Primary care doctors can provide better care for patients with mental health concerns by simply changing the way they phrase questions regarding self-harm and suicide, a recent study suggests.

The research, published in October in Patient Education and Counseling, was conducted as part of the larger DeSTRESS Project, which examined mental health in low-income communities. The study noted that about 45% of people who die by suicide annually had seen their primary care doctor in the month before their death, meaning that questions regarding suicidal ideation or self-harm are important for doctors to pose.

Researchers on the project examined 52 recorded consultations between patients and their primary care doctors regarding suicide and/or self-harm, and found that doctors often phrased questions in a way that invited a “no” response. Such questioning can make patients more hesitant to respond affirmatively or to report thoughts of self-harm or suicide, the researchers said.

Joseph Ford, a researcher at the University of Exeter and an author of the study, said that such phrasing, especially in a clinical setting, is important due to how, "There’s no such thing, really, as a neutral question.”

Subtle differences, such as using the word “any” instead of “some” during questioning, can embed within it a certain expectation for a “yes” or “no” response, Ford added.

“If I say, ‘Do you have any plans for today,’ that embeds a negative response, but if I say, ‘Do you have some plans for today,’ that embeds a preference for a positive response,” Ford said. “That’s a fairly subtle example of how it can occur — there are more overt examples. So, if I say, ‘You don’t have any plans for today, do you?’ — that quite clearly embeds an expectation for a negative response.”

The study found that primary care doctors often asked questions in a way that would subtly invite that “no” response from their patients, such as asking, “You’re not having any thoughts of harming yourself?” or, "You’ve not had any thoughts of suicide or anything like that?” The negative framing of this line of questioning can make it that much more difficult for patients to report thoughts of self-harm or suicidal thoughts, Ford said.

“When you transfer that to a clinical setting where time is limited, and this might be the first time that the patient has talked about this, it’s important to be aware of those very subtle nuances that can be embedded in questions,” Ford said.

The existing societal stigma that surrounds discussion of suicide or self-harm means that, “Patients are finding it very difficult to talk about these topics,” Ford said, noting that parents in particular can struggle to address these issues in a clinical setting.

“Parents [expressed] the fear that their children would be taken away from them,” Ford said. “That’s a very clear manifestation, I think, of a wider stigma that we all, to some extent, probably feel. Even if we don’t necessarily agree with it, we probably sense that the stigma is there.”

While further research into this particular topic has not yet been decided, Ford said that the investigators will potentially be looking at expanding the scope of the project into other demographics to see if the pattern persists across a wider array of cases. Though finding these patterns within the consultations in this existing study was “remarkable,” Ford said, the next step would be to determine how widespread they are in other primary care settings.

The patterns found in this study highlight that there are “perhaps a few ways that these discussions could be made easier” when it comes to addressing thoughts of depression, self-harm, or suicide, Ford said, which could potentially lead to better diagnostics within primary care settings.

“It’s not that the doctors that we were seeing were making it particularly difficult,” Ford noted. “It is these very subtle nuances of language … which can perhaps shift things towards a negative response to the question, or embed the idea that this is an uncomfortable thing to be talking about.”

The article, “Asking about self-harm and suicide in primary care: Moral and practical dimensions,” was published Oct. 14, 2020 in Patient Education and Counseling. It was authored by Joseph Ford and Felicity Thomas of the University of Exeter, Richard Byng of the University of Plymouth, and Rose McCabe of the University of London.