Behavioral Aspects of Medicine - Exam 2

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Behavioral Aspects of Medicine - Exam 2
2014-07-08 08:55:49
PAP 528

Suicidality, Psychopharm, Non-pharm Treatment Modalities, Anxiety Disorders, Mood (Affective) Disorders
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  1. Pharmacokinetics
    • ADME
    • Absorption, Distribution, Metabolism, Excretion
  2. Absorption
    Movement of a drug from its site of administration into the central compartment/bloodstream
  3. Distribution
    from the blood stream to interstitial and intracellular fluids
  4. Metabolism
    In most cases, biotransformation reactions generate more polar metabolites that are readily excreted from the body
  5. Excretion
    The kidney is the most important organ for excreting drugs and their metabolites
  6. Half Life
    The time needed to clear 50% of drug from plasma. After 4 half lives, elimination is 94% complete.
  7. Volume of Distribution
    Amount of drug in the body divided by the concentration in the blood.
  8. Induction
    • (enzymes)
    • increases rate of metabolism.
    • Result = decreased duration & intensity of drug action.
    • Cytochrome P450 Monooxidase (CYP-450) System of Drug Metabolism
    • Caffeine, omeprazole, smoking, Carbamazepine (Tegretol), Phenobarbital, Phenytoin, Ritonavir, Oxcarbazepine, Modafinil, Topiramate, St John’s wort
  9. Inhibition
    • (enzymes)
    • decreases rate of metabolism.
    • Result = increased duration & intensity of drug action.
    • Cytochrome P450 Monooxidase (CYP-450) System of Drug Metabolism
    • PAROXETINE (Paxil)
    • FLUOXETINE (Prozac)
    • BUPROPRION (Welbutrin)
    • SERTRALINE (Zoloft)
  10. Receptors
    • Cell membrane proteins that are stimulated by specific neurotransmitters
    • receptors:
  11. Neurotransmitters
    • Cholinergic
    • Monoamines
    • Neuropeptides
    • Amino acids
  12. Cholinergic
    • (Neurotransmitters)
    • (ACH (Acetylcholine))
  13. Monoamines
    • (Neurotransmitters)
    • Catecholamines (Dopamine, Norepinephrine, Epinephrine)
    • Serotonin
    • Histamine
  14. Neuropeptides
    • (Neurotransmitters)
    • eg: Opioids (endorphins)
  15. Amino acids
    • (Neurotransmitters)
    • GABA, Glycine: Inhibitory
    • Glutamate, Aspartate: Excitatory
  16. Classes of Psychotropic Medications
    • Antidepressants
    • Antipsychotics
    • Mood Stabilizers
    • Anti-anxiety agents (anxiolytics)
    • Psychostimulants
    • Dementia Drugs
    • Antiparkinsonians
    • Medications for Treatment of Substance Dependence
  17. SSRIs
    Increase serotonin at brain neurons by blocking serotonin reuptake, long-term possibly effect receptor numbers and distribution.
  18. MAOIs
    • Inhibit the action of MAO-A and B enzymes that metabolize: 5-HT (serotonin), DA (dopamine), NE (norepinephrine).
    • Dietary restriction - Must be tyramine-free throughout Tx and for 2wks after D/C of med (fermented/aged foods, red wine, caution with chocolate and caffeine)
  19. Benzodiazepines
    Bind to the BDZ-GABA-Cl receptor complex, facilitating the action of GABA (inhibitory neurotransmitter) on CNS excitability.
  20. Antipsychotics
    • Antagonism of dopamine receptors.
    • Typical, atypical (novel)
  21. Antidepressants
    • SSRIs (Selective Serotonin Reuptake Inhibitors)
    • SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
    • TCAs (Tricyclics) {or heterocyclics}
    • MAOIs (Monoamine Oxidase Inhibitors)
    • Others
  22. Mood Stabilizers
    • Lithium - monitor kidney function
    • Valproic Acid (Depakote)
    • Carbamazepine (Tegretol) - bad in pregnancy
    • Lamotrigine (Lamictal)
  23. Anti-anxiety agents (anxiolytics)
    • Benzodiazepines (diazepam, lorazepam, alprazolam)
    • Non-Benzodiazepine (buspirone)
  24. Choosing a medication
    • Diagnosis
    • Symptoms
    • Risks / Benefits
    • Alternative Treatments
    • Comorbid Medical Diagnoses
    • Concurrent Treatments, including: OTC, herbal, & supplement preparations
  25. Choosing an Antidepressant
    • Previous Response / Tolerability
    • Family History
    • Comorbid Psychiatric Symptoms
    • Comorbid Psychiatric Diagnoses
    • Comorbid Medical Diagnoses
    • Concurrent Treatments
  26. Obsessive‑compulsive disorder with depression
    Tx with SSRI, clomipramine (Anafranil, a TCA), or SNRI usually first choice.
  27. Panic disorder with depression
    • avoid trazodone and bupropion
    • because they are relatively ineffective for panic. Start Tx w/: paroxetine (Paxil), sertraline (Zoloft), venlafaxine (Effexor).
  28. Bipolar disorder with depression
    avoid TCAs.
  29. Comorbid conditions - use of antidepressants
    • Agoraphobia
    • Borderline Personality Disorder
    • Depression (unipolar / bipolar)
    • Dysthymic Disorder
    • Generalized Anxiety Disorder (GAD)
    • Hypochondriasis
    • Obsessive-Compulsive Disorder
    • Panic Disorder
    • Premenstrual Dysphoric D/O (PMDD)
    • Post-Traumatic Stress Disorder (PTSD)
    • Schizoaffective Disorder
    • Social Phobia
  30. MDD
    • maximum daily dose
    • major depressive disorder
  31. TD
    • tardive dyskinesia – involuntary movements especially of lower face (tongue thrusting, dry lips)
    • Lower risk of TD with newer (atypical/novel) antipsychotics
  32. ESP
    • ExtraPyramidal Symptoms – atypical involuntary muscle contraction (gait, movement, posture)
    • Lower ESP with newer (atypical/novel) antipsychotics
  33. Prolactin side effect
    • Increased with all antipsychotics, except clozapine, ziprasidone, aripiprazole and (maybe) quetiapine.
    • SSRIs, particularly paroxetine, may also increase prolactin and exacerbate neuroleptic-induced prolactinemia.
  34. Benzodiazepines for Anxiety - Advantages
    • well tolerated
    • quick onset
    • effective
    • safe in overdoes
    • low cost
  35. Benzodiazepines for Anxiety - Disadvantages
    • withdrawal reactions
    • sedation
    • risk of abuse
    • poor antidepressant effect
  36. SSRIs for Anxiety - Advantages
    • effective
    • relatively safe
    • no risk of abuse
    • effective on depression
  37. SSRIs for Anxiety - Disadvantages
    • possible increase in anxiety during initial period of use
    • not for immediate symptomatic relief
    • sexual side effects
    • other side effects - insomnia/sedation, headache, GI upset, anxiety, agitation
  38. Types of psychotherapy
    • Psychoanalysis
    • Brief Psychodynamic Psychotherapy
    • Group Psychotherapy
    • Family Therapy & Couples Therapy
    • Behavior Therapy
    • Dialectical Behavior Therapy
    • Cognitive Therapy
    • Cognitive-Behavior Therapy
    • Hypnosis
    • Biofeedback
    • Interpersonal Therapy
  39. Electroconvulsive Therapy
    • (ECT)
    • Induction of a bilateral generalized seizure.
    • Adverse cognitive effects: confusion, disorientation, memory loss.
    • These are (mostly) reversible.
    • Newer developments in technique decrease adverse effects, offer potential for better acceptance among clinicians & patients.
    • First performed in 1938.
    • Still the fastest & most effective Tx for Major Depressive D/O.
    • For pts. who have failed med trials, not tolerated meds, severe or psychotic syx, are acutely suicidal or homicidal, or have marked syx of agitation or stupor.
    • (intractable, refractory depression)
    • other indications: schizophrenia, bipolar mania, catatonia
    • Contraindication - increased intracranial pressure (space occupying lesion)
  40. cerebral commissurotomy
    cutting the corpus callosum to disconnect the two hemispheres of the brain, for control of intractable seizures
  41. Anxiety
    • Refers to many states in which the sufferer experiences a sense of impending threat or doom that is not well defined or realistically based.
    • Can be: Adaptive or Pathologic;
    • Can be: Transient or Chronic;
    • Variety of psychological & physical manifestations.
  42. Anxiety disorders
    • Most common group of psychiatric illnesses in U.S.
    • > 23 million people affected every year (approx. 7.3 % of population)
    • Heterogeneous group of disorders in which feeling of anxiety is the major element.
  43. Types of anxiety disorders
    • Panic d/o w/ agoraphobia
    • Panic d/o w/o agoraphobia
    • Agoraphobia
    • Social phobia
    • Specific phobia
    • Obsessive-Compulsive d/o
    • Generalized Anxiety d/o
    • Acute Stress d/o
    • Posttraumatic Stress d/o
    • Substance-induced Anxiety d/o
    • Anxiety d/o due to a general medical condition
    • Anxiety d/o NOS
  44. Panic Disorder
    • Recurrent unexpected panic attacks.
    • Seen w/ or w/o agoraphobia.
    • Twice as common in women,
    • Lifetime prevalence 2% to 3%.
    • Typical onset in 20s, most cases begin before age 30.
    • > 60% comorbid depression.
  45. Panic Attacks
    • Typically come on suddenly,
    • Peak within minutes,
    • Last 5 to 30 minutes.
  46. Dx of Panic Disorder
    • 1 of these must occur x > 1 month:
    • Persistent concern about having additional attacks
    • Worry about the implications of the attacks (losing control, “going crazy”)
    • Significant change of behavior related to attacks (restrict activities)
    • Plus 4 of 13 typical symptoms:
    • Palpitations, pounding heart
    • Sweating
    • Trembling, shaking
    • Sensation of SOB or smothering
    • Feeling of choking
    • Chest pain/discomfort
    • Nausea or abdominal distress
    • Feeling dizzy, unsteady, lightheaded, faint
    • Derealization or depersonalization
    • Fear of losing control, going crazy
    • Fear of dying
    • Paresthesias
    • Chills or hot flashes
  47. UPO
    • until proven otherwise
    • (think of general medical conditions before psychiatric UPO)
    • EKG/bloodwork to rule out cardiac issues or drug abuse before moving onto psychiatric causes for symptoms
  48. CBT
    cognitive behavioral therapy
  49. Specific phobia
    • Women > Men
    • Lifetime prevalence: 25%
    • Typical onset in childhood, most occur before age 12.
    • Tend to run in families
    • ?Learned – paired w/ traumatic events
    • Intense fear of particular objects or situations (snakes, heights).
    • It is the most common psych d/o.
    • Tend to remit spontaneously w/ age
    • In adulthood often become chronic.
    • Rarely cause disability
    • Tx: systematic desensitization
  50. Social phobia
    • (social anxiety disorder)
    • Intense fear of being scrutinized in social or public situations
    • May be generalized or limited to specific situations.
    • Men = Women
    • Prevalence of 3% to 5%
    • Typical onset in adolescence, most occur before age 25.
    • Fear of being embarrassed
  51. Treatment of Social Phobia (Social Anxiety Disorder)
    • Mild cases: CBT
    • But, many cases require medication.
    • SSRIs: ie- Paroxetine [Paxil], Sertraline [Zoloft]
    • Beta blockers: ie- Propranolol [Inderal]
    • Benzodiazepines: ie- Alprazolam [Xanax]
  52. Generalized Anxiety Disorder
    • Intense, pervasive worry over virtually every aspect of life; (job performance, health, marital relations, social life)
    • Difficulty controlling the worry;
    • Associated w/ physical manifestations of anxiety.
    • Lifetime prevalence is approx. 5%.
    • Typical age of onset is early 20s, but may begin at any age.
    • Do Not have panic attacks, phobias, obsessions, or compulsions;
    • Rather, they experience pervasive anxiety & worry (apprehensive expectation) about a number of events or activities that occur most days x at least 6 mos.
    • Plus, at least 3 of the following syx:
    • Restlessness, easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance.
  53. Treatment of Generalized Anxiety Disorder
    • Relaxation techniques;
    • Meds: SSRIs, Buspirone (BuSpar), Benzodiazepines, Beta-blockers
  54. Post traumatic stress disorder
    • Persistent re-experience of a trauma, efforts to avoid recollecting the trauma, & hyperarousal.
    • Prevalence: 0.5% in Men, 1.2% in Women.
    • May occur at any age;
    • May begin hours/days/years after the initial trauma.
    • People w/ PTSD have endured a traumatic event (combat, physical assault, rape, explosion) in which they experienced, witnessed, or were confronted with actual or potential death, serious physical injury, or a threat to physical integrity.
    • Event re-experienced through repetitive intrusive images or dreams, or through recurrent illusions, hallucinations, or flashbacks of the event.
    • Pats. make efforts to avoid recollection of event, thru psychological mechanisms or actual avoidance of circumstances that will evoke recall.
    • Feelings of detachment from others;
    • Exhibit evidence of autonomic hyperarousal (ie- difficulty sleeping, exaggerated startle response).
  55. Treatment of PTSD
    • Psychotherapy (individual or group)
    • Plus meds (directed at specific syx):
    • SSRIs x > 6 mos. = most effective for reducing syx;
    • TCAs can also be effective;
    • **Propranolol & other beta blockers may have a role in preventing development of PTSD if given early after trauma.
  56. Obsessive-Compulsive Disorder
    • Pats. experience recurrent obsessions & compulsions that cause significant distress and occupy a significant portion of their lives.
    • Lifetime prevalence: 2% to 3%.
    • Typical onset between late teens and early 20s; but, one third show syx of OCD before age 15
    • Seen more frequently after brain injury or disease (head trauma, seizure d/o’s, Huntington’s disease).
    • Monozygotic twins have higher concordance rate than dizygotic twins.
  57. Components of OCD
    • Obsessions: recurrent intrusive ideas, thoughts, or images that cause significant anxiety & distress.
    • Compulsions: repetitive purposeful physical or mental actions that are generally performed in response to obsessions.
    • The compulsive “rituals” are meant to neutralize the obsessions, diminish anxiety, or somehow magically prevent a dreaded event or situation.
  58. Obsessional Thinking of OCD v Delusional Thinking of Schizophrenia
    • Obsessions are usually unwanted, resisted, & recognized by patients as coming from their own thoughts;
    • Delusions are generally regarded as distinct from patients’ thoughts and are typically not resisted.
  59. Treatment of OCD
    • CBT (desensitization, et al);
    • Plus Meds:
    • SSRIs: Paroxetine (Paxil), Fluoxetine (Prozac), Sertraline (Zoloft);
    • TCA: Clomipramine (Anafranil)
  60. Anhedonia
    inability to experience pleasure from activities usually found enjoyable, e.g. exercise, hobbies, music
  61. Major Depressive Disorder
    • (MDD)
    • At least 5 of the following symptoms for at least 2 weeks duration and at least one of these symptoms is depressed mood or anhedonia
    • -Significant change in weight
    • -Sleep disturbance
    • -Psychomotor agitation or retardation
    • -Fatigue or loss of energy
    • -Excessive guilt or feelings of worthlessness
    • -Difficulty concentrating
    • -Recurrent thoughts of death or suicide
    • Must be a change from previous functioning
    • Symptoms must cause social/occupational dysfunction or distress
    • Cannot be caused by a medical condition, medication or drugs
    • Symptoms cannot be caused by bereavement
    • Occasionally no subjective depressed mood is present; only anxiety and irritability are displayed
    • Hopelessness and helplessness are common
    • Decreased libido
    • Patients may appear demented because of poor attention, poor concentration, and indecisiveness
    • Assess for risk of suicide
    • Check for hypothyroid
  62. Prevalence of Depression
    • Males: 3-5%
    • Females: 8-10%
    • Doubled from 1992 to 2002
    • More common in populations with greater burden of medical illnesses, including residents of assisted living/nursing homes, recipients of home health care, and patients suffering from medical conditions
    • Two times more common in first degree relatives compared to the general population
  63. Course of Depression
    • First onset may occur at any point from childhood to old age
    • Most episodes remit completely, either spontaneously or with treatment (episodes last from several months to a year)
    • Persistent major depression (lasting 2 or more years) occurs in 20% of patients
    • Highly recurrent, with up to 90% of patients suffering a second episode, with the greatest risk in the first few months and years following remission
    • Second only to cardiovascular disorders as the leading cause of functional disability (day-to-day functioning)
    • Impacts the outcomes of comorbid medical conditions as well as increases the risk of strokes, diabetes, CAD
  64. Pathological grieving
    more than 12 months of grieving a loss
  65. DDX of MDD
    • Differential Dx of Major Depressive Disorder
    • Normal bereavement
    • Adjustment disorder with depressed mood
    • Dysthymia
    • Bipolar Disorder
    • Anxiety Disorder
    • Schizophrenia and Schizoaffective disorder
    • Dementia
    • Mood disorder due to a general medical condition
    • substance induced mood disorder
  66. Normal bereavement as DDX of MDD
    • Same symptoms, lasting <1 year, but functioning (i.e. go to work, take care of self/children)
    • Symptoms should not cause severe functional impairment lasting more than 2 months
    • Treatment: Supportive psychotherapy
  67. Adjustment Disorder with Depressed Mood as DDX of MDD
    • Change in mood and or behavior, which occur within 3 months of a stressor (i.e. break-up) and must not last more than 6 months
    • Treatment: Supportive psychotherapy because usually self-limited
  68. Dysthymia as DDX of MDD
    • Depressed mood >2 years, but mood does not hit rock bottom
    • Dysthymia is a chronic type of depression in which a person's moods are regularly low. However, symptoms are not as severe as with major depression.
  69. Bipolar Disorder as DDX of MDD
    • Ask if patient was ever manic (i.e.- patient comes in for help when depressed, not when they are manic)
    • Cyclothymia - mild form of bipolar, lasts > 2 years
    • Check for hyperthyroid
  70. Anxiety Disorder as DDX of MDD
    • Symptoms of anxiety often coexist with depressive symptoms
    • Focus on the treatment of depression because it carries a higher morbidity and mortality (i.e.- Antidepressants also treat anxiety)
  71. Schizophrenia and Schizoaffective D/O as DDX of MDD
    • Severe psychotic depression may be difficult to distinguish from primary psychotic disorder
    • In psychotic depression, generally the mood symptoms usually precede the psychotic symptoms
    • In Schizophrenia, there is absence of mood symptoms
  72. Dementia as DDX of MDD
    • Dementia and depression may present with apathy, poor concentration, and impaired memory
    • Differentiation can be difficult in the elderly. A trial of antidepressants may be useful because depression is reversible and dementia is not
    • “Pseudodementia” is defined as depression that mimics dementia
  73. Mood Disorder due to a General Medical Condition as DDX of MDD
    Symptoms are a direct physiological consequence of a medical disorder and not an emotional response to a physical illness (i.e.- hypothyroidism)
  74. Substance Induced Mood D/O as DDX of MDD
    • Alcohol, sedatives, antihypertensives, and oral contraceptives can cause depressive symptoms
    • Withdrawal from sympathomimetics (“Uppers” such as cocaine) or amphetamines can cause a depressive syndrome. Withdrawal from cocaine = depression. WORRY ABOUT SUICIDE WHEN PATIENTS ARE WITHDRAWING FROM COCAINE!
  75. Treatment of Major Depressive Disorder
    • Antidepressants (SSRIs, TCAs, MAOIs, atypical agents)
    • SSRI – safer
    • TCA, MAOI – cardiac toxicity, riskier
    • Suicide risk goes up because energy returns before mood starts to improve
    • Black box warning – medication for depression might cause increased risk of suicide
  76. Side effects of concern for Atypical agents:
    • Excessive and rapid weight gain in some atypical antipsychotics
    • Bupropion (Wellbutrin) - lowers seizure threshold
    • Venlafaxine (Effexor) - can cause HTN
    • Trazodone (Desyrel) - priapism and hypotension (inhibition of alpha-1 receptors)
  77. Side effects of concern for MAOIs:
    • orthostatic hypotension
    • hypertensive crisis (tyramine in diet)
    • drug interactions with epinephrine, meperidine (demerol), and SSRIs can be life-threatening
  78. Side effects of concern for TCAs:
    dry mouth, blurry vision, constipation
  79. Side effects of concern for Lithium:
    • GI symptoms
    • Teratogenic (pregnancy test prn; pt. using bc?)
    • Nephrotoxic (check renal functions)
    • Conduction defect (check EKG/get a baseline)
    • Tremors
    • Hypothyroidism (check TFTs)
    • Thirst, acne, weight gain, leukocytosis (usually benign), diabetes insipidus
  80. Enuresis
    • Bed wetting
    • Use TCA (Imipramine (Tofranil)) to treat children
  81. Insipidus
    frequent urination
  82. Bipolar Disorder v Schizophrenia
    • Bipolar:
    • psychotic
    • delusions of grandiosity
    • expansive or labile mood when manic
    • depressed mood when depressed
    • Schizophrenia:
    • psychotic
    • bizarre delusions
    • absence of mood symptoms
  83. labile
    characterized by rapidly shifting or changing emotions, as in bipolar disorder and certain types of schizophrenia; emotionally unstable
  84. Dysthymic Disorder
    • (dysthymia)
    • Depressed mood most of the day, more days than not, for at least 2 years, mood does not hit rock bottom
    • Presence of at least two depressive symptoms
    • Over a 2 year period, the patient has not been without symptoms for more than 2 months consecutively
    • No major depressive episode has occurred during the first two years of the disturbance
    • Symptoms do not occur with a chronic psychotic disorder
    • Symptoms cause significant social or occupational dysfunction or marked subjective distress
    • R/O substance abuse and GMC (general medical condition)
  85. Course of Dysthymic Disorder
    • Symptoms are similar to major depression. Common symptoms are anhedonia, feelings of inadequacy, social withdrawal, guilt, irritability, decreased productivity
    • Changes in sleep, appetite, or psychomotor behavior are less common
    • Patients often complain of multiple physical problems, which may interfere with social or occupational functioning
    • Psychotic symptoms are not present
    • Episodes of major depression may occur after the first two years of the disorder, known as "double depression"
    • Lifetime prevalence = 6%
    • Onset: childhood or adolescent
    • Dysthymia occurring prior to the onset of major depression has a worse prognosis than major depression without dysthymia
  86. DDX of Dysthymic Disorder
    • Major depressive disorder
    • substance induced mood disorder
    • mood disorder due to general medical condition
    • personality disorders
  87. GMC
    general medical condition
  88. Major Depressive Disorder as DDX of Dysthymic D/O
    Dysthymia leads to chronic, less severe depressive symptoms.
  89. Substance-Induced Mood Disorder as DDX of Dysthymic D/O
    Alcohol, bezodiazepines, and other sedative-hypnotics can mimic dysthymia symptoms, as can chronic use of cocaine and amphetamines. Anabolic steroids, oral contraceptives, methyldopa [Aldomet], beta-blockers, and isotretinoin [Accutane] have also been linked to depressive symptoms.
  90. Mood Disorder due to General Medical Condition as DDX of Dysthymic D/O
    • Depressive symptoms consistent with dysthymia may occur in stroke, Parkinson’s, multiple sclerosis, Huntington’s, vitamin B-12 deficiency, hypothyroidism, Cushing’s disease, pancreatic CA, and HIV.
    • R/O by history, PE, and labs as indicated.
  91. Personality Disorders as DDX of Dysthymic D/O
    Frequently co-exist with dysthymic disorder.
  92. Treatment of Dysthymic Disorder
    Hospitalization is usually not required, unless suicidality is present.
  93. Antidepressants for Dysthymic Disorder
    SSRIs are most often used. If SSRIs have failed, a TCA such as desipramine [Norpramin] is often effective.
  94. Psychotherapy for Dysthymic Disorder
    • Cognitive psychotherapy may help patients deal with incorrect negative attitudes about themselves.
    • Insight oriented: Help patients resolve early childhood conflict, which may have precipitated depressive symptoms.
    • Combined psychotherapy and pharmacotherapy produces the best outcome.
  95. MDD v Dysthmia
    • Major Depressive Disorder:
    • "Hit rock bottom", one or more discrete episodes
    • Lifetime prevalence of 3-6%
    • Female to Male ratio 2:1
    • Onset anywhere from childhood to old age
    • Functional impairment
    • Can present wit psychotic features
    • Dysthymia:
    • Chronic, mild form of MDD
    • Lifetime prevalence 6%
    • Female to Male Ratio 3:1
    • Onset in childhood/adolescence
    • Usually functional (go on with life)
    • No psychosis
  96. Suicide Risk
    Always assess for suicide risk in patients with any mood disorder
  97. Suicide
    act of intentionally causing one's own death
  98. Suicidal Ideations
    thoughts about or an unusual preoccupation with suicide
  99. Suicidal Intent
    refers to the aim, purpose, or goal of the behavior rather than the behavior itself
  100. Suicidal Plan
    is a proposed method of carrying out a design that will lead to a potentially self-injurious outcome
  101. Suicide attempt
    self-inflicted, potentially injurious behavior with a nonfatal outcome for which there is evidence (either explicit or implicit) of intent to die. A suicide attempt may result in no injuries, injuries, or death
  102. Deaths by suicide in US
    • 37,000
    • (1 million worldwide)
  103. Number of people receiving emergency medical treatment after attempting suicide
  104. Suicide is the ____ leading cause of death worldwide
  105. There are __ nonfatal suicide attempts for every completed suicide. The number is __ for adolescents.
    • 10-40
    • 100-200
  106. Methods of suicide
    • Firearm (more men) 57% overall, 62% in men
    • Suffocation (hanging)
    • Poisoning/overdose (more women)
    • Fall
    • Cut/pierce
  107. Majority of suicides completed by ___, second leading method is ___ for men and ____ for women.
    • Firearms (57% overall, 62% in men)
    • Hanging
    • Poisoning
  108. Risk factors for suicide
    • psychiatric illness
    • prior hx of suicide attempts (5-6x more likely to try again)
    • Hopelessness and impulsivity (higher risk than depression)
    • Age, sex, race (females 4x more than males, males successful 3x more often)
    • Marital status - never married - highest risk, widowed, separated/divorced, married w/o children, married w/ childred - least risk (Basically living alone)
    • Occupation - least skilled workers, and then physicians
    • Health
    • Adverse childhood experiences
    • Family Hx and genetics
    • Access to firearms
    • Sociopolitical, cultural, economic forces
  109. Protective factors against suicide
    • Social and family support
    • being pregnant, having children
    • religion
    • effective clinical care for any disorders
    • access to clinical interventions and support
  110. Contracting for Safety
    • In Clinical Practice: the concept of "contracting for safety" or agreeing to a "no harm contract" has been used to imply that patients can promise clinicians that they will try not to harm themselves when they are suicidal.
    • Doesn't really work, gives false sense of security
  111. C-SSRS
    • Columbia - Suicide Severity Rating Scale
    • Part of a national and international public health initiative involving the assessment of suicidality
  112. Poor rescue plan
    attempting suicide when no one is likely to find you