Figures
Abstract
Background
General practitioners (GPs) have a key role to play in suicide prevention, but the rates at which they question patients with depression about suicidal thoughts and plans are rather low. Little is known about GPs' characteristics associated with such inquiries. Our objectives were to describe GPs' attitudes, perceived barriers, and self-reported practices in this questioning of these patients and to analyze factors associated with these practices.
Methodology
This cross-sectional survey was conducted among participants in a panel of randomly selected French GPs (1249/1431 participated: 87.3%). GPs were interviewed with a standardized questionnaire covering their professional and personal characteristics, attitudes, and practices in exploring the suicide risk of their patients with depression. We built a suicide inquiry score by summing the responses to 5 items and used a multiple linear regression analysis to explore the characteristics associated with this score.
Principal Findings
Most GPs reported inquiring about the presence of suicidal ideation often or very often; less than 30% reported that they frequently explored signs of a specific suicide plan. The mean suicide inquiry score was 12.4 (SD, 2.9; range, 5–20). False ideas, such as thinking that patients who report suicidal ideas do not often commit suicide, were frequent (42.3%). Previous continuing medical education on suicide, participation in a formal mental health network, and patients who committed suicide in the past 5 years were associated with a higher score. Reluctance to question patients about suicide and perception of insufficient skill were associated with a lower score.
Conclusions/Significance
This study showed great variability in French GPs' practices in exploring suicide risk in patients with depression. Interventions aiming at improving GPs' initial training and continuing medical education in suicide and/or depression, and their collaboration with mental health specialists should be developed, and their impacts assessed.
Citation: Bocquier A, Pambrun E, Dumesnil H, Villani P, Verdoux H, Verger P (2013) Physicians' Characteristics Associated with Exploring Suicide Risk among Patients with Depression: A French Panel Survey of General Practitioners. PLoS ONE 8(12): e80797. https://doi.org/10.1371/journal.pone.0080797
Editor: Yinglin Xia, University of Rochester, United States of America
Received: July 29, 2013; Accepted: October 4, 2013; Published: December 10, 2013
Copyright: © 2013 Bocquier et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The French Regional Panel of General Practices received funding from: 1) the Direction de la Recherche, des Etudes, de l′Evaluation et des Statistiques (DREES) – Ministère du travail, des relations sociales, de la famille, de la solidarité et de la ville/Ministère de la Santé et des Sports; 2) the Institut de la Recherche en Santé Publique (IReSP) in the frame of the Research Program 2011 “Santé mentale, prévention, prospective, thématiques générales de l′IReSP.” The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Suicide is a major public health problem worldwide (accounting for approximately 1 million deaths per year), including in France where the suicide rate (14.7 per 100 000) remains one of the highest in Europe [1]–[3]. The presence of a psychiatric disorder is the most consistently reported risk factor for suicidal behavior; more than half of people who die by suicide had a depressive disorder at the time [4]–[6]. Among people with depression, more than half report suicidal ideation [7], and about 4% die by suicide [8]. General practitioners (GPs) have a key role to play in suicide prevention [6], [9] as they manage most cases of depression [10], [11]. Furthermore, half to two thirds of suicide completers visited their GP in the month before their death [9], [12]. Training GPs to recognize and treat depression appropriately can reduce population rates of completed and attempted suicide [13].
All practice guidelines recommend that persons with depression be screened for suicide risk by exploring their suicidal thoughts and plans [1], [5], [14]–[18]. If suicidal ideation or intentions are detected, then risk factors for suicide and the imminence of suicidal behavior must be assessed [5]. Evidence from the literature shows great variability in primary care physicians' practices in exploring suicide risk [19]–[23]. In postal surveys, about 80% of British GPs stated that they sometimes screened for suicidal ideation among patients with signs or symptoms of depression [19], and 58% of American primary care physicians reported direct questioning about suicide when they managed their most recent case of a patient with depression [20]. Two recent American studies using standardized patient designs found lower rates of suicide risk screening (36–42%) [21], [22]. Other studies have found that GPs detect suicidal ideation in 20% to 50% of patients presenting with such ideation [24]–[26].
Only a few studies have analyzed physicians' characteristics associated with exploring suicide risk [21], [22], [26]; they found that both personal (e.g., age, personal experience with depression) and professional (e.g., participation in continuing medical education, CME) characteristics are linked with this exploration. Potential relations between physicians' attitudes towards suicide (e.g., false ideas about suicide management) and their practices in exploring suicide risk are also assumed [19], [27], [28], but, to the best of our knowledge, have not been explored by a quantitative approach.
This study among a panel of French GPs aimed to i) describe their attitudes towards suicide, perceived barriers, and self-reported practices in questioning patients with depression about suicidal thoughts and plans; and ii) investigate whether GPs' self-reported practices were associated with their attitudes, perceived barriers towards suicide management, or personal and professional characteristics.
Materials and Methods
Sampling
In 2008, around 58,000 GPs (31.6% of them women) were in private practice in France [29]. This survey is the third in a series nested in the national panel of French GPs, designed to collect data regularly about their activity and practices. Its methodology has been presented elsewhere [30]–[32]. Briefly, 5170 GPs were randomly selected from the Ministry of Health's exhaustive database of health professionals in France. Sampling was stratified for location of the general practice (urban, suburban, or rural), gender, age (<49, 49–56, >56), and annual workload, defined by number of office consultations and house calls (<2849, 2849–5494, >5494) in 2008. Information on each GP was obtained from the National Health Insurance Fund (NHIF). To limit a selection bias that might result from particular opinions/attitudes, the specific topics to be studied were not mentioned to GPs before they were asked to participate in the panel.
Of the 5170 private GPs initially selected, 4111 (79.5%) could be contacted after a maximum of 10 attempts; 223 were not eligible, as 112 had already retired or planned to within the next year, 39 planned to move their practice within the next year, and 72 practiced exclusively alternative medicine (e.g., homeopathy or acupuncture). Finally, 1431/3888 eligible and contacted GPs (36.8%) agreed to join, i.e., to respond to 5 consecutive surveys during a 30-month period. The GPs who refused to take part did not differ from participants according to practice location, but were more frequently male (p = 0.02), older (p<10−3), and had a higher workload in 2008 (p<10−3). Lack of time (46.2%) and lack of interest in the panel (15.6%) were the reasons given most frequently for refusal [30].
Ethics statement
GPs who agreed to participate in the panel sent back a signed written consent to our team. The National Data Protection Authority, responsible for ethical issues and protection of computerized individual data in France, approved the panel and its procedures.
Procedure and questionnaire
This cross-sectional survey took place during the last quarter of 2011. Professional investigators contacted the panel members and interviewed them with computer-assisted telephone interview (CATI) software. GPs were interviewed with a standardized 40-item questionnaire covering their professional and personal characteristics and their practices and opinions in the area of depression management. These results have been presented in detail elsewhere [31], [32].
The questionnaire included 5 items on self-reported practices in exploring suicide risk, proposed in a random order (listed in Table 1). For each item, participants were asked to report the frequency (never, sometimes, often, very often) at which they asked these questions of patients with depression. These items correspond to a stepwise approach to exploring suicide risk [5], [6]; the last two items are warning signs that the patient has a detailed and specific suicide plan.
We collected information on common inaccurate attitudes towards suicide and suicidal patients [33]–[35]: (i) questioning a patient with suicidal ideas can trigger suicidal behavior; (ii) no one can do much for a person who has decided to commit suicide; (iii) patients who report suicidal ideas do not often commit suicide. GPs were asked to report their degree of agreement with each item (strongly disagree, somewhat disagree, somewhat agree, strongly agree); the answers were subsequently categorized into disagree and agree.
We assessed the following perceived barriers to inquiring about suicide and self-assessed effectiveness in depression management: (i) lack of training on this topic; (ii) reluctance to question patients about suicide; (iii) perception of lack of skill in questioning patients about suicide; (iv) lack of time; (v) perception of effectiveness in managing patients with major depression (yes, no).
We collected information on the following personal characteristics of panel members: (i) age (categorized into ≤50 vs. >50 years, based on the median in the sample); (ii) gender; reported personal history of (iii) depression, (iv) antidepressant treatment; (v) psychotherapy; and (vi) reported history of depression in a close friend or family member; and professional characteristics: (i) area of practice (urban, suburban, or rural); (ii) annual workload (number of office consultations and house calls in 2008 categorized into ≤5000 vs. >5000, based on the median in the sample); (iii) reported CME on suicide risk assessment and management (categorized as never, more than 3 years ago, less than 3 years ago); (iv) participation in a formal mental health network (i.e., a network of GPs and mental health specialists financially supported by regional health agencies aimed at promoting access to and coordination of care).
Two items assessed GPs' experience with suicide among their patients: had any patient attempted suicide and had any completed suicide in the past 5 years (yes, no).
Finally, data on their patients' characteristics were extracted from the NHIF databases, and dichotomized according to the median in the sample. We used proportions of patients on their patient list (all patients seen at least once during 2011) with each of the following characteristics: aged 70 years or more; covered by CMUC (Complementary Universal Health Insurance, a program that exempts individuals who have annual incomes below 9000 € from any out-of-pocket costs [36]), an indicator of a very low socioeconomic status or deprived clientele; and with a chronic disease (ALD status: attributed by the NHIF to persons with specific and expensive chronic diseases that make them eligible for 100% reimbursement for treatment). We selected these items because older age, low socioeconomic status, and chronic psychiatric and/or somatic disease are risk factors for suicidal behavior [2], [5].
Statistical analyses
Because of the differences mentioned above between GPs who participated in the panel and those who refused, we weighted the data to match the sample more closely to the national French GP population for age, gender, location of practice, and 2008 workload [30], [37].
We built a suicide inquiry score by summing the responses to the 5 items listed in Table 1 (never = 1, sometimes = 2, often = 3, very often = 4; alpha Cronbach = 0.7).
First, we conducted descriptive analyses of GPs' attitudes, perceived barriers, experience of suicide among their patients, self-reported practices about questioning patients with depression about suicide, and the suicide inquiry score. Second, we conducted bivariate analyses of the relations between GPs' characteristics and the suicide inquiry score with comparisons of means, and t-tests. Third, we developed a multiple linear regression model to test whether this score was associated with GPs' attitudes, perceived barriers, personal and professional characteristics, or experience of suicide among their patients. The variables entered into the model were all selected a priori based on the literature review; to test the robustness of the results we also ran the model again with a backward procedure. We also calculated the variance inflation factors (VIF) to measure collinearity between the independent variables and checked the model assumptions by analyzing residuals. The coefficient of determination, R2, and the adjusted R2 were calculated to assess the percentage of variance explained by the model, and the global significance of the model was tested with the F-test.
All analyses were based on two-sided p values, with p<0.05 indicating statistical significance. All analyses were conducted with SAS 9.2 statistical software (SAS Institute, Cary, NC).
Results
Sample characteristics
Of the 1431 GPs initially included in the panel, 1249 (87.3%) agreed to participate in this survey. Their mean age was 51.4 years (SD, 8.4), 72.9% were men, and 60.5% worked in urban areas. Those who refused to respond to this survey did not differ significantly from participants for gender, age, place of practice, or number of office visits and house calls in 2008.
Self-reported practices in exploring suicide risk, attitudes, and perceived barriers
Most GPs (81.0%) reported at least one suicide attempt among their patients over the past 5 years, and 43.0% at least one completed suicide. Most (86.4%) reported that when they saw patients with depression, they inquired often or very often about suicidal ideation: 72.3% about intent to commit suicide; 53.6% about a suicide plan; 28.0% about the patient's setting his or her affairs in order; and 17.0% about whether the patient had written a letter (Table 1). The mean suicide inquiry score was 12.4 (SD, 2.9; range, 5–20; 1st quartile, 10; median, 12; 3rd quartile, 14). Its distribution was close to Gaussian (Figure S1).
According to 9.5% of the GPs, questioning a patient with suicidal ideas can trigger suicidal behavior; 30.4% agreed that no one can do much for a person who has decided to commit suicide, and 42.3% that patients who report suicidal ideas do not often commit suicide (Table 2). The perceived barriers to suicide screening most frequently reported by GPs were lack of training in this risk exploration (37.4%), lack of time to perform it (30.2%), and lack of skill in it (26.2%) (Table 2).
Factors associated with the suicide inquiry score
In the bivariate analysis, GPs who agreed that patients who report suicidal ideas do not often commit suicide had a lower suicide inquiry score than the others, and all perceived barriers to exploring suicide risk were associated with a lower score (Table 2). The personal and professional characteristics associated with a higher score were: an age of 50 years or younger, a personal history of psychotherapy, previous CME on the topic of suicide, participation in a formal mental health network, and patients who had attempted or completed suicide in the past 5 years (Table 3).
In the multiple linear regression analysis, previous CME on suicide (especially within the past 3 years), participation in a formal mental health network, and a patient with a completed suicide in the past 5 years were associated with a higher score. Reluctance to question patients about suicide and perceived lack of skill in such questioning were associated with a lower score. The suicide inquiry score did not vary according to GPs' attitudes towards suicide (Table 4). Using a backward selection procedure led to similar results except for GPs' age (β = −0.419, p = 0.013; full results available upon request). Collinerarity between independent variables was very small (VIF<2).
Discussion
In this survey of a national panel of randomly selected GPs, more than 80% reported they had patients who had attempted suicide in the past 5 years, and more than 40%, patients who had completed suicide. While most of them reported asking patients with depression about suicidal ideation often or very often, less than 30% reported frequent exploration of more details, especially signs of a specific suicide plan. To assess GPs' practices in exploring suicide risk, we built a score by summing their reported practices in exploring suicidal ideation, intention to commit suicide, a suicide plan, and whether patients have set their affairs in order or written a letter; this score revealed great variability in GPs' practices. Participation in CME about suicide or in a formal mental health network, and having a patient who completed suicide in the past 5 years were all associated with a higher score. Reluctance to question patients about suicide and perceived lack of skill in this questioning were associated with a lower score.
Limitations and strengths
These findings must be interpreted in the light of the following methodological limitations. First, although the participation rate in this panel was relatively high for panels of physicians requiring participation in repeated surveys (see for example [38]: response rate = 19%), nonparticipants were more frequently male, older, and had a higher workload than participants. As none of these factors was independently associated with the suicide inquiry score, this may not have modified this score.
Second, the survey questionnaire explored self-reported practices in exploring suicide risk among patients with depression, which may differ from actual practices. Depression is a well-known risk factor for suicide, and a social desirability bias may have led to an overestimation of these practices. The percentage of GPs who reported asking patients with depression about suicidal ideation often or very often (86.4%) is close to that observed in a previous study using a similar design [19]. However, it was higher than in other studies that used standardized patients or vignettes with open-ended questions (2–40%) [21]–[23]; the latter methods reflect actual physician practice more accurately but they are extremely difficult and expensive to use on a large sample of GPs [39]. However, such a desirability bias is less likely to have modified the direction of the associations found in our regression model.
Third, GPs were asked to report these practices among patients with depression on a frequency scale; thus, their responses may partly reflect the characteristics of the patients in their practice (e.g., frequency of severe depression). Such an effect is probably limited since we found no association between the suicide inquiry score and characteristics of their patients.
Finally, the cross-sectional nature of our study prevents any causal inference. In particular, we cannot rule out that GPs who took a CME course on suicide or participated in a formal network would already have had higher suicide inquiry scores before this CME course or network participation.
One important strength of this study is that it included various types of factors potentially associated with GPs' practices in exploring suicide risk: personal and professional characteristics, as well as attitudes towards suicide and perceived barriers to suicide management. Most previous studies on this topic have included a more limited set of explanatory variables [22], [26].
This study suggests several ways to improve GPs practices in suicide risk exploration among patients with depression. Although it can be argued that GPs do not have time for this, previous studies suggest that French GPs spend more time with patients with mental health problems who require the prescription of medication (25 minutes on average) [40] and that consultation length is associated with screening for suicidal ideation [26].
Comparison with the literature and interpretation of the findings
The lack of association between GPs' self-reported practices in exploring suicide risk and their gender, age, and self-assessed effectiveness in depression management is in line with most previous published studies [21], [22], [26]. GPs' practices were not related to their personal history of depression or antidepressant/psychotherapeutic treatment, in contrast to a previous study that found a positive association between personal experience with depression and suicide exploration [21].
Concerns about the impact of screening for suicidal ideation on the risk of committing suicide have often been put forward to explain low levels of this screening [19], [28], [41]. To the best of our knowledge, our study was the first to test whether GPs' practices in this regard vary according to their attitudes towards suicide, and we found no significant association. The percentage of French GPs in our study who agreed that questioning a patient with suicide ideas can trigger suicide completion (9.5%) was much lower than in a 2008 British study (25%) [19]. It was also lower among GPs who had attended a CME session on suicide in the past 3 years than among the others (results not shown). GPs' attitudes may have changed in recent years, perhaps in response to increasing participation in CME in this field [31], [42].
Previous CME on suicide (with a higher size effect for recent CME) and participation in a formal mental health network were the two factors most strongly associated with this questioning. These results are strikingly different from those we have found related to other aspects of depression management, such as prescriptions of antidepressants or referral for psychotherapy: the latter were strongly associated with GPs' personal characteristics and attitudes, but independent of CME or network participation [31], [32]. As the literature indicates, CME appears to have a positive impact on asking depressed patients about suicidal thoughts [42]–[44]. Trained GPs may conduct in-depth explorations of suicide risk more frequently, partly because they are less reluctant to question patients about suicide and have more skill and expertise in such questioning. Indeed, reluctance and perceived lack of skill were both associated with a lower suicide inquiry score in our study. Trained GPs may also have more knowledge about planning and structuring follow-up for patients with suicidal ideation, or information about support facilities for such patients [45], [46]. Mental health networks seek to improve information, train members, and facilitate collaboration between GPs, psychiatrists, psychologists, and nurses, in both private practice and hospitals [47]. They are thus applying the principles of collaborative care models [6]. GPs who participate in mental health networks may be more likely to conduct in-depth explorations precisely because they can more easily ask for advice when in difficulty, or refer patients at high risk of suicide to specialists [48].
Finally, we found that GPs' previous experience with completed suicide among their patients was common and associated with in-depth exploration. Using a qualitative design, Davidsen showed that patient suicide has a substantial emotional impact on GPs that lasts many years; GPs were struck by guilt, failure, and self-scrutiny when a patient committed suicide [49]. His qualitative study suggested that GPs' propensity to question patients about suicide risk did not change after the suicide of a patient. Our results, however, suggest that such an event may affect GPs' practices.
Conclusions
This study showed great variability in the practices of French private GPs in the field of suicide risk exploration. Part of the explanation for these differences may lie in the variability in their skills and expertise in questioning patients about suicide, their training in this field, and their collaboration with mental health specialists. Improving GPs' initial training and CME on depression, suicide risk recognition, and management and promoting collaborative care organizations in this field have been shown to be effective in decreasing suicide rates at the population level [13]. Such interventions should be developed, and their impacts on GPs' practices and suicide rates at the population level should be evaluated.
Supporting Information
Figure S1.
Number of general practitioners according to the suicide inquiry score (French nationwide panel of general practitioners, weighted data, n = 1237).
https://doi.org/10.1371/journal.pone.0080797.s001
(DOC)
Acknowledgments
We thank all GPs who participated in the survey as well as the members of the supervisory committee of the French National Panel of Ambulatory General Practices (DREES; ORS and URPS-ML of Bourgogne, Pays de la Loire, and Provence-Alpes-Côte d'Azur). The authors also thank Jo Ann Cahn for supervising the English of this manuscript.
Author Contributions
Conceived and designed the experiments: P. Verger HD HV P. Villani. Performed the experiments: HD. Analyzed the data: EP. Contributed reagents/materials/analysis tools: P. Verger HD HV P. Villani AB. Wrote the paper: AB.
References
- 1. Wasserman D, Rihmer Z, Rujescu D, Sarchiapone M, Sokolowski M, et al. (2012) The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. Eur Psychiatry 27: 129–141.
- 2. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, et al. (2008) Suicide and suicidal behavior. Epidemiol Rev 30: 133–154.
- 3. Chan Chee C, Gourier-Frery C, Guignard R, Beck F (2011) [The current state of mental health surveillance in France]. Sante Publique 23 Suppl 6S13–29.
- 4. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM (2003) Psychological autopsy studies of suicide: a systematic review. Psychol Med 33: 395–405.
- 5. Hawton K, van Heeringen K (2009) Suicide. Lancet 373: 1372–1381.
- 6. McDowell AK, Lineberry TW, Bostwick JM (2011) Practical suicide-risk management for the busy primary care physician. Mayo Clin Proc 86: 792–800.
- 7. Gensichen J, Teising A, Konig J, Gerlach FM, Petersen JJ (2010) Predictors of suicidal ideation in depressive primary care patients. J Affect Disord 125: 124–127.
- 8. Coryell W, Young EA (2005) Clinical predictors of suicide in primary major depressive disorder. J Clin Psychiatry 66: 412–417.
- 9. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, et al. (2005) Suicide prevention strategies: a systematic review. JAMA 294: 2064–2074.
- 10. Kovess-Masfety V, Alonso J, Brugha TS, Angermeyer MC, Haro JM, et al. (2007) Differences in lifetime use of services for mental health problems in six European countries. Psychiatr Serv 58: 213–220.
- 11. Timonen M, Liukkonen T (2008) Management of depression in adults. BMJ 336: 435–439.
- 12. Luoma JB, Martin CE, Pearson JL (2002) Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 159: 909–916.
- 13. Rihmer Z, Dome P, Gonda X (2012) The role of general practitioners in prevention of depression-related suicides. Neuropsychopharmacol Hung 14: 245–251.
- 14.
[National Agency for Health Accreditation and Evaluation] Agence Nationale d'Accréditation et d'Evaluation en Santé (2002) [Outpatient management of isolated depressive episodes in adults] Prise en charge d'un épisode dépressif isolé de l′adulte en ambulatoire. [Clinical guidelines] Recommandations pour la pratique clinique [in French]. Paris: ANAES. 85 p.
- 15.
National Institute for Health and Clinical Excellence (2009) Depression: the treatment and management of depression in adults (update) (Clinical guideline 90).
- 16. O'Connor E, Gaynes BN, Burda BU, Soh C, Whitlock EP (2013) Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med 158: 741–754.
- 17.
U.S. Department of Health and Human Services (HHS) Office of the Surgeon General, National Action Alliance for Suicide Prevention (2012) 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC. 184 p.
- 18.
McNamee JE, Offord DR (1994) Prevention of suicide. Canadian Task Force on the Periodic Health Examination Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada. 456–467.
- 19. Bajaj P, Borreani E, Ghosh P, Methuen C, Patel M, et al. (2008) Screening for suicidal thoughts in primary care: the views of patients and general practitioners. Ment Health Fam Med 5: 229–235.
- 20. Williams JW Jr, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, et al. (1999) Primary care physicians' approach to depressive disorders. Effects of physician specialty and practice structure. Arch Fam Med 8: 58–67.
- 21. Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, et al. (2007) Let's not talk about it: suicide inquiry in primary care. Ann Fam Med 5: 412–418.
- 22. Hooper LM, Epstein SA, Weinfurt KP, DeCoster J, Qu L, et al. (2012) Predictors of primary care physicians' self-reported intention to conduct suicide risk assessments. J Behav Health Serv Res 39: 103–115.
- 23. Stoppe G, Sandholzer H, Huppertz C, Duwe H, Staedt J (1999) Family physicians and the risk of suicide in the depressed elderly. J Affect Disord 54: 193–198.
- 24. Bryan CJ, Corso KA, Rudd M, Cordero L (2008) Improving identification of suicidal patients in primary care through routine screening. Primary Care & Community Psychiatry 13: 143–147.
- 25. Nutting PA, Dickinson LM, Rubenstein LV, Keeley RD, Smith JL, et al. (2005) Improving detection of suicidal ideation among depressed patients in primary care. Ann Fam Med 3: 529–536.
- 26. Verger P, Brabis PA, Kovess V, Lovell A, Sebbah R, et al. (2007) Determinants of early identification of suicidal ideation in patients treated with antidepressants or anxiolytics in general practice: a multilevel analysis. J Affect Disord 99: 253–257.
- 27. Kaplan MS, Adamek ME, Martin JL (2001) Confidence of primary care physicians in assessing the suicidality of geriatric patients. Int J Geriatr Psychiatry 16: 728–734.
- 28. Schulberg HC, Bruce ML, Lee PW, Williams JW Jr, Dietrich AJ (2004) Preventing suicide in primary care patients: the primary care physician's role. Gen Hosp Psychiatry 26: 337–345.
- 29.
Sicart D (2008) [Physicians: Estimates as of 1 January 2008] Les médecins: estimations au 1er janvier 2008. [Statistical Series] Série Statistique. [Office of Research, Evaluation, and Statistics] Direction de la recherche, des études, de l′évaluation et des statistiques [in French]. Paris: [Ministry of Health, Young People, and Sports] Ministère de la santé, de la jeunesse et des sports: 111 p.
- 30. Verger P, Flicoteaux R, Schwarzinger M, Sagaon-Teyssier L, Peretti-Watel P, et al. (2012) Pandemic influenza (A/H1N1) vaccine uptake among French private general practitioners: a cross sectional study in 2010. PLoS One 7: e41837.
- 31. Dumesnil H, Cortaredona S, Verdoux H, Sebbah R, Paraponaris A, et al. (2012) General practitioners' choices and their determinants when starting treatment for major depression: a cross sectional, randomized case-vignette survey. PLoS One 7: e52429.
- 32.
Verdoux H, Cortaredona S, Dumesnil H, Sebbah R, Verger P (2013) Psychotherapy for depression in primary care: a panel survey of general practitioners' opinion and prescribing practice. Soc Psychiatry Psychiatr Epidemiol. In press.
- 33. Hjelmeland H, Knizek BL (2004) The general public's views on suicide and suicide prevention, and their perception of participating in a study on attitudes towards suicide. Arch Suicide Res 8: 345–359.
- 34. Kocmur M, Dernovsek MZ (2003) Attitudes towards suicide in Slovenia: a cross-sectional survey. Int J Soc Psychiatry 49: 8–16.
- 35. Beautrais AL, Horwood LJ, Fergusson DM (2004) Knowledge and attitudes about suicide in 25-year-olds. Aust N Z J Psychiatry 38: 260–265.
- 36. Saliba B, Ventelou B (2007) Complementary health insurance in France. Who pays? Why? Who will suffer from public disengagement? Health Policy 81: 166–182.
- 37. Potthoff RF (1994) Telephone sampling in epidemiologic research: to reap the benefits, avoid the pitfalls. Am J Epidemiol 139: 967–978.
- 38. Joyce CM, Scott A, Jeon SH, Humphreys J, Kalb G, et al. (2010) The “medicine in Australia: balancing employment and life (MABEL)” longitudinal survey – protocol and baseline data for a prospective cohort study of Australian doctors' workforce participation. BMC Health Serv Res 10: 50.
- 39. Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M (2000) Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA 283: 1715–1722.
- 40. Videau Y, Saliba-Serre B, Paraponaris A, Ventelou B (2010) Why patients of low socioeconomic status with mental health problems have shorter consultations with general practitioners. J Health Serv Res Policy 15: 76–81.
- 41. Crawford MJ, Thana L, Methuen C, Ghosh P, Stanley SV, et al. (2011) Impact of screening for risk of suicide: randomised controlled trial. Br J Psychiatry 198: 379–384.
- 42. Ventelou B, Paraponaris A, Sebbah R, Aulagnier M, Protopopescu C, et al. (2005) Un observatoire des pratiques en médecine générale: l′expérience menée en région Provence-Alpes-Côte-d'Azur. Revue française des affaires sociales n° 1: 127–160.
- 43. Kaplan MS, Adamek ME, Rhoades JA (1998) Prevention of elderly suicide. Physicians' assessment of firearm availability. Am J Prev Med 15: 60–64.
- 44. Pfaff JJ, Acres JG, McKelvey RS (2001) Training general practitioners to recognise and respond to psychological distress and suicidal ideation in young people. Med J Aust 174: 222–226.
- 45. Fanello S, Paul P, Delbos V, Gohier B, Jousset N, et al. (2002) [General practitioners' practices and attitudes in regard to suicidal behavior]. Sante Publique 14: 263–273.
- 46. Vannoy SD, Tai-Seale M, Duberstein P, Eaton LJ, Cook MA (2011) Now what should I do? Primary care physicians' responses to older adults expressing thoughts of suicide. J Gen Intern Med 26: 1005–1011.
- 47. Hardy-Baylé MC, Bronnec C, Chaillet MP (2004) Place de la recherche dans les réseaux de santé. L'exemple du réseau de promotion pour la santé mentale dans les Yvelines Sud. Revue française des affaires sociales n° 1: 127–141.
- 48. Kisely S, Duerden D, Shaddick S, Jayabarathan A (2006) Collaboration between primary care and psychiatric services: does it help family physicians? Can Fam Physician 52: 876–877.
- 49. Davidsen AS (2011) ‘And then one day he'd shot himself. Then I was really shocked’: general practitioners' reaction to patient suicide. Patient Educ Couns 85: 113–118.