended AFOV configurations, and randoms rates, while high, appear to be manageable with existing detector technology. This initial assessment suggests that for whole-body applications, substantial gains in NEC may be possible by extending the AFOV.

Suicide Inquiry in Primary Care: Creating Context, Inquiring, and Following Up

PURPOSE We wanted to describe the vocabulary and narrative context of primary care physicians’ inquiries about suicide. METHODS One hundred fifty-two primary care physicians (53% to 61% of those approached) were randomly recruited from 4 sites in Northern California and Rochester, New York, to participate in a study assessing the effect of a patient’s request for antidepressant medication on a physician’s prescribing behavior. Standardized patients portraying 2 conditions (carpal tunnel syndrome and major depression, or back pain and adjustment disorder with depressed mood) and 3 antidepressant request types (brand-specific, general, or none) made 298 unannounced visits to these physicians between May 2003 and May 2004. Standardized patients were instructed to deny suicidality if the physician asked. We identified the subset of transcripts that contained a distinct suicide inquiry (n = 91) for inductive analysis and review. Our qualitative analysis focused on elucidating the narrative context in which inquiries are made, how physicians construct their inquiries, and how they respond to a patient’s denial of suicidality. RESULTS Most suicide inquiries used clear terminology related to self-harm, suicide, or killing oneself. Three types of inquiry were identified: (1) straightforward (eg, “Are you feeling like hurting yourself?”); (2) supportive framing (eg, “Sometimes depression gets so bad that people feel that life is no longer worth living. Have you felt this way?”); and (3) no problem preferred (eg, “You’re not feeling suicidal, are you?”). Four inquiries were glaringly awkward, potentially inhibiting a patient’s disclosure. Most (79%) suicide inquiries were preceded by statements focusing on psychosocial concerns, and most (86%) physician responses to a standardized patient’s denial of ideation were followed up with relevant statements (eg, “I hope you would tell me if you did.”). CONCLUSION Although most suicide inquiries by primary care physicians are sensitive, clear, and supportive, some language is used that may inhibit suicide disclosure. Some physician responses may unintentionally reinforce patients for remaining silent about their risk. This study will inform future research in the development of quality improvement interventions to support primary care physicians in making clear, appropriate, and sensitive inquires about suicide.

Care management for depression and osteoarthritis pain in older primary care patients: a pilot study

To establish the feasibility of and to generate preliminary evidence for the efficacy of a care management program addressing both physical and emotional pain associated with late‐life depression and osteoarthritis.

Course of Suicide Ideation and Predictors of Change in Depressed Older Adults

BACKGROUND Rates of suicide among older adults in the United States are higher than that of other age groups. Therefore, it is critically important to deepen understanding of the processes that drive suicide risk among at-risk older patients. To this end, we examined the longitudinal course of suicide ideation in a sample of treatment-seeking depressed adults 60 years of age or older. METHODS Secondary analyses were conducted with a longitudinal dataset including 343 older adults seeking treatment for depression in the context of a naturalistic treatment setting. Participants completed assessments of depressive symptoms and thoughts of suicide every three months for one year. Multi-level mixed models were used to examine the trajectory of suicide ideation over five waves. RESULTS Depressive symptoms contributed significantly to change in thoughts of suicide early in treatment for depression. Age-related differences were also observed, such that increasing age was associated with significantly greater reports of suicide ideation. LIMITATIONS Use of a single measure to ascertain severity of depressive symptoms and thoughts of suicide. CONCLUSIONS Clinicians should expect to see the most pronounced decrease in thoughts of suicide during the first two months of depression treatment for older adults. Further, clinicians should be especially vigilant to monitor suicide ideation for adults, with increasing vigilance for those at more advanced ages.

Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis

Objective To characterise suicide-risk discussions in depressed primary-care patients. Design Secondary analysis of recordings and self reports by physicians and patients. Descriptive statistics of depression and suicide-related discussion, with qualitative extraction of disclosure, enquiry and physician response. Setting 12 primary-care clinics between July 2003 and March 2005. Participants 48 primary-care physicians and 1776 adult patients. Measures Presence of depression or suicide-related discussions during the encounter; patient and physician demographics; depression symptom severity and suicide ideation as measured by the Patient Health Questionnaire (PHQ9); physicians decision-making style as measured by the Medical Outcomes Study Participatory Decision-Making Scale; support for autonomy as measured by the Health Care Climate Questionnaire; trust in their physician as measured by the Primary Care Assessment Survey; physician response to suicide-related enquiry or disclosure. Results Of the 1776 encounters, 128 involved patients scoring >14 on the PHQ9. These patients were seen by 43 of the 48 physicians. Suicide ideation was endorsed by 59% (n=75). Depression was discussed in 52% of the encounters (n=66). Suicide-related discussion occurred in only 11% (n=13) of encounters. 92% (n=12) of the suicide discussions occurred with patients scoring <2 on PHQ9 item 9. Suicide was discussed in only one encounter with a male. Variation in elicitation and response styles demonstrated preferred and discouraged interviewing strategies. Conclusions Suicide ideation is present in a significant proportion of depressed primary care patients but rarely discussed. Men, who carry the highest risk for suicide, are unlikely to disclose their ideation or be asked about it. Patient-centred communication and positive healthcare climate do not appear to increase the likelihood of suicide related discussion. Physicians should be encouraged to ask about suicide ideation in their depressed patients and, when disclosure occurs, facilitate discussion and develop targeted treatment plans.

Positron range and coincidence non-collinearity in SimSET

The authors have modified SimSET to model positron range and annihilation radiation non-collinearity. Positron range in water is sampled using the empirical model developed by Palmer and Brownell (IEEE Trans. Med. Imag., vol. 11, p. 373-8, 1992). The positron is projected from the decay location in a random direction with adjustment for the density and effective atomic number and weight of intervening tissues. The positron range algorithm was validated by comparing simulated range distributions to the model and with data published by Derenzo (5th Int. Conf. Positron Annihilation, Sendai, Japan, 1979). Annihilation non-collinearity is simulated as a Gaussian-distributed variation from 180 degrees with a standard deviation of 0.5 degrees. Tests verify the simulated noncollinearity is Gaussian distributed and that the azimuthal angle is unbiased.

Coherent scatter implementation for SimSET

At 140 keV, 3% of photon scatter interactions in human tissues are coherent scatter; at Tl-201 emission energies, this fraction increases to approximately 7%. However, since coherent scatter at these energies is sharply forward-peaked, it is often the dominant scatter interaction at small angles. SimSET (Simulation System for Emission Tomography), which previously modeled only photoelectric absorption and Compton scatter, has been extended to include coherent scatter. The current implementation uses form factor and anomalous scattering amplitude data from the Livermore Evaluated Photon Data Library. Interaction probability and angular distribution tables for several human tissues and common detector materials were calculated using the independent atoms approximation and human-tissue composition data from the ICRP Reference Man. These data were also used to generate new tables for photoelectric absorption and Compton scatter, significantly improving the accuracy of SimSET and extending its photon tracking capability to lower photon energy (from 50 keV to 1 keV). The form, content, and structure of the tables were carefully designed for efficient data storage, access, and use by the software. The derived data tables and implementation of coherent scatter were validated by comparing simulation results to published differential cross-section data.