Task 4: depression and suicide Flashcards
1
Q
predisposing factor for depression - genetics
A
- greater genetic influence for adolescent than childhood depression
- children of depressed parents at greater risk
- heritability: 15-80% for depressive symptoms
2
Q
family environment and depression
A
- low levels of parental warmth and high levels of hostility and conflict: associated with increased depressive symptoms
- parental mental health problems impact on parenting -> more difficult to meet child’s need and provide confiding relationship
3
Q
Temperament/personality as risk factor for depression
A
- children who adapt slow to new experiences, socially reticent, easily upset
- raised levels of anxiety, high self-criticism
- negative attributional style: tendency to self-blame
4
Q
early / chronic adversity and depression
A
- poverty / social disadvantage
- physical, sexual, emotional abuse
5
Q
Neurobiological factors and depression
A
- underactivity of cerebral amine systems
- abnormalities in cortisol secretion
- functional and anatomical brain differences in depressed young people
6
Q
precipitating factors depression
A
stressful live events:
- losses (parental separation)
- disappointments and failures (peer problems, bullying, academic difficulties)
7
Q
maintaining factors depression
A
- persistent depressive symptoms
- psychosocial scars: individuals may experience residual effects from depressive episode
8
Q
Treatment brief/minor depression
A
exploration of difficulties, activity scheduling and follow up
9
Q
treatment mild to moderate depression
A
1) CBT: psychoeducation, self-monitoring, competence in emotion recognition, challenges to cognitive distortions, activity scheduling
2) interpersonal psychotherapy for adolescents (IPT-A): addresses problem relationship areas (conflict, transitions, losses)
10
Q
More persistent moderate / severe depression
A
- therapy and anti depressants
- SSRIs
- slight increased risk of suicide
11
Q
epidemiology depression
A
- increases from childhood to adolescence
- 1 to 8% in adolescents
- in childhood equally common in boys and girls
- in adolescents ratio is 2:1 (2 girls)
12
Q
epidemiology suicidal behavior
A
- increases in mid-adolescence
- deliberate self-harm (DSH) common in adolescents (7-9%)
- 3x more common in females
13
Q
individual predisposing factors for suicidal behavior
A
- Psychiatric disorders, especially major depressive disorders, but also anxiety, substance misuse, conduct disorder
- hopelessness, despair, low self-esteem, self-blame
- Experience of abuse
- gay/bisexual
- impulsivity, risk-taking
- presence of psychiatric comorbidities: MDD, anxiety, substance misuse, conduct disorder
14
Q
DSH as impulsive response
A
- DSH may be an impulsive response to problems in attempt to find an immediate relief for distress/escape from situation instead of using problem solving strategy/assessing support
- Mostly an impulsive act with many individuals thinking about it for just minutes before acting
15
Q
family as predisposing factor for suicidal behavior
A
- Communication difficulties (also risk factor for repeated episodes)
- Parental divorce
- Family history of mental health problems and suicide/suicide attempts
16
Q
wider environment as predisposing factor for suicidal behavior
A
- School problems, difficulties with relationships with peers, boy/girlfriends, teachers
- social isolation
- Exposure to suicide (attempts) in family or friends
- suicide contagion (suicide within community influences others): media coverage, social media
17
Q
How to assess risk associated with self harm?
A
-Physical severity is not a good indicator of intent, as young people are often unaware of the objective degree of lethality of specific substances and quantities -> belief about potential lethality is important
18
Q
Factors associated with high suicidal intent:
A
- Carried out in isolation
- Timed so that intervention is unlikely
- Precautions taken to avoid discovery
- Preparations made in anticipation of death
- Other people informed of individual’s intention beforehand
- Advance planning of attempt
- Suicide note
- Failure to alert others following the attempt
19
Q
course of self-harm
A
- 10% of adolescents who self-harm do so again in the following year, especially likely in first 2-3 months
- Previous self-harm, depression, substance misuse, extensive family psychopathology, poor social adjustment, social isolation, poor school record -> increase likelihood of repetition
- 0.5% kill themselves -> risk factors: male, older age, high suicidal intent, mood disorders, substance abuse, violent method of self-harm, previous psychiatric admission
20
Q
treatment self-harm
A
- Young person should be kept safe
- Family-based problem-solving therapy: improve communication, reduce conflict (effective is not depressed)
- Dialectic behavior therapy: aims to improve self-acceptance, increase assertiveness, reduce interpersonal conflicts, avoid situations that trigger distress
- CBT
21
Q
prevention DSH and suicide
A
- Identification of those at highest risk by prompt recognition of depression / other problems associated with suicidal behavior
- Reducing access to methods of self-harm
- Establishing crisis intervention
22
Q
protective factors suicide
A
- Evaluation of protective factors is essential to an objective assessment for suicide risk
- Family cohesion
- religious beliefs
- Coping and survival skills
- Significant relationships
- Cherished animal/pet
- Compelling interest/hobby
- Supportive school environment/caring teachers
- Core values and beliefs
- Will to live
- In general factors related to sense of commitment/having a reason for living
23
Q
screening for depression / suicide
A
-PCPs should ask questions about depression, suicidal thoughts, and other risk factors associated with suicide during routine checks and other visits
24
Q
Initial risk assessment
A
- Explore psychiatric history, previous attempts, familial suicide, suicidal ideations and plans
- practitioner can use individualized symptoms in previous attempts to detect current risk in individuals presenting without typical suicidal symptoms
- frequency, intensity and duration of ideation?
- specific plans? steps taken?
- assessment of lethality of plan
-Not uncommon to have low intent to die / ambivalence toward death but still exhibit suicidal ideations / behaviors
- determine stress level, substance (ab)use
- understand stressors and circumstances
25
No-suicide/contract for safety
- > goal: improve compliance, encourage utilization of coping strategies, reducing likelihood of future suicidal behavior
- > important part: patient will contact PCP when suicidal ideations occur
- no studies found effectiveness
- still, it indicates to the patient that the practitioner cares
- problem if the contract is used as a brief screening tool
26
Low suicide risk
- occasionally feel down, no history of depression or serious emotional distress, supportive family and friends, willing to get help to resolve problems, no longer contemplate suicide after the interview
- if no self-injury/prior attempts and safe and supportive environment: outpatient therapy
27
moderate suicide risk
- depression/poor impulse control, dysfunctional family atmosphere
- became suicidal after fighting with parents / friends
- agree to see a therapist and contact the practitioner if thoughts return
- if supportive family, then outpatient therapy
- if psychiatric illness and unsupportive family: psychiatric hospitalization
28
high suicide risk
- concrete plan that includes method, time and place
| - hospitalization is needed
29
preventive strategies
- promoting mental health
- restricting means and access
- recognizing psychiatric illness
- ensuring a clinical setting
30
Military
- prevalence of childhood trauma: 43% among those in US military who died by suicide
- US marine: 50% reported at least one significant life stressors prior to recruit training
- individuals with childhood abuse may be more likely to enter military
31
diathesis (predisposition) - stress model
early childhood adversity leads to genetic polymorphism -> modifies expression of neurological systems -> impact biological and psychological trait development -> increasing diathesis for propensity to react to stressors for suicidal behavior
32
HPA axis
- Association of blunted cortisol and HPA axis responsiveness in suicidal behavior
- Early life adversity can lead to epigenetic regulation of genes involved in HPA
33
seretonin
- Childhood trauma: low expressing 5HTTLPR -> increased risk for suicide in bipolar
- low serotonergic functioning = increased impulsivity and self-destructive and aggressive behavior in adults
- in general, the findings are inconsistent: more studies needed
34
oxytocin
- support affiliation and attachment through its role in stress reduction
- low oxytocin (adverse experiences, e.g. due to parental neglect) -> less emotion regulation (if then a certain stressor happens, maybe suicide happens)
- low CSF oxytocin levels have been found in suicide attempters with high suicide intent
35
Gender and suicide
females: more likely to experience suicidal ideation and attempts
males:
- complete suicide more frequently
- greater possibility to have compounding risk factors (conduct and alcohol abuse disorder, choice of more lethal methods, higher levels of aggression, violence)
36
higher rates among teenage females in china and India
> Intergenerational and gender conflicts more distilled and pronounced in traditional agricultural societies emerging into egalitarian industrial societies
> Widespread availability of toxic pesticides in rural areas
> Feeling of suppression and helplessness, low social status within patriarchal and subjugating system
> Sense of hopelessness compounded by heightened awareness of injustice
37
native and indigenous ethnic minorities
- High prevalence of mental health disorders, substance and alcohol abuse, social deprivation and stressful life events
- loss of family links, community support
- socioeconomic difficulties, marginalization, racism. inequality in education, cultural clashes with parents, lack of belonging
- possible involvement of trans-generational trauma, adolescencent perceived historical loss, acculturation, loss of land and social exclusion
38
alcohol and drug use
- Substance abuse is a risk
- Alcohol use especially the initiation of use in the pre-teen, is an important risk factor
- Use of alcohol while down/depressed -> risk
