Topic 4: Suicidality In Patients With TBI Flashcards
What is the definition of a suicide attempt?
Any non-fatal self-inflicted injurious behavior performed with intent to die as a result of that behavior
What is the definition of a suicidal intent?
Clinical determination via past or present evidence, either implicit or explicit, that a person wishes to die, intends to kill himself or herself, and understands the probable consequences of his/her actions or potential actions
What is the definition of suicidal ideations?
Thoughts of engaging in suicidal behavior where the individual has thoughts of suicide
- without suicidal intent
- with an undetermined degree of suicidal intent
- with some suicidal intent
What is known about potential neurobiological mechanisms of suicide in non brain damaged suicidal individuals?
Research on non-brain damaged samples of suicidal individuals suggests serotonergic hypofunction particularly in basal orbifrontal region of the PFC as a significant marker of suicide risk.
What are behavioral consequences of hyposerotonergic function?
Reduction in inhibitory control, leading to increased aggression/impulsivity with elevation of risk for high lethality suicidal behavior
What happens to the frontal poles as a result of TBI?
Vulnerability to injury of serotonergic and noradrenergic projections from the brain stem to the frontal cortex.
How are serotonine levels influenced by TBI?
Increase of extra cellular serotonin levels immediately after TBI. Presence of increased concentrations of serotonin and noradrenaline in the synapses may lead to down-regulation of receptors and the onset of depressive symptoms
What is the prevalence of depression in TBI patients.
Diagnosis of major depression in 11 to 33% of patients with TBI. Depression appears to be related to the severity of TBI.
Increased rate of depression in TBI could be due to the effects of TBI on …
- brain functioning
- psychological impact on the accident
- psychosocial problems
What is the definition of suicide?
Any death caused by self-inflicted injurious behavior performed with any intent to die as a result of behavior
What suggests the observation that depression is significantly more frequent in TBI than in without brain injury but with similar baseline characteristics who underwent similar levels of stress
It suggests that neuro pathological processes associated with TBI act as predisposition in the development of depression
How might neurological basis explain depression subsequent to TBI ?
Deactivation of lateral and dorsal prefrontal cortices and increased activation of ventral limbic and paralimbic structures, including the amygdala.
Also, abnormalities in the serotonergic system.
In TBI patients, impulsivity and aggression may be due to …
Pre-injury traits or symptoms resulting from frontal lobe damage resulting in inhibition
There is a higher risk of suicide in patients with severe TBI than in patients with mild injuries, however, elevated risk of suicide also in patients with concussions. This is surprising, since patients with concussions do not suffer the same long term effects as patients recovering from more severe TBI. The assumption that can be made is …
Association not the consequence of injury per se
Association arises from pre-morbid or concomitant characteristics
After severe injury, suicidality more likely to be directly related to the injury and injury sequel are, including …
- the pattern of neuropathology
- reduced adaptive abilities
- psychological reactions to the injury
- the presence of psychiatric disorders
Not all studies found a relationship between severity of head injury and suicidality, the association between TBI severity and suicide may be …
Mediated by patients depression regarding their post-injury level of functioning
What are the 3 warning signs from the American association for suicidology indicating need for immediate intervention
- threatening to hurt or kill oneself
- looking for ways to kill oneself such as seeking access to pills, weapons, or other means
- talking or writing about death, dying or suicide
What are the warning signs from the American association for suicidology indicating need for mental health treatment but not necessarily immediately?
- hopelessness
- rage, anger of revenge-seeking behavior
- feeling trapped
- increasing alcohol or drug use
- withdrawing from friends and family
What are the disadvantages of the currently available measures for suicide risk assessment?
They are designed for the general population and therefore not specific for TBI or brain damaged population, it is unclear what adaptations are necessary for brain-injured individuals.
Treatment of comorbid psychiatric disorders in patients with TBI is imperative and may include:
- psychofarmacological interventions
- psychological interventions
- psychosocial interventions
- rehabilitation
- environmental measures
- emergency intervention
Which psychofarmacological interventions can be used in depression following TBI ?
- SSRI: SSRIs appears to be similarly beneficial for depression following TBI than for idiopathic depression. Ssri treatment may also improve various neuropsychiatric symptoms resulting from TBI including; irritability, aggression, anxiety and poor impulse control, which are all risk factors for suicide.
- tricyclic and tetracyclic antidepressants (TCA’s): are less effective for depression following TBI than for idiopathic depression. Anticholinergic effects may further impair cognition in patients with TBI. TCA’s may increase seizure rates among patients with TBI
What kind of psychological interventions can be used to treat depression following TBI ?
- CBT
- interpersonal therapy
- problem-solving therapy
Treatment approaches may require modification for patients with TBI because of cognitive impairments and personality changes.
Why is psychosocial intervention an important component in prevention of suicide in TBI patients ?
Because depressed patients with TBI tend to require more emotional support than they can achieve with their own resources
Why is neuro rehabilitation important in decreasing suicide risk?
Because persistence of disability appears strongly associate with depressive symptoms, suggesting that neuro rehabilitation is important in decreasing suicide risk as it improves functional ability
According to the article of Brown, what are the most common psychiatric problems in patients with brain injury?
- depression
- anxiety (GAD and panic)
- apathy
- psychosis
- conversion disorder
Depression is the most common problem in patients with brain disorders. What kind of brain disorders?
- TBI -> one month after TBI 26% has a depression, 42% at some point the following year
- Stroke -> 22%, mostly in people with right hemispheric lesions
- AD -> 30%
- PD -> 17%
- epilepsy
What measurements can be used to assess depression in brain injured patients?
- BDI
- Hospital Anxiety and Depression Scale (HADS) -> focuses on loss of interest and enjoyment. Have reasonable reliability in patients with TBI
- 10-item stroke aphasic depression questionnaire -> stroke
- visual analogue mood scale -> aphasic patients or those with cognitive impairment
- Cornell Scale for Depression in Dementia -> for AD patients, BDI performs poorly
What about anxiety disorders in patients with neurological conditions.
GAD is the most common anxiety disorder in patients with neurological conditions, frequently comorbid with depression
- TBI patients -> 9-25%
- Stroke -> 30%
Panic is complexly associated with epilepsy.
Social phobia or agoraphobia is significant following TBI (7%) and may also occur following stroke
Brain injury van be associated with acute stress disorder and later PTSD
How can anxiety be assessed in patients with neurological conditions?
- Hamilton Anxiety Rating Scale -> GAD in PD
Definition of apathy
Apathy refers to a constellation of behavioral, emotional and motivational features including reduced interest in participation in normal, purposeful behavior
What is the prevalence of apathy in patients with neurological conditions ?
- TBI (46%)
- hypoxic brain damage (79%)
- stroke (20-25%)
- all dementia subtypes
Definition of psychosis
Psychosis is a constellation of symptoms including delusional beliefs and ideas and hallucinatory experiences that can manifest with or without insight.
What is the prevalence of psychosis in patients with neurological disorders?
Psychosis is more common in global deterioration in patients with diffuse cerebrovascular disease, or in patients with degenerative white-matter disease.
- AD patients (34%)
- vascular dementia (54%)
- Lewy bodies dementia (visual hallucinations are a primary diagnostic criterion and therefore present at the earliest stage)
- epilepsy
What is the most useful measure that is sensitive to apathy?
Verbal fluency
Which tests are sensitive for depression in patients with neurological conditions?
Tests of long-term verbal learning and memory, complex psychomotor tests, measures of attention and times executive tests
An analysis on the FDA document (which issued an alert to health care professionals about an increased risk of suicide ideation and behavior in people treated with anti-epileptic drugs) demonstrates several methodological flaws, which include:
- the assessment of suicidality was based on spontaneous reports of patients and not gathered in a systematic prospective manner in every patient who was randomized to study drug or placebo
- statistical significance was only found in 2 of the 11 AEDS studied.
- most epilepsy trials included patients taking adjunctive therapies
- suicidal behavior was greater in certain geographic regions
What kind of bidirectional relation has been identified between suicidality and epilepsy? And which question is raised?
Patients with a history of suicidal behavior have a fivefold higher risk of developing epilepsy. The bidirectional relation raises the question of common pathogenic mechanisms operant in both conditions, such as serotonin dysfunction, a hyperactive HPA axis, as well as glutamate and gamma-aminobutyric acid disturbances
Suicidality in epilepsy is multifactorial. Major operant variables are:
- post ictal suicidal ideation
- a past and current history of psychiatric disorders
- a family history of mood disorder complicate with suicidal attempts
