Friday, February 11, 2005

"I was just going to take all my medication"

At Albany Medical College's FP Student Blog, a med student meets a suicidal patient:
I had an odd feeling while interviewing a patient for a routine follow up on depression medicine. She told me that the meds were not even touching her depression - she had tried almost every medicine out there. Perhaps because of her visible hopelessness I asked her if she'd ever thought about hurting herself. She said she thought about it all the time. I asked her if she'd decided how she would do it. She said, "I was just going to take all of the medications I have" (she has a lot)...

Suicide is a larger problem than most people realize with a prevalence of 10-12 in 100, 000. Click here for some more disturbing epidemiology and info. However, not all depressed people will commit suicide and not all attempters are necessarily depressed (i.e. they may be hearing voices (like Mike) commanding them to harm themselves). Although it can be associated with depression, suicide is a whole other animal that FP docs need to know how to recognize and treat.
Kudos to the med student for the mental status exam, and for asking about suicide. I wasn't able to access his resource (registration required), but here are some thoughts:

First, I hope that FP's have psych consultants who can help them. Second, I hope they aren't relying too much on screening tools and "no-harm contracts." Their track records are poor.

So, how to assess and treat suicidal patients? I can't say it better than Dr. Jan Fawcett, who has researched this topic extensively:

"No one has been able to show that suicide is predictable in individuals," Fawcett (said). And to add insult to injury, research has shown that people often either don’t communicate or flat out deny suicidal intentions to a mental health professional before they attempt suicide, Fawcett said.

"This is important, because many professionals seem to think that if someone denies suicidal intent, they won’t commit suicide—that is far from the truth."

For instance, Fawcett participated in a study led by Katie Busch, M.D., in which they examined the medical records of 76 inpatients from different hospitals who committed suicide either as inpatients or immediately after discharge.

What they found in the charts surprised them: 78 percent of patients denied suicidal thoughts and intent as their last communication to mental health professionals before their suicide. "Many clinicians use a patient’s denial of suicide to relieve their anxiety [about the suicide]," noted Fawcett. "But this denial is not to be relied upon..."

People who plan to commit suicide are much more likely to communicate their intent to the people with whom they are close..."We better interview the significant others and believe what they say," added Fawcett.

When Is Risk Greatest?

Clinicians should assess patients for suicide during times of greatest risk, Fawcett said. One of these times is within a week after admission to or discharge from a psychiatric hospital, and another is during times of abrupt clinical change—the sudden worsening or even improvement of a patient’s mental status.

Other risk-increasing situations include the experience of real or anticipated loss, patients with bipolar disorder who enter a mixed state, and the onset of alcohol or substance abuse.

Suicides occur in patients diagnosed with a broad range of disorders, Fawcett pointed out. In 1997 researchers Brian Barraclough, M.D., and Clare Harris, Ph.D., at the University of Southampton’s Community Clinical Sciences Research Division reviewed the literature and found that people with a spectrum of psychiatric disorders were at significantly elevated risk for suicide. People with eating disorders, for instance, are 23 times as likely to take their own lives, people with major depression 20 times as likely, and people with bipolar disorder, 15 times.

Fawcett said there are also risk factors that may occur independently of a person’s psychiatric diagnosis that could heighten the risk for suicide, such as depression, anxiety, agitation, panic, hopelessness, and anhedonia.

Chronic or Acute?

Once a clinician determines that a patient is at risk for suicide, he or she must then decide whether the patient is likely to commit suicide within days or weeks or may not attempt suicide in the near future but within the next year or two.

Placing patients into acute- or chronic-risk categories is crucial, Fawcett said, because patients in each group have unique traits that require specific interventions.

He discovered this unexpected clustering of risk indicators as principal investigator of the NIMH-funded Collaborative Study on the Psychobiology of Depression, in which he and his colleagues collected prospective data on 954 patients with mood disorders, 85 percent of whom were hospitalized. The results of the study appeared in the August 1991 issue of the American Journal of Psychiatry.

By the 10th year of the study, 34 patients in the sample committed suicide. Almost a third of the suicides occurred in the first year.

When Fawcett examined the risk factors for those who committed suicide, he found that the more typical risk factors—suicidal ideation, suicide plans, and a history of attempts, for instance—predicted suicide in two to 10 years from the time of the initial patient interview.

But those who committed suicide within the first year of the interview had different risk factors, such as severe psychic anxiety, in which people ruminate about bad things that may happen to them, insomnia, moderate alcohol abuse, and severe anhedonia and agitation.

Focusing the Intervention

In light of what he has learned through research and years of work with inpatients, Fawcett said, "My goal is to get an assessment of severe anxiety to be a routine part of suicide assessment."

Clinicians must be aware, however, that anxiety and agitation in at-risk patients are intermittent. In addition, Fawcett noted, anxiety is not always apparent. "Some of the worst anxiety is often delusional, and people who look put together may have the delusion that they are going to be punished. . .so you have to ask the right questions."

To combat severe agitation and anxiety, Fawcett recommended that clinicians use high-dose benzodiazepines such as lorazepam and alprazolam. However, this treatment is not well suited to patients with borderline personality disorder.

Lithium has been found to be associated with a reduction in suicide attempts. In 2001 Ross Baldessarini, M.D., a professor of psychiatry at Harvard Medical School, reviewed 33 studies from 1970 to 2000 and found that long-term lithium treatment yielded 13-fold lower rates of suicide and reported attempts than without it or after it was discontinued.

Clozapine has also been found to reduce the risk of suicide attempts, Fawcett noted.

Behavioral interventions may also be helpful, albeit understudied in relation to suicide. "I believe that cognitive-behavioral therapy is another important weapon in the fight against depression and suicide," Fawcett said.

Fawcett then presented good news and bad new to meeting attendees: "Is suicide preventable? With the treatment of acute risk factors, suicide can be prevented on a short-term basis," but it is far more difficult to treat people who are at long-term, or chronic, risk for suicide, because these patients may lack the symptoms, such as agitation or severe anxiety, that can be targeted with specific medications.
For an interview with Dr Fawcett, click here. For more resources from the American Association of Suicidology, including info for patients, click here.
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