Suicide/PMS/PMDD/postpartum Flashcards
Suicidal Ideation
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
Suicide attempt vs Suicide
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
Suicide
Epidemiology
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
Suicide
RF
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
suicide
Protective Factors
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)
Suicide Rates Across the United States
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
Suicide-related Characteristics
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
Methods of Suicide
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
Suicide Risk Assessment
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)
suicide
Alert signs
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)
Suicide
Active Suicidal Ideation
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?”
Passive Suicidal Ideation
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
suicide
Focused Patient Inquiry
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
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.
Management – Suicidal Ideation
No-harm contracts
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
Management – Suicidal Ideation
Safety Plans
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
Suicide
Tx of suicidal pt
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)
Suicide
Nonpharmacological Tx
Cognitive behavioral vs Dialectical behavior therapy
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
Suicide
Pharmacologic Tx
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
Suicide
DSM V
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
Pathophysiology PMS & PMDD
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
Premenstrual Syndrome (PMS)
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
PMS
S/Sx
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
PMS
Dx
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)
Premenstrual Dysphoric Disorder (PMDD)
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
Premenstrual Dysphoric Disorder (PMDD)
Risk factors
History of traumatic events
Comorbidanxietydisorders
Smoking
Obesity- linear relationship of BMI and risk of incident PMS
Premenstrual Dysphoric Disorder (PMDD)
S/Sx
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
PMDD
DSM Criteria
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
PMS & PMDD
Nonpharmacological Treatment
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
PMS & PMDD
Pharmacologic Treatment
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
Postpartum Period
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
postpartum
patho
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
postpartum
RF
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)
postpartum
Epidemiology
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
postpartum
Impact
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
postpartum
screening tools
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)
Postpartum Blues
Sx and Tx
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
Postpartum Depression
Sx
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
Postpartum Depression
onset/duration of Sx an lab studies
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
Postpartum Depression
Management
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)
Postpartum Psychosis
Sx
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
Postpartum Psychosis
onset of Sx and lab studies
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)
Postpartum Psychosis
Management
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
