Mood Disorders I and II

Question 1

Why study major depression?

Answer 1

• Common – 8-10% of men; 15-20% of women lifetime prevalence – 1 year prevalence about 7%; 19 million Americans suffering
• Incidence and prevalence increasing with time – cohort of women born in the 70’s and 80’s– as high as 25% prevalence
• Burden of Disease – projected to be the 2nd leading cause of disability world wide by 2020 (WHO study) [heart disease #1]
  
  • cost $100mill USD/yr (2012)
• Treatable if someone seeks help; many families affected differently

Question 2

DSM-5 Criteria for Major Depression

Answer 2

• Five or more of the following must be present for TWO WKS and represent a change from previous functioning. Must have 5 of the following 9 symptoms and must include either depressed mood or loss of interest or pleasure (anhedonia)
  
  • (1) Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation by others (In children and adolescents, can be irritable mood).
  • (2) Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
  • (3) Significant weight loss when not dieting or weight gain or increased or decreased appetite nearly every day.
  • (4) Insomnia or hypersomnia nearly every day.
  • (5) Psychomotor agitation or retardation (Observable by others).
  • (6) Fatigue or loss of energy nearly every day.
  • (7) Feelings of worthlessness or excessive/inappropriate guilt.
  • (8) Diminished ability to think or concentrate—or indecisiveness.
  • (9) Thoughts of death or suicide.
    
    • most ppl with depression never become suicidal
• Above cannot be due to a general medical condition or the direct physiological effects of a substance.
• Must cause significant impairment or distress in social, occupation, or other areas of functioning
• Definitions:
  
  • Mood = what the patient states they are feeling in general
  • Affect = what we observe at the moment
  • Mood:Affect::Climate:Weather

Question 3

Acronym for NINE DSM criteria

Answer 3

• S(adness)
• I(nterest)
• G(uilt)
• E(nergy)
• C(oncentration)
• A(ppetite)
• P(sychomotor agitation or retardation)
• S(uicidal thoughts)

Question 4

Depression RF

Answer 4

• 2W:1M – ration narrows to 1:1 postmenopausal
• Age onset: peak 20-30 (40?) –decreasing w/ time –some studies suggest that 10% of adolescents may now have depressive symptoms
  
  • also: second smaller peak >65=elderly indivs with medical issues
• FHx – moderate genetic risk (heterogenous vs bipolar which is more linked)
  
  • Parents: 1 rent 10-15%, 2 rents 20-30%
  • MZ twins 50%, DZ twins 15-20%
    
    • (if take into consideration “Affective Disorder Spectrum” – Major Depression, ETOH**, Somatization, Antisocial personality then genetics more robust)
    • Having an FHx as a genetic base + psychological/environmental disruptions
• Single, divorced, widowed > married
  
  • **except in elderly males – high suicide group
• Income, profession, religion, geography have minimal impact
• Cultural: some trends – lower in AA men, Asians; higher in
• Hispanic women and American Indians
• **Childhood major negative events/trauma are a big risk factor – loss, neglect, abuse
• Onset of illness usually a series of negative life events, but can also be 1 catastrophic event – death, loss, medical illness, etc.
• 50% of people with only 1 episode
  
  • 2 episodes=70% of another
  • 3 episodes or more=95% chance of another
  • for most it’s a reoccurring chronic illness
• Triggers to relapse over time are less and less (stress vulnerability model)

Question 5

What are the five possible outcomes that may occur during the THREE phases of tx of Depression

Answer 5

• Three phases of tx:
  
  • Acute
  • Continuation
  • Maintenance
• Five Possible Outcomes (5 R’s)
  
  1. Response
  2. Remission
  3. Relapse
  4. Recovery
  5. Recurrence

Question 6

How does MD develop?

Answer 6

• 1. Genetic predisposition – smaller hippocampus, abnml serotonin transport protein
• 2. Poor psychological coping strategies or skills- secondary to trauma, loss, dysfunction, societal situations, etc (lack of resiliency)
• 3. Triggering events – Biological (could be medicines, substances, diseases), psychological, environmental
• 4. Change in brain processes and conceptualization that cause us to interpret external or internal stimuli in different ways - negative cognitions, pessimism, physical changes, withdrawal, retreat, lack of rewards, altered self awareness
• 5. These symptoms hinder our ability to reach our previous neurobiological homeostasis/return to nml via neurogenesis through enrichment:
     * Social connection
     * Exercise
     * New learning

Question 7

MD Pathophys

Answer 7

• neurodegenerative brain disorder, but we do not yet have a biological marker!
  
  • The closest marker we have is the theory of chronic low level increases in cortisol secondary to stress which causes a disruption in healthy neurogenesis and may add to neurodegeneration.
  • inbalance occurs
• Genetics and epigenetic are involved and it is a very heterogeneous phenomenon.
• the longer the depression in untx the greater the chronicity of illness and evidence of physiological brain changes

Question 8

What are the FOUR theories of MD…NIMS!

Answer 8

1. Monoamine theory
2. Inflammatory theory
3. Structural theory
4. Network hypothesis

Question 9

Monoamine hypotheses of Depression

Answer 9

• Traditionally the theory of low levels of 3 major neurochemicals involved in emotions…chemical inbalance
• The monoamines (norepinephrine, dopamine, and serotonin) have been widely implicated in depression.
  
  • The data are particularly voluminous for serotonin.
• All present antidepressant drugs affect changes in one or more of these systems
• this theory is an oversimplification of this heterogenous disorder
• Serotonin PW: mood, memory processing, sleep, cognition
  
  • Raphe nucleus
• DA PW: reward (motivation), pleasure, euphoria, motor fxn (fine tuning), compulsion, perseveration
  
  • frontal cortex, nucleus accumbens, VTA, striatum

Question 10

Inflammatory theory

Answer 10

• Low levels of chronic inflammation from a or b produce a TOXIC inflammattory milieu:
  
  • a. active illness (SLE or CAD)
  • –OR– b. persistent heightened level of corticosteroids from “stress”
• neurodegeneration increases and neurogenesis is inhibited.
• IL-6 which interferes w/ serotonin metabolism=main culprit.
• cytokines also create disruption of other end-organs and create higher risk for heart disease and Alzheimer’s.
• Hypersecretion of cortisol (Cushing’s dz) can cause acute and more severe depression.

Question 11

Structural theory

Answer 11

• Depression is caused by abnml changes in brain areas that can be identified premorbidly and are exacerbated in active illness.
• Atrophy of the prefrontal cortex, amygdala, and hippocampus and enlargement of the insula and anterior cingulated cortex done via MRI suggest this.
• Enhancing neurogenesis in atrophied areas (BDNF infusion into the rat hippocampus-quickly alleviated depression) or altering GABA (neuronal excitatory/inhibitory) in the insula are areas of exploration.

Question 12

Network hypothesis

Answer 12

• It is not specifically an altered brain area that causes depression but aberrancies in the tracts between areas.
• Diffusion tension imagery has revealed white matter abnormalities in the tracts between the medial prefrontal cortex, amygdala, and hippocampus.
  
  • also PET scans show major changes
• Glucose activity:
  
  • REDUCED in the hippocampus and dorsolateral prefrontal cortex
  • INCREASED in the amygdala, ventral striatum, and subgenual cingulated gyrus (an area that is stimulated by deep brain stim).
• Sertoninergic agents reactivate a juvenile-like plasticity in the neuronal tracts which if also stimulated by nml external phenomenon or psychotherapy = recovery.
• Depression will only improve if neurogenesis can occure in those tract to return the ineraction and perceptions to nml
• Depression is therefore a result of miscommunication and misinterpretation of various brain regions involved with interpreting emotions.
  
  • less neurons, less firing, and less connection

Question 13

What happens with untreated/undertreated depression?

Answer 13

• The longer the depression the greater the chronicity of illness
  
  • <6 months=60% chance of remission
  • >24 months=10 –15 % of remission
• Depression leads to future risk factors for:
  
  • 1) More Major Depression
  • 2) Other Co-Morbid Psychiatric illnesses
    
    • 60% of the time – EtOH and anxiety disorders are most common
  • 3) Cardiac events-CAD (cytokines and inflammation)
  • 4) Neurological events-strokes, seizures, Parksonism, dementias (Alzheimers)

Question 14

Other MD Etiologies

Answer 14

• Psychological: loss, abandonment, lack of nurturing, emptiness, anger turned inward, developmental arrest at a dependent stage with a disordered parent, low self esteem, failures, lack of self object stability and consistency
• Environmental: poverty, deaths, famine, wars, oppression, abuse, torture, drugs, learned helplessness, side effects of medications, chemical toxins, infectious diseases, medical conditions

Question 15

Biophysical formulation

Answer 15

• major depression is NOT a homogenous entity, may respond to numerous approaches
• in order to achieve the best outocme, need to understand the pt and all the variables effecting their presentation
• empahsis on tx is based on combo of your understanding and their conception of their illness
• biological, psychological, and/or environmental or social

Question 16

Condition which may CAUSE or MIMIC MD: Medications

Answer 16

• **Corticosteroids
• OCP
• ANTI-psychotics
• Immunosuppresives (AIDS)
• Interferons
• Reserpine
• Isotretinoin (acne tx-Accutane)
• Propranolol/Beta-Blockers

Question 17

Condition which may CAUSE or MIMIC MD: Infectious

Answer 17

• **Mononucleosis (EBV)
• Tertiary syphilis
• Toxoplasmosis
• Influenza
• Viral hepatitis
• HIV

Question 18

Condition which may CAUSE or MIMIC MD: Endocrine and Metabolic/Nutritional

Answer 18

• Endocrine (hyper or hypo):
  
  • -thyroidism
  • -adrenocortical function
    
    • Cushing’s and Addison’s
  • -parathyroidism
  • Diabetes
• Metabolic/Nutritional
  
  • uremia
  • pellegra
  • anemia

Question 19

Condition which may CAUSE or MIMIC MD: Neurologic

Answer 19

• Temporal lobe epilepsy
• Frontotemporal dementia
• Parkinson’s
• Huntington’s
• Subdural hematoma
• Head trauma
• Strokes
• MS

Question 20

Condition which may CAUSE or MIMIC MD: Neoplasms and Substances

Answer 20

• Neoplasms
  
  • Lymphomas
  • Abdominal malignancies (**pancreatic CA)
  • Brain tumors
• Substances
  
  • **ALCOHOL
  • **HEROIN
  • **MJ
  • prescribed psychotropics (may MIMIC depression):
    
    • Benzodiazepines
    • Opiates
    • ANTI-psychotics
    • …substance/medication induced MD

Question 21

Condition which may CAUSE or MIMIC MD

Answer 21

• Medications
• Infectious
• Endocrine
• Metabolic/Nutritional
• Neurologic
• Neoplasms
• Substances

Question 22

**A GOOD medical work-up**

Answer 22

• Medical work-up is always a good first step even if the symptoms are quite definitive for MD
  
  • Hx, PE, labs
• If there is an underlying medical condition it is usually quite obvious from other signs and symptoms
  
  • Depression and the medial illness may co-exist-cant just tx one alone
• BUT remember to come back to the depression
• Whenever you hear hoof beats it’s most likely to be HORSES and not a Zebra

Question 23

DSM 5 additional specifiers for MD diagnoses

Answer 23

• With anxious distress
• With mixed features (anxiety and sadness)
• With melancholic features
  
  • ​mood worse in am, terminal insomnia, excessive guilt, marked wt loss, total lack of pleasure (anhedonia)
• With atypical features
  
  • ​wt gain, over-sensitive mood reactivity, oversleeping, leaden paralysis- feel like can’t move arms/legs
• With mood congruent psychotic features- about 10% of episodes:
  
  • hallucinations and delusions that have depressive content “I feel like I am rotting, the devil is telling me bad things”
• With mood in-congruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern
  
  • 20% in Chicago’s latitude have an element of this
  • worse in winter: wt gain and sluggishness
  • spring: wt loss and hyper

Question 24

Other disorders and variants on MD

Answer 24

• important to identify other disorders as tx and prognosis may be different
• in some cases removing the offending agents or condition may make big difference in outcomes
  
  • Ex: substance-EtOH, dz state-hypOthyroidism
• diagnosis is ultimately never as important as treating the pt for their unique circumstances

Question 25

Persistent Depressive Disorder

Answer 25

• accounts for (2-3%)
• 2 years of duration
• less common and less responsive to therapy
• depressed mood for most of the day on more days than not- course tends to be non-remitting
• TWO of the following Six (lots of similarities to MDD)
  
  • poor appetite -or- overeating
  • low energy/fatigue
  • insomnia -or- hypersomnia
  • low self-esteem
  • poor concentration -or- difficult decision making
  • feelings of hopelessness
• Has never been free of symptoms for >2 mo, no signs of other significant mental disorder that would explain symptoms
• can have Major Depressive Disorder on top of this disorder

Question 26

Premenstrual Dysphoric Disorder

Answer 26

• In the majority of menstrual cycles at least 1 of the following need to be present during the final week before start of menstruation:
  
  • Marked affective lability
  • Marked irritability and anger or interpersonal conflicts
  • Marked depressed mood, feelings, or hopelessness
  • Marked anxiety, tension, and/ or feeling on edge
• At least 1 of the following also needs to be present
  
  • Decreased interest
  • Poor concentration
  • Lethargy
  • Change in appetite
  • Hypersomnia or insomnia
  • Sense of being out of control
  • Physical symptoms-breast tenderness, bloating, muscle pain
• Must have a total of 5 or more of the above
• Causes significant distress or impairment
• Not an exacerbation of another similar disorder- i.e. Major Depression

Question 27

MDD specifiers-Melancholia

Answer 27

• severe type of depression
• MD but also:
  
  • lack of reactivity of any pleasure situation
  • early AM mood wordse
  • early morning awakening
  • marked agitation or retardation
  • excessive guilt
• **use of ANTI-depressants essential
• DST usually positive-clear HPA axis dysfxn

Question 28

MDD specifier-ATYPICAL

Answer 28

• oversleeping
• overeating
• leaden paralysis
• interpersonal sensitivity
• mood reactivity-leading to roller-coaster type of mood

Question 29

MDD specifier-Psychotic (10%)

Answer 29

• MDD features but also presence of psychotic element
• NIHILSM-there is no future-the world will end
• DELUSIONS-“I am bad”, “I have caused others to be poisoned”, “I have cancer in my bowel-I am rotting from the inside”
• HALLUCINATIONS-usually negative; usually auditory
• use of ANTI-psychotic or ECT essential
• newer agents (SSRIs) may not work as well
• DO NOT confuse with schizophrenia
• be careful to rule out Bipolar

Question 30

MDD specifier-Seasonal

Answer 30

• 20% of ppl at this latitude have a seasonal mood fluctuation
• sxs similar to atypical depression but pts tend to become hyper in the summer
• worst pt of yr is Oct-Feb
• light therapy helps 50% (ANTI-depressants just as effective)

Question 31

MDD vs. Bereavement

Answer 31

• Bereavement not classified as a psychiatric disorder
• For majority of ppl its a nml life rxn – it is expected that someone will feel empty and grieve the loss.
• may have depressed mood, irritable, take some time off, not sleep well, etc. –
  
  • These symptoms come in waves but the indiv can still experience pleasure & joy.
• grieving & mourning is cultural based- expectations are that by 3 mo. many of the symptoms have resolved and the person moves on with their life.
• However, losses are a precipitant of MDD and one should not hesitate to tx as an MDD if symptoms are severe enough.
• Complicated (pathological) grief often involves many symptoms of PTSD on top of MDD and bereavement
  
  • these individuals get stuck on the loss and can’t progress
  • aggressive tx is indicated
• Stronger (abnml) signals that indicate a more severe condition:
  
  • guilt about life areas outside of the death
  • worthlessness psychomotor retardation
  • sustained suicidal ideation
  • prolonged fxnl impairment

Question 32

Stages of Bereavement

Answer 32

• numbeness-hours to days (seldome wks)
• depression-few wks to <1 yr
  
  • exacerbation son holidays, birthdays, other memorable events
    
    • insomnia, restlessness, irritability
• some days good, some bad
• recovery-usually <6 months
  
  • accept the loss and return to a pre-morbid level of functioning which might include previous or new roles
• most ppl start to feel better 6-10 wk after the death

Question 33

Do you treat uncomplicated bereavement?

Answer 33

• most ppl are resilient and do fine
• if concerned about MDD consider:
  
  • past hx
  • intensity and duration
  • pervasiveness of symptoms
• dont wait to normalize-longer the delay to tz the depression the worse the prognosis

Question 34

DSM-5 Adjustment Disorder

Answer 34

• some signs of depression that cause clinical concern (significant emotional or behavioral disturbances) in response to an acute stressor that occurred within 3 months of the onset of symptoms.
• does NOT meet criteria for other (more significant) disorders
• once the stressor is removed the symptoms should abate within 6 months
• can be depressed/anxious/behavioral in nature
• Usually brief therapy or social interventions are all that is needed

Question 35

Agitated/Anxious

Answer 35

• diagnosis often missed because of absence of sadness
• high risk of acting out and suicidal or homicidal potential
• seen often in ELDERLY and ADOLESCENCE
• watch for substance induced

Question 36

Special Population-ELDERLY Depression

Answer 36

• often masked depression
  
  • irritable, angry, agitated, (more common than sadness), dont care
  • often somatic in presentation to point of delusional dementia
  • cognitive changes often confused with dementia
• new incident rate increases past age 65
• suicide rate highest in elderly males
• highest growing population
• misconception that it is a part of aging or is not treatable
• less likely to seek out help
• response rate to intervention is just as good as adults

Question 37

Special Population-TEEN Depression

Answer 37

• high risk for impulsive actions
• often missed because of teenage angst misconception
• teens aware of what depression is-they dont trust adults
• high risk suicide group
• tx intervention available-more controversial and variable (potentially harmful)
• most severe mental illnesses start now
• irritability often prominent
• sadness present but hidden by irritability
• acting out behavior
• impulsivity/recklessness
• substance experimentation, change in friends, grades, behaviors
• withdrawn

Question 38

Bipolar I Disorder

Answer 38

• Individuals with Bipolar Disorder suffer a life-long illness that can devastate their lives & their families’ lives.
• classic forms of Bipolar I are relatively uncommon (0.6-0.8% of the general population)
  
  • if Bipolar variants are included the prevalence may be as high as 4-6% of the pop = significant national health issue.
• To be diagnosed you must have experienced at least one Manic episode, although most commonly there will be episodes of Major Depression and other mood states in the hx.
• Diagnosis is often ignored or missed because of lack of good hx taking
  
  • missing diagnosis leads to morbidity and delay of tx (avg=5 yrs)
  • tx are very helpful if applied

Question 39

What is a manic episode (DSM-5 Criteria)?

Answer 39

• A. A distinct period of abnormally and persistent elevated, expansive, or irritable mood present for most of the day for at least 1 week duration
• B. During the period of mood disturbance at least 3 of the following are
• present (FOUR if the mood is only irritable)
  
  • 1. Inflated self-esteem or grandiosity
  • 2. Decreased need for sleep
  • 3. More talkative than usual or pressure to keep talking
  • 4. Flight of Ideas or subjective experience of racing thoughts
  • 5. Distractibility
  • 6. Increase in goal-directive activities or psychomotor agitation
  • 7. Reckless behaviors in pleasurable areas (have consequences)– buying, speeding, sexual indiscretions, foolish business ventures
• C. Marked impairment in functioning in job, social activities, or relationships with others -or- there are psychotic features
• D. Symptoms not caused by a substance or medical condition

Question 40

Cycling between Mania and Depression

Answer 40

• Individuals usually cycle clearly f/m Mania to Depression over the course of wks to mos.
• Some pts will end up with a Mixed Bipolar state where they will have symptoms of BOTH mania and depression at the same time.
  
  • Often these individuals are very refractory to treatment.
• a cohort of bipolar individuals:
  
  • 40-45% of time spent in a depressive phase
  • 5-10% hypomanic or manic phase
  • 45% euthymic state
• 2/3 of pts never make it back to their pre-morbid level of functioning.
  
  • Even when indivs are euthymic there is evidence of brain fxn abnormalities.
  • math, reasoning, and informational processing abilities are impaired.
  • Verbal memory, attn, and executive functioning < baseline.
• Life span decreased by 8-10 yrs primarily due to metabolic syndrome co-morbidities and a 15-20x higher risk of suicide.
• Their insight into their illness is always suspect leading to issues of substance abuse, non-compliance with meds/tx, and potentially challenging life courses

Question 41

Epidemiology (Types) of Bipolar

Answer 41

• Bipolar I: 0.6-0.8% lifetime prevalence
• Bipolar II: 0.5-0.8% lifetime prevalence
• Bipolar spectrum: 4-6% lifetime prevalence (controversial)
• ……………………………………
• bipolar secondary to medical conditions (depression) or substances
• M=W
• **higher socioeconomic
• onset late adolescence, early adulthood
• strong genetics:
  
  • MZ twins: 65-80%
  • DZ twins: 10-15%
  • 1 rent: 10%
  • 2 rents: 50%
• much greater chance of becoming psychotic
• pathophys of depressed phase looks v. similar to MDD on neuroimaging

Question 42

What are the hints that a person might be bipolar when presenting with depression?

Answer 42

• Early age onset (before age 20)
• Psychotic Depression
• 1st episode of depression is postpartum especially if psychotic
• Rapid onset and offset of depressive symptoms
• Recurrent depression with > 5 episodes
  
  • non-responsive to usual intervention
• Bipolar FHx
• Seasonal Mood Disorder
• Atypical Depression
• Hypomania associated w/ ANTI-depressants
• Repeated loss of efficacy of ANTI-depressants over time
• Trait mood lability, hyperthymic temperament
• Depression w/ mixed mood states
  
  • many anxious or mixed hyper features-racing, irritable, hostile
• Bipolar symptoms (hypomania) can at time be imitated by substances (i.e. cocaine, caffeine, prednisone) or general medical conditions (i.e. hyperthyroidism, closed head injury)
  
  • good medical work-up is always a first step to diagnosis.

Question 43

Distinguishing Bipolar Disorders

Answer 43

• Bipolar I: a manic episode (depressive episode is not needed, although usually occurs)
• Bipolar II: hypomanic symptoms-at least 4 days in a row; at least 3 symptoms on mania, but not severe enough to cause impairment in functioning or hospitalization
  
  • no psychosis, must hv a hx of MDD
• Cyclothymic Disorder-2 yr duration
  
  • hypomaniac symptoms at times, but depression never to point of MD or BPI or BPII criteria
• (BP unspecified:)
  
  • potential pts who have some symptoms of mania and hypomania at times, but never enough to meet full criteria
  • anyone with significant mood fluctuations and irritabilit that are not induced by substances

Question 44

Bipolar Pathophys-General

Answer 44

• neurodegenerative process even when the mood is stable-evidence of cognitive changes in verbal memory, attn, and executive functioning
• in depression the neuroimaging looks similar to MD, but mania involves activation of many areas
• with age there is a cerebral atrophy and the brains look more similar to schizophrenia
• pts with bipolar have enlarged ventricles and increased white matter HYPERdensities

Question 45

Bipolar cellular pathophys

Answer 45

• use of anticonvulsant leads to theories on calcium or sodium gate abnormalities and stabilization of neuronal pathways
• some evidence of a specific gene defect associated with chrom 18q or 22q in linkage studies

Question 46

Course of Bipolar illness

Answer 46

• only 1/3 recover at 1 yr out
• most bipolar will gravitate to the depressive end of the spectrum
• only 50% were working at 3 yrs after the diagnosis
• impulsivity, addictions, distractibility lead to high co-morbidity and potential suicide
• **medications are essential along with support

Question 47

Suicide Epidemiology

Answer 47

• 10th leading cause of death in the US
• >43k ppl in 2013 in US
  
  • over 460k suicide attempts documented
• devastating action that effects both families of the victim (guilt, anger, loss, shame) and for HC providers
• major emphasis in clinical practice to prevent suicide-lots of screening for this and moos disorders

Question 48

Suicide Statistics/Epidemiology

Answer 48

• 12.9/100,000 per yr in the US
• Males – 19.9
• Females-5.5
• Caucasions-14.1
• Asians-6.2
• African-American-5.1
• Hispanics-5.9
• Adolescents- 10.5(but often give the least warning and most impulsive)
• Elderly- 17.6 (often sudden and told of a terminal disease)
• Middle age(45-64)- 18.6 – now the top risk group demographically
• Veterans - 34.9 – transition back makes them vulnerable
• >90% of the time there is the presence of a mental disorder
• bipolar (15x nml)>Schizophrenia>MDD
  
  • anxiety disorders, eating disorders, and substance use disorders also high on the list
• greatest risk of suicide is within inthe 1st yr of diagnosis

Question 49

Suicide Terminology

Answer 49

• suicide ideation
• suicide plan or intent
• suicide attempt
• completed suicide
• self harm-no desire to die, but instead an attempt to relieve pain or feel smthg real; overlap exists and needs to be explored
• 34% of those with suicide ideation think of plan
• 72% of those with a plan try to attempt
  
  • 51% firearms
  • 25% suffocation- usually hanging
  • 17% poisoning
• There are probably many more deaths due to suicide that are not documented- single passenger accidents, drowning, accidental OD, stigma preventing MD from listing true reason on death certificate because of the family desire or insurance reasons.
• 3F:1M attempted suicide
• 4M:1F successful suicide

Question 50

Suicide Ideation

Answer 50

• relatively common symptom (20% of adolescence will experience this at some pt; 10% of adults in any given year)
• usually present when someone is under a lot of stress and feels there is no way out.
• illustrated by statements such as “I wish I were dead”, “The world would be a better place without me”, “I wouldn’t mind if I developed cancer and died”.
• These thoughts are often fleeting but can begin to persist on a daily basis.

Question 51

Suicidal intent

Answer 51

• Thoughts have moved to thinking about how someone would commit suicide.
• Looking on websites, asked others, have begun to secure the means to commit suicide or thought out when/how

Question 52

Suicide attempt

Answer 52

• actual carrying out of an act that could end one’s life.
• The degree to which the attempt might be lethal depends a lot on the means and the place of action.
• ratio of attempts:completions=12:1.
• 460k attempts/yr in the US that are evaluated in the ED.
• Determining whether someone really wanted to die vs just relieve pain or get help is essential in psychiatric triage.

Question 53

Suicide RF

Answer 53

• **70% who die decide in last 10 minutes of life (impulsive decision)
• currently has a feasible plan in mind
• x hx of prior attempts
• x psychosis (especially command hallucinations)
• x high anxiety
• x impulsivity
• x presence of a mental disorder
• x substance abuse (especially if intoxicated)
• x hopelessness
• x lack of support
• x Fhx of completed suicide
• x significant negative life event in the last 3 mo
• x presence of guns in the house

Question 54

Suicide Pathophys

Answer 54

• Lower serotonin receptor numbers
• Lower serotonin levels in the CNS
  
  • Both of these are done post mortem=useless
  • some recent PET scans claim that they can identify which individuals are more likely to resort to suicide attempts
• Lack of effective coping strategies, presence of impulsivity also have strong correlation with attempts.
• Most ppl who call or show up in the ED for suicidal thoughts are wanting to live and are asking for help.

Question 55

Suicide Prevention

Answer 55

• 1. Ask- you will never put the thought of suicide into someone’s mind
• 2. Use behavioral incidents (as taught in interviewing skills) and appropriate gates– details are important in such a sensitive area
     * ​“What exactly were you thinking”
     * “Did you actually go out and buy a gun?”
     * “What did you plan to do with it?”
• 3. Do a risk analysis based on each patient’s unique situation
• 4. Remove the means; triage the pt and make sure theyre safe
• 5. Explore each person individually for risk analysis-combination of risks and protective measures
     * support, faith, or religion, on medication, having children