Suicide/PMS/PMDD/postpartum

Question 1

Suicidal Ideation

Answer 1

Thoughts of hurting oneself (can range from a detailed plan to a fleeting consideration)
Does not necessarily include the final act of suicide
In 2022, estimated 13.2 million American adults seriously thought about suicide, 3.8 million planned a suicide attempt, and 1.6 million attempted suicide

Question 2

Suicide attempt vs Suicide

Answer 2

Nonfatal, self-directed, potentially injurious behavior with the intent to die
May not result in injury

Death caused by self-directed, injurious behavior with the intent to die
In 2022, there were 49,476 deaths by suicide
Preventable problem

Question 3

Suicide

Epidemiology

Answer 3

In the United States:
10th most common cause of death
2nd leading cause of death among individuals aged 10 -24 (after unintentional injuries)
One death every 11 minutes
Women attempt suicide 3–4x more often than men
Men are 4x more likely to complete suicide
Men aged 85 and older have the highest rateof suicide

Question 4

Suicide

RF

Answer 4

Prior attempt (greatest risk factor)
Access to a firearm
Men > 65 years old
Positivefamily history

Modifiable risk factors:
Mental illness
Chronic medical illness
Substance use disorder
Life stressors (unemployment, financial stressors, homelessness, divorce)

Ethnic groups: American Indian/Alaska Native population and Non-Hispanic whites

Special groups: Military personnel, Healthcare workers, First responders, Mining/construction workers, Lesbian, gay, or bisexual young people

Question 5

suicide

Protective Factors

Answer 5

Reflective and deep-thinking skills
Participation in programs to help with mental illness and substance use disorder
Access to psychiatric help
Support from friends and family
Cultural programs discouraging suicide
Religious beliefs (faith in God and religious activities)
Constructive activities (sports or artistic pursuits)

Question 6

Suicide Rates Across the United States

Answer 6

People living in rural areas have much higher rates of suicide than people living in urban areas

States with the highest suicide rates:
Wyoming
Montana
Alaska

Question 7

Suicide-related Characteristics

Answer 7

Characteristics of individuals who have suicidal ideation include:
Preoccupation with death
Sense of isolation and withdrawal
Few friends or family members
Emotional distance from others
Lack of humor (anhedonia)
Distracted – “in their own world”
Focus on the past
Dwell in past losses and defeats; anticipate no future
Voice that others and the world would be better off without them
Dominated by hopelessness and helplessness
They cannot help themselves
No one else can help them

Question 8

Methods of Suicide

Answer 8

Firearms
50%
Most common method of completed suicide
More commonly used by men

Hanging/suffocation – 28%
Poisoning – 11%

Prescription medications are used more than illicit substances
More commonly used by women

Self-inflicted trauma

Question 9

Suicide Risk Assessment

Answer 9

Process of making close observations, evaluations, and estimations of an individual’sprobability to commit suicide

Includes evaluating a patient’s suicidal ideation, plan, and intent

Several scales to evaluate the severity of suicidal ideation and assess the risk of suicide
Columbia-Suicide Severity Rating Scale (C-SSRS)
Beck Scale for Suicide Ideation (BSI)
Suicidal Ideation Attributes Scale (SIDAS)
Patient Health Questionnaire-9 (PHQ-9)

Question 10

suicide

Alert signs

Answer 10

Patient created a clear plan
Patient started writing a will, funeral plan, or suicide note
Unexpected visiting friends and family members
Recent visit to the primary care physician
Patient is in severe, acute, immediate stress
Recent suicide attempt was a highly lethal method (deep, cutting wounds)

Question 11

Suicide

Active Suicidal Ideation

Answer 11

Experiencing current, specific, suicidal thoughts
Conscious desire to inflict self-harming behaviors
Level of desire, above zero, for death to occur

Example of an Active SI assessment
“Over the past day or two, when you have thought about suicide, did you want to kill yourself? How often? Do you want to kill yourself now?”

Question 12

Passive Suicidal Ideation

Answer 12

General wish to die
No plan of inflicting lethal self-harm to kill oneself

Often received less attention from clinicians

Example of a Passive SI assessment
“In the past month, have you ever wished you were dead?”

Studies have shown that prediction of suicide attempt based on reported passive SI verses active SI shows no significant difference

Question 13

suicide

Focused Patient Inquiry

Answer 13

Suicidal ideation
Determine whether the person has any thought of hurting him or herself
“Have you ever had thoughts of harming or killing yourself?”
“Have you wished you were dead or wished you could go to sleep and not wake up?”
Asking the question is evidence of a clinician’s concern
A positive response requires further inquiry…frequency, duration, and controllability of suicidal thought; prior suicide attempts

Suicide plan
Ask about any plans for suicidal acts (current and past)
“Have you been thinking about how you might do this?”
“Have you started to work out the details of how to kill yourself?
More specific plans indicate greater danger
A positive response requires further inquiry…specific plan details and required methods in the patient’s possession → Psychiatric Emergency

Suicidal intent
Determining the extent of the patient’s intent to die
Any level of intent above zero is considered an affirmation of suicidal intent
Determine what the patient believes his or her suicide would achieve
A way for family and friends to realize their emotional distress
Relief from their emotional pain
Heavenly reunion with a departed loved one

History of suicide attempts
Prior attempts → increased risk of future attempts

Present and past risk factors for suicide

Homicide
Questions of suicide must be coupled with an inquiry into the patient’s potential for homicide

Question 14

Answer 14

This algorithm provides an overview to help determine the level of care for adults who initially present to their outpatient clinician with suicidal ideation. However, there are no evidence-based criteria for determining level of care. Medically stable patients who present with suicidal behavior should receive an immediate psychiatric assessment in an emergency department or crisis clinic.

Question 15

Management – Suicidal Ideation

No-harm contracts

Answer 15

Also known as a “Safety Contract” or “No Suicide Contract”
Written or verbal contract in which the patient promises not to hurt or kill themselves for a period of time
An agreement to take certain actions such as calling a crisis line or contacting the therapist prior to hurting oneself
Has been in use since 1973
Repeated studies, have shown there is no evidence to indicate that no-harm contracts actually help prevent suicide

Question 16

Management – Suicidal Ideation

Safety Plans

Answer 16

Evidence-based and effective technique to reduce suicide risk
Patient/family work with the clinician to identify effective coping techniques to use during crisis events…What will they do when they have suicidal thoughts?

Includes:
Patient’s own warning signs or triggers for suicidal thoughts
Coping strategies
Social contacts/supports
Emergency contacts
Reducing access to lethal means
Back-up plan: calling the Suicide & Crisis Lifeline 988

Question 17

Suicide

Tx of suicidal pt

Answer 17

Treatment of a suicidal patient involves a 2-phase process

Phase 1
The suicidal patient must not be left alone
Remove anything that the patient may use to hurt or kill him or herself
Treated in a secure, safe place
Hospitalization – offers one of the best settings for safety and treatment

Phase 2
Diagnosis and comprehensive treatment of the underlying mental disorder
Continual close monitoring by an interprofessional team (PCP, mental health nurse, psychiatrist, social worker)

Question 18

Suicide

Nonpharmacological Tx

Cognitive behavioral vs Dialectical behavior therapy

Answer 18

Cognitive behavioral therapy:
Problem-oriented strategy that focuses on current problems and finding solutions
Strongly recommended for patients with a recent history of self-directed violence to reduce future incidents
Patient satisfaction with CBT focused on suicide prevention is generally high

Dialectical behavior therapy:
Incorporates CBT elements, skills training, and mindfulness techniques
Aims to develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance
Suggested for individuals with borderline personality disorder (BPD) who have recently engaged in self-directed violence

Question 19

Suicide

Pharmacologic Tx

Answer 19

Antidepressants
Selective serotonin reuptake inhibitors (SSRIs)
Avoid olderantidepressantgroups such as tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) given the potential for lethal overdose
Antidepressants have an FDA black box warning for increased suicidal risks in children, adolescents, and young adults

Ketamine
Anesthetic drug that is a racemic mixture of two enantiomers: S-ketamine (esketamine) and R-ketamine
Single infusion of ketamine can mitigate suicidal ideation within one hour, with benefits persisting for up to one week

Esketamine (Spravato)
More potent version of ketamine
FDA approved for treating depressive symptoms in adults with unipolar major depression that includes acute suicidal ideation or behavior
Given in conjunction with an oral antidepressant

Lithium
Suggested for patients with mood disorders, especially bipolar disorder, to decrease the risk of death by suicide

Clozapine
Atypical antipsychotic suggested for patients with schizophrenia or schizoaffective disorder who have suicidal ideation or a history of suicide attempts

Electroconvulsive therapy (ECT)
Involves a brief electrical stimulation of the brain while the patient is under anesthesia to produce a brief seizure
Suggested for severely depressed suicidal patients

Question 20

Suicide

DSM V

Answer 20

In the fifth edition of theDiagnostic and statistical manual of mental disorders(DSM-5)and earlier versions of the manual, suicide is conceptualized primarily as a specific symptom of:
Major Depressive Disorder (MDD) and Borderline Personality Disorder (BPD) OR
Possible negative consequence of other psychiatric diagnoses

Because of suicide’s importance as a psychiatric complication, (DSM-5), took a major step in suggesting Suicidal Behavior Disorder (SBD) as a “condition for further study”…SBD might be included in a later edition, pending further research

Question 21

Pathophysiology PMS & PMDD

Answer 21

Premenstrual mood disorders include:
Premenstrual syndrome (PMS)
Premenstrual Dysphoric Disorder (PMDD)
The exact mechanism of these disorders is unknown

Several factors may contribute to the condition:
Cyclic changes in hormones
Signs and symptoms of premenstrual syndrome change with hormonal fluctuations (progesterone) and disappear with pregnancy and menopause

Chemical changes in the brain
Fluctuations of serotonin, a neurotransmitter that is thought to play a crucial role in mood states, could trigger premenstrual mood symptoms

Insufficient amounts of serotonin may contribute to premenstrual depression, fatigue, food cravings and sleep problems

Question 22

Premenstrual Syndrome (PMS)

Answer 22

Recurrent luteal-phase disorder characterized by a variable cluster of psychological and physical symptoms
Occurs ~7-10 days before the onset of menstruation
Epidemiology
~80-90% of ♀ of reproductive age
Peak age range 25-40 years

Question 23

PMS

S/Sx

Answer 23

Type and intensity of symptoms vary from patient to patient and from cycle to cycle

Symptom duration
Few days – 2 weeks
End with menses or shortly after

Alcohol consumption is associated with a moderate increase in the risk of development

Common symptoms:
Irritability/agitation
Anxiety/depression
Sleep disturbances
Difficulty concentrating
Fatigue
Bloating/weight gain
Breast fullness/pain
Headache
Food cravings/changes in appetite

Question 24

PMS

Dx

Answer 24

Diagnosis is based on three elements:
Symptoms are consistent with PMS
Symptoms occur consistently only during the luteal phase of the menstrual cycle
Negative impact on the patient’s function and lifestyle

No physical examination findings or laboratory testing aids in diagnosis

Labs are used to rule out other etiologies:
Thyroid disorders (TSH)
Cushing syndrome (cortisol)
Hyperprolactinemia (FSH, prolactin, estradiol)

Question 25

Premenstrual Dysphoric Disorder (PMDD)

Answer 25

A severe form of premenstrual syndrome (PMS) characterized by mood, behavioral, and physical symptoms causing significant distress and/or functional impairment

Epidemiology
5-8% of ♀ of reproductive age
Often underdiagnosed

Question 26

Premenstrual Dysphoric Disorder (PMDD)

Risk factors

Answer 26

History of traumatic events
Comorbidanxietydisorders
Smoking
Obesity- linear relationship of BMI and risk of incident PMS

Question 27

Premenstrual Dysphoric Disorder (PMDD)

S/Sx

Answer 27

Symptoms
Occur regularly for most cycles over the past year
Present during the second half of the menstrual cycle (luteal phase)
End with menses or shortly after
Severe enough to interfere with routine daily activities or overall functioning

Common symptoms:
Markedly depressed mood
Decreased interest in daily activities
Anxiety
Irritability/Anger
Difficulty concentrating
Sleep disturbances
Food cravings
Bloating/weight gain
Breast fullness/pain
Suicidal thoughts may be present

Question 28

PMDD

DSM Criteria

Answer 28

Diagnosis
Based on clinical diagnostic criteria:
≥5 of the 11 symptoms listed in the tables must be present
≥ 1 of the affective symptoms
≥ 1 of the behavioral or cognitive symptoms

Premenstrual Symptom Screening Tool (PSST)
19 item questionnaire that allows patients to rate the severity of their symptoms

Question 29

PMS & PMDD

Nonpharmacological Treatment

Answer 29

Adequate rest/sleep
Regular exercise → ↑ beta-endorphin levels = decreases pain perception and elevates mood
Activities that are relaxing to decrease stress

Dietary changes:
↑ protein consumption
↑ dietary calcium and magnesium
↑ consumption of complex carbohydrates → increased levels of tryptophan, a serotonin precursor
↓ sugar, salt, alcohol, and caffeine consumption
Eat smaller meals more frequently

Question 30

PMS & PMDD

Pharmacologic Treatment

Answer 30

NSAIDS
For relief of aches, pains, and dysmenorrhea

Serotonin reuptake inhibitors (SRIs)
Drugs of choice for anxiety, irritability and other emotional symptoms
No SRI appears to be more effective than another
fluoxetine, sertraline, paroxetine, and citalopram
Continuous dosing vs. intermittent dosing

Hormone manipulation (prevention of ovulation)
Combination contraceptives – pill, patch, vaginal ring
Progesterone 200-400 mg by vaginal suppository once daily
Oral progesterone 100 mg at bedtime for 10-12 days before menses
Long-acting progestin (medroxyprogesterone) 200 mg IM every 2-3 months
Gonadotropin-releasing hormone (GnRH) agonist for severe or refractory symptoms
Leuprolide + low-dose estrogen/progestin

Question 31

Question 32

Postpartum Period

Answer 32

The time after giving birth when a woman’s body returns to its pre-pregnant state
Usually lasts six to eight weeks, but can last longer
Common time for the emergence or exacerbation of psychiatric disorders

Three most common disorders:
Postpartum blues
Postpartum depression
Postpartum psychosis

Postpartum psychiatric disorders are not distinct entities in the DSM-V
Use a “with peripartum onset” modifier if the onset of symptoms occur during pregnancy or within 4 weeks postpartum

Question 33

postpartum

patho

Answer 33

Believed to be multifactorial

Hormonal factors
Drastic changes in hormonal levels (↓ estrogen, progesterone, and cortisol) within 48 hours after delivery
Estrogen levels can have an effect on serotonin and dopamine levels → affective and psychotic symptoms
Estrogen promotes synthesis, prevents degradation, and inhibits reuptake of serotonin
Estrogen decreases the release of GABA, the main inhibitory neurotransmitter in the brain, promoting increased dopamine transmission

Psychosocial factors
Women who report inadequate social supports, marital discord or dissatisfaction, or recent negative life events are more likely to experience postpartum depression

Biologic vulnerability
Women with a prior history of depression or family depression of a mood disorder are at increased risk
Women with a prior history of postpartum depression or psychosis having 90% risk of recurrence

Question 34

postpartum

RF

Answer 34

Young age (< 25 years)
History of psychotic illnesses (anxiety and depression)
Previous episode of postpartum psychiatric disorder (up to a 90% recurrence rate)
Family history of psychiatric illnesses
Stressful life events (during pregnancy or near delivery)
Unintended pregnancy
Poor social support
Financial difficulties
History of intimate partner violence or sexual abuse
Cesarean sections, traumatic birth experience, or other perinatal complication (gestational diabetes)
Difficulties with breastfeeding
Women with infants having health problems and/or infants admitted to the NICU
Childcare stress (inconsolable crying infant)

Question 35

postpartum

Epidemiology

Answer 35

Prevalence
Postpartum blues: very common, up to 80% of pregnancies
Postpartum depression: often underdiagnosed, approximately 10%–25% of pregnancies
Postpartum psychosis: rare, < 1–2 per 1000 births
Age: more common in women < 25 years of age

Question 36

postpartum

Impact

Answer 36

Maternalsuicide
One of the leading causes of maternalmortality
Rates of maternalmortality due tosuicide are similar tomortality from infection
Infanticide
Killing of a child within a year of its birth
~300 in the US each year
Negative effects on children
Untreated postpartum mood disorders in mothers are associated with long-term effects on cognitive, behavioral, and emotional development in childhood through adolescence

Question 37

postpartum

screening tools

Answer 37

Several validates screening questionnaires for postpartum psychiatric disorders

Edinburgh Postnatal Depression Scale (EPDS)
Used to assess patients for postpartum depression
Screeningtool recommended by the American College of Obstetricians and Gynecologists (ACOG)
Self-reported 10-item questionnaire

Patients are asked how often they have felt certain ways about specific things in the past7 days

Each item on the questionnaire has 4 possible answer choices, each of which is assigned a score from 0 to 3

The scores from each item are added together to determine the final score (maximum score, 30)

A score of ≥ 10 or a score other than 0 on item 10 (thoughts of harming myself) always requires more thorough evaluation

Patient Health Questionnaire-9 (PHQ-9)
Self-reported 9-item questionnaire
Patients are asked how often have you been bothered by specific problems in the past2 weeks
Each item on the questionnaire has 4 possible answer choices, each of which is assigned a score from 0 (not at all) to 3 (nearly every day)
The scores from each item are added together to determine the final score (maximum score, 27)

Question 38

Postpartum Blues

Sx and Tx

Answer 38

Most common postpartum psychiatric disorder

Symptoms may include:
Feelings of guilt and/or overwhelmed (especially about being a mother)
Crying
Rapid change in mood and irritability
Anxiety
Poor concentration
Eating too much or too little
Insomnia or frequent awakenings at night

Symptoms are mild and do not interfere with activities of daily living

Onset of symptoms: 2-3 days of delivery; peaks over the next few days (day 4-7)

Duration of symptoms: lasting up to and no more than 2 weeks

Management:
Resolves spontaneously
Provide reassurance and encourage self-care

Question 39

Postpartum Depression

Sx

Answer 39

Symptoms may include:
Disinterest in self, in child, and in normal activities
Feeling isolated, unwanted, or worthless
Feeling a sense of shame or guilt about parenting skills
↑ Anger outbursts
Appetite/weight changes (↑/↓)
Sleep disturbances (↑/↓)
Impaired concentration
Suicidal ideationor frequent thoughts of death

Symptoms aremore severeandpatientshave an inability to cope

↑ risk of developing major depressive disorder later in life

Question 40

Postpartum Depression

onset/duration of Sx an lab studies

Answer 40

Onset of symptoms: within 4 weeks of delivery and up to 1 year after delivery

Duration of symptoms:>2 weeks

Laboratory studies:
Ifpatientshave a history of medical conditions known to cause depressive symptoms, tests should be ordered to assess status

Question 41

Postpartum Depression

Management

Answer 41

Management team should include both the patient’s obstetrician and a psychiatrist

First-line therapies
Mild depression:psychotherapyalone
Cognitive behavioral therapy or Family-centered therapy

Moderate-to-severe depression:psychotherapy+ anantidepressant
Antidepressants
Most are relatively safe; amount of drug in breast milk is typically low
Monotherapywith selective serotonin reuptake inhibitors (SSRIs)

Best options:paroxetine (Paxil) 10–50 mg/day,sertraline (Zoloft) 50–200 mg/day (unlikely to have ↑ drug levels in breastfed infants)
Other relatively safe options:
Tricyclic antidepressants(TCAs):nortriptyline25–150 mg/day
Serotonin–norepinephrinereuptake inhibitors (SNRIs)

Question 42

Postpartum Psychosis

Sx

Answer 42

Symptoms are similar to non-obstetric psychosis
Symptoms may include:
Hallucinations involving any one of the 5 senses: tactile, visual, auditory, gustatory, olfactory
Paranoia, confusion, or delusions
Disorganized speech and behaviors
Obsession with caring for the infant
Severeinsomniaor frequent awakenings at night
Irritability,anxiety,hyperactivity, and psychomotoragitation
Homicidal or violent thoughts related to the infant (infanticide)
Suicidal ideationor attempts

Symptoms are often severe, interfere with daily activities, and require hospitalization

Question 43

Postpartum Psychosis

onset of Sx and lab studies

Answer 43

Onset of symptoms: few days to 1 year after delivery (most commonly 2 weeks after delivery)

Laboratory studies:
Obtained to rule out other potential causes of psychosis (infections, endocrine dysfunction, illicit drug use, metabolic encephalopathy)

Question 44

Postpartum Psychosis

Management

Answer 44

Postpartum psychosis is considered a Psychiatric Emergency
Usually, a brief and limited illness that responds rapidly to treatment

Hospitalization
Especially if there is homicidal orsuicidal ideation
The patient should be under the care of a psychiatrist (not an obstetrician)
Ensure safety of the patient and infant:
Mother should remain hospitalized until stable
Mother should not be left alone with the infant
Supervised visits with the infant may be possible

Antipsychotics
Typically first-line therapy
Best option: older 2nd-generation antipsychotics
May be combined with antidepressants or mood stabilizers depending on the symptoms
Mood stabilizers (used inbipolardisorder):
Lithium(ifnotbreastfeeding)
Valproate(ifbreastfeeding)
Antidepressants
Major depression with psychotic features
Schizoaffective disorderwith affective symptoms
Considerbenzodiazepinesforinsomnia