Is there an elephant in the room? Suicide prevention in the general practice: Suicide prevention in the general practice

General practices play a significant role in suicide prevention. However, their role is not optimally utilized because they may not be fully equipped to prevent suicide. There is a need for more insights and strategies to improve suicide prevention in general practice. The aim of this dissertation is to provide insight into suicide prevention in general practice and describe the possibilities and innovations for improvement. Chapter 2 discusses a study in which we examined how often general practitioners (GPs) inquire about suicidal thoughts in patients who consult their GP for a depression. Suicidal thoughts were assessed about in approximately half of these consultations. Discussing suicidal thoughts was more common among men, younger patients, and patients with a new episode of depression. Four out of ten patients who were asked about suicidal thoughts reported having such thoughts. The main reasons for not assessing suicidal thoughts included GPs assuming, based on their clinical experience, that patients did not have suicidal thoughts. Chapter 3 describes a qualitative study in which we conducted interviews with professionals from general practices, including GPs and mental health practice nurses. Important challenges for suicide prevention included assessing which patients might experience suicidality, partly due to a perceived lack of competence, and collaboration with mental healthcare services. Facilitating factors included the presence of mental health practice nurses, as they have more time, expertise, and experience with such issues. The interventions offered within the SUPRANET community, especially suicide prevention training, were perceived as helpful. Chapter 4 presents a national registration study using data from statistics Netherlands. It compares risk factors for suicide between different healthcare settings: mental healthcare services, general practice, or neither. Patients who died by suicide were more than five times more likely to have received mental healthcare services in the one to two years prior to their death than the reference group. The primary general risk factor for suicide, male gender, showed a decreasing association with suicide in mental healthcare services compared to no mental healthcare services. This also applied to lower income levels and single-person households or single-parent families. Overall, the differences were small and not distinct enough to argue for different suicide prevention strategies per healthcare sector. Chapter 5 describes a study in which an algorithm was created using machine learning techniques to recognize suicidal behaviour based on automatically recorded data in general practices. We compared individuals with a registration of a suicide or suicide attempt with an at-risk control group. The algorithm recognized approximately four out of ten patients with a suicide (attempt). The performance of this algorithm was insufficient for implementation in clinical practice. Nonetheless, this study provides insights into how automated screening techniques may support professionals in general practices. Chapter 6 describes a study in which we attempted to capture the experiences and satisfaction of patients regarding suicide prevention in general practice. Since we failed to include an adequate number of patients, we present the lessons learned from this study instead. The main obstacle was the chosen setting: a depression consultation in the general practice. The main recommendation for future research is, therefore, to choose a design that allows patients to be included without the involvement of GPs. In chapter 7, we investigated whether an intervention involving pop-up windows which appeared during consultations with patients with depression would increase the frequency of assessment of suicidal thoughts over a period of two years. The intervention showed no such effect. It is possible that better alignment of the pop-up windows or simultaneous implementation with other interventions, such as training, yields a greater effect.