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The Suicidal Patient. Peter M. Hartmann, M.D. Clin. Prof. of Family & Community Medicine June 2011. Objectives:. Evaluate patients with suicidal ideation in the office setting. Determine appropriate management strategies for suicidal patients. List four risk factors for completed suicide. - PowerPoint PPT Presentation
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Peter M. Hartmann, M.D.Clin. Prof. of Family & Community Medicine
June 2011
Objectives:1. Evaluate patients with suicidal
ideation in the office setting.2. Determine appropriate
management strategies for suicidal patients.
3. List four risk factors for completed suicide.
Case 1:79-year-old MWM retired postal
worker is depressed. His wife of 57 years died 3 months ago. Brought in by oldest daughter who is worried that he “won’t eat since Mom died.” Has lost 22 pounds.
What added information do you want?
More History:Meets criteria for MDDHas suicidal ideation. Wants to “join wife.”No prior attempts.Thought about shooting himself with his
handgun.Got gun out of safe and loaded it.Lives alone.Not particularly religious.Uncle died from suicide.
Risk Factors:Elderly maleCaucasianRecently bereavedMajor depressive disorderHas ideation, plan and actionLives aloneNo religious injunctionPositive family history
Management:Immediate hospitalization (commit prn)Know commitment laws in your State.Remove gun from house.? Do PE and labs for clearance for
psychiatric admission.If too physically ill, admit to general
hospital with sitter and suicide precautions.
DOCUMENT!!
Get the Guns Out of House!
EpidemiologySuicide is 11th leading cause of death in U.S.
“Accidental” deaths and noncompliance with medical treatment may be “hidden” suicide.
18% of depressed patients in primary care practices have suicidal ideation.
Seasonal variation (May for men; May and Oct-Nov for women)
Men commit suicide > women (but women have more attempts.
Suicide Rate In US by Race and Sex
Suicide Intent in High School Students by Gender in US
More Epidemiology:Elderly men have highest rateOne of top 3 causes of death in adolescentsIncreased incidence in: 1.early-onset mood disorders2.traumatic brain injury,3.homosexual and bisexual adolescents4.borderline & antisocial personality
disorders5.eating disorder patients
Epidemiology Continued:6. Alcohol/substance abusers7. Sex abuse history8. Caucasian > African-American9. Native American10. Schizophrenia and other
psychoses11. Immigrants
Additional Risk FactorsDivorced, widowed, singleLive aloneUnemployedMood or anxiety disorder (esp. anxious
depression)Bipolar disorderPrior attemptsPositive family history
More Risk Factors:Serious physical illness especially
disfiguring ones or with chronic pain
Bereavement
Change in occupational or financial status
Shame over being found guilty of crime
Murderer
Case 2:43-year-old MBF elementary school teacher has
recurrence of depression. You have successfully treated her 4 years ago with sertraline for her first episode of major depression. She and husband have a 24-year-old daughter and her 5-year-old granddaughter living with them. She says she “wishes she just wouldn’t wake up one morning.”
What else do you want to know?
More History:Meets criteria for MDD.Does not feel worthwhile (“Should have been
better parent and teacher.”).Will not harm herself.No plans and no action.No prior attempts nor family history.Roman Catholic, believes that suicide is
mortal sin.Husband, daughter, priest and friends are
supportive.
Risk Assessment = Low:Middle aged African-American
femaleNo intent, plan or action.Religious prohibitionStrong social supportChild in householdNo personal or family history
Management:Have her commit to safety? No suicide contractInstructions regarding Crisis CenterRemove any guns from houseAntidepressant titrated to full doses (don’t
undertreat)Consider sertraline (worked before)Warn regarding increased suicidal ideation initiallyReturn visit in 1-2 weeksDOCUMENT!!
Etiology
Bio-psycho-social-spiritual Model:
Biological Factors:Dysfunction in serotonin
neurotransmitter system (aggression pathways) with drop in CSF 5-HIAA levels in suicidal people or murderers
Increased with family history (5 x average risk)
Identical twins 2 x concordance as fraternal
AkathesiaImpulsive-aggressive behavior
Psycho-Social-Spiritual FactorsAnxious +/or
depressed mood
Externalizing behaviors
Recent loss of relationship
No religious prohibition
Hopelessness
Lack of social support
Lack of meaning or purpose in life
Case 3:14-year-old SWM high school sophomore is
good student and superior athlete. Has few good friends. Parents bring him in because grades have gone down, irritable for couple of months (better now), and losing weight. Mother wonders if mono could cause this. Father expresses surprise that he gave away his iPOD and CD collection to his friend because “he deserved them.”
What additional information do you want?
More History:Was “down” and irritable but more
cheerful now.Trouble sleeping, always tired.School no longer interests him.“Hates himself;” “Nothing gets better.”When asked about suicidal thoughts, he
says, “I don’t know, maybe.”No prior history of depression or suicide
attempts.
Additional History:Positive family history of depression in
mother, aunt, and older brother. No suicides.
Christian but not “into religion.”Would not want to hurt parents.When asked, “If you did want to end
your life, how would you do it?,” he replied, “I guess I would hook a hose to the car exhaust in the garage.”
Risk Assessment = moderate - highSays “maybe” about suicidal
thoughts but has a plan.Adolescent white maleDown, irritable mood that lightened
recently without treatment.AnhedonicGave away prized possessions.
Management:Outpatient may be reasonable if he
commits to safety, parents accept responsibility and will watch him, and he will not be alone.
IOP or admission also good options.Psychiatric consultation Therapy +/- antidepressant (worsening
of suicidal ideation)DOCUMENT!!
Booster with AntipsychoticLow dose antipsychotic can make
antidepressant more effective (e.g., aripiprazole 5-10 mg hs).
Side effects of antipsychotics are a problem:1.Sedation2.Metabolic Syndrome3.Extrapyramidal 4.Prolongation of QTc
Prolongation of QTcQTc from beginning of QRS to end of T waveHR > 70, normal QT < ½ R-R intervalQT has inverse relationship to HR
(slower heart rate leads to longer QT interval)Corrected QT via formulas
(e.g., Bazett: QTc in sec ÷ √R-R interval in sec)Normal QTc per Bazett:
Male < 430 msecFemale < 450 msec
(Worry if > 500 msec)
QRS – T Complex
Prolonged QT Interval
Heart Rate and QT Interval
Risks for PTc ProlongationCertain drugsFemaleOlder ageNighttime (normal increase of 20 msec)Cardiovascular diseaseLow potassium or magnesiumPoor metabolismHypertropic cardiomyopathyCongenital (e.g., Brugada Syndrome)
Psychiatric Drugs at Risk of Causing TdP:ChlorpromazineHaloperidolMesoridazineMethadonePimozideThioridazine
Arizona Center for Education and Research on Therapeutics funded by AHRQ (www.QTdrugs.org)
QTc & Antidepressants or Antipsychotics:1. Monitor BP & P2. Baseline EKG if age > 50 or personal/family
history of syncope, electrolyte abn., or CV disease
3. Repeat EKG at steady state4. Worry if QTc > ½ R-R or > 500 msec5. Holter if bradycardia6. Obtain potassium, magnesium and calcium
levels if on multiple drugs, congential QT prolongation, liver disese, female, long QTc, or bradycardia.
EvaluationSensitive but low specificity (unpredictable)
Suicide assessment scales not clinically useful
Non-judgmental and open-ended questions
Always ask depressed patients about suicidal ideation; primary care providers often don’t ask (will not increase risk).
How to Ask:“Have you ever wished you would go to sleep and
never wake up?”
“Have you been having thoughts about death recently?”
“Have you had thoughts about hurting yourself?”
“Have you felt badly enough that you had suicidal thoughts?”
“Are there any circumstances when you might consider suicide?”
History [DOCUMENT!]
Psychiatric illness
Alcohol or other substance use/abuse
Presence of guns or pills in house
Children at home
Chronic physical illness (pain or disfiguring)
Hx childhood abuse
Social support
Willing to commit safety
Case 4:32-year-old DWM unemployed construction
worker is in ED stating he wants to kill himself. Emergency doctor notes strong odor of alcohol on breath, slurred speech, and poor balance. CBC, metabolic profile and U/A all normal. Blood alcohol level not back yet. Patient asking for you to see him.
What added information do you want?
Added information:Says, “My life is ruined. I want to die!”When asked how, he says, “I would run in
front of a truck.”Physical exam unremarkable except
nicotine stains on teeth and fingers of right hand.
BAL returns at 0.2% (approximately 7 drinks in 180 lb male).
Management:Observe carefully for missed organic
pathology such as a subdural from trauma.
Keep him safe in ED or holding area while he “sleeps it off.”
Reassess suicidal ideation when no longer intoxicated (typically ideation resolves).
Arrange for treatment of alcoholism.
First Things First
Tx after an attempt: Seen after attempt:
1. Manage medical issues first (airway, suture lacerations, etc.)
2. If medically unstable, admit to medical unit and initiate suicide precautions (sitter).
3. Do not leave unattended.
4. Obtain ETOH and toxicology screen
Divulges ideation in office:20% of suicidal patients see PCP
within one day of attempt (usually physical complaints).
If ideation only, can often treat as outpatient.
Remove guns and pills.
Treat underlying condition:a. Proper doses of medication (Lithium reduces risk in bipolar and unipolar depression)
b. Psychotherapy c. ECT prn (highly effective)
Offer hope
Uncertain value of “no suicide” contract
Refer or consult with mental health professional prn.
Use of Benzodiazepines:Considered acceptable for short
term use.
May be indicated for insomnia, agitation, significant anxiety, or panic attacks.
Risk of disinhibition.
Case 5:38-year-old MWF quality management staff
member in your hospital has brother with bipolar disorder. She has been worried that he is not taking his medication as directed. His wife fears that he may harm himself. He denies any suicidal thoughts when they ask him. However, he committed suicide by overdosing on sedatives and alcohol. His sister comes to see you concerning new onset abdominal pain. You cannot find a cause.
How would you manage her?
Family SurvivorsFeel stigmatizedOften have guiltAbandonment feelingsIncreased psychosomatic complaints &
vulnerable to medical and psychiatric illnesses
Behavioral problems in kidsWant PCP to contact them for supportConsider suicide group for family
PreventionRecognize and fully treat psychiatric illnessTake all comments seriouslyHigh index of suspicion (adolescents often
give away prized possessions before suicide)Assure social supportEducation of public and patientsWatch for suicide clusters in adolescentsSuicide hot lines
Questions?