Patients were eligible to be interviewed until recruitment ended. Otherwise the interviewer followed up by phone to schedule an in-person or phone interview about a week later. Eligible patients were mailed an invitation letter with the option to opt out by calling the research team. A probable suicide attempt was defined by using ICD-10 codes for self-harm or possible self-harm. As previously described ( 11), probable suicide attempts were identified by a member of the research team during a manual EHR review to confirm participants had a documented self-injury or suicide attempt and were not currently hospitalized or institutionalized. Study participants were recruited from Kaiser Permanente in Washington State between July 2016 and October 2017 by using electronic health record (EHR) and claims data to identify patients with a probable suicide attempt within 60 days of having reported no thoughts of self-harm on question 9 of the PHQ-9. The purpose of this study was to explore the perspectives of patients who made a suicide attempt after having reported no thoughts of self-harm during a health care visit prior to their attempt and to identify factors that may facilitate or preclude patients from disclosing suicidal ideation in health care settings. There are many reasons that patients may not report suicidal ideation to health care providers prior to a suicide attempt, but no research has qualitatively explored this topic from the patient perspective. One study of patients who attempted suicide in the week after completion of the PHQ-9 found that one-fourth of suicide attempts were by patients who responded “not at all” to question 9 ( 9). Yet the sensitivity of this tool (among others) is only moderate. For example, for detecting suicidal ideation ( 7), question 9 on the PHQ-9 performs similar to diagnostic interviews, and responses to question 9 are a strong predictor of suicide attempt and suicide death ( 8– 10). However, the link between asking patients about suicidal ideation and the ability of health systems to help prevent suicide is not clear. Question 9 on the nine-item Patient Health Questionnaire (PHQ-9), for example, asks about the frequency of thoughts about self-harm in the past 2 weeks (i.e., “thoughts you would be better off dead, or of hurting yourself in some way”) ( 6). Moreover, health care systems nationwide are implementing routine depression screening and monitoring ( 5), and depression questionnaires often include questions about suicidal ideation. Therefore, the Joint Commission now recommends screening all patients in acute and nonacute care settings for suicidal ideation ( 4). Outpatient medical settings provide opportunities for suicide prevention, given that nearly half of persons who die by suicide make health care visits in the month prior to death and the majority make a visit in the year prior to death ( 2, 3). emergency department for a nonfatal self-harm event ( 1). In 2016, approximately 45,000 Americans died by suicide and a half-million individuals visited a U.S. Nonjudgmental listening and expressions of caring without overreaction among providers may help patients overcome fear of reporting suicidal ideation. Patients who made a suicide attempt after reporting no suicidal thoughts during a health care visit either were not experiencing suicidal thoughts at the time of the visit or did not report them because of fear of stigma, clinicians’ overreaction, and loss of autonomy.
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