Transcript The Suicidal Patient

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 MDD
 Has 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 male
 Caucasian
 Recently bereaved
 Major depressive disorder
 Has ideation, plan and action
 Lives alone
 No religious injunction
 Positive 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!
Epidemiology
 Suicide 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 rate
 One of top 3 causes of death in adolescents
 Increased incidence in:
1. early-onset mood disorders
2. traumatic brain injury,
3. homosexual and bisexual adolescents
4. borderline & antisocial personality disorders
5. eating disorder patients
Epidemiology Continued:
6. Alcohol/substance abusers
7. Sex abuse history
8. Caucasian > African-American
9. Native American
10. Schizophrenia and other psychoses
11. Immigrants
Additional Risk Factors
 Divorced, widowed, single
 Live alone
 Unemployed
 Mood or anxiety disorder (esp. anxious
depression)
 Bipolar disorder
 Prior attempts
 Positive 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 female
 No intent, plan or action.
 Religious prohibition
 Strong social support
 Child in household
 No personal or family history
Management:
 Have her commit to safety
 ? No suicide contract
 Instructions regarding Crisis Center
 Remove any guns from house
 Antidepressant titrated to full doses (don’t undertreat)
 Consider sertraline (worked before)
 Warn regarding increased suicidal ideation initially
 Return visit in 1-2 weeks
 DOCUMENT!!
Etiology
Bio-psycho-social-spiritual Model:
Biological Factors:
 Dysfunction in serotonin neurotransmitter
system (aggression pathways) with drop in CSF 5HIAA levels in suicidal people or murderers
 Increased with family history (5 x average risk)
 Identical twins 2 x concordance as fraternal
 Akathesia
 Impulsive-aggressive behavior
Psycho-Social-Spiritual Factors
 Anxious +/or depressed
mood
 Externalizing behaviors
 Hopelessness
 Lack of social
support
 Recent loss of
relationship
 No religious prohibition
 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 - high
 Says “maybe” about suicidal thoughts but
has a plan.
 Adolescent white male
 Down, irritable mood that lightened
recently without treatment.
 Anhedonic
 Gave 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 Antipsychotic
 Low dose antipsychotic can make antidepressant more
effective (e.g., aripiprazole 5-10 mg hs).
 Side effects of antipsychotics are a problem:
1. Sedation
2. Metabolic Syndrome
3. Extrapyramidal
4. Prolongation of QTc
Prolongation of QTc
 QTc from beginning of QRS to end of T wave
 HR > 70, normal QT < ½ R-R interval
 QT 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 msec
Female < 450 msec
(Worry if > 500 msec)
QRS – T Complex
Prolonged QT Interval
Heart Rate and QT Interval
Risks for PTc Prolongation
 Certain drugs
 Female
 Older age
 Nighttime (normal increase of 20 msec)
 Cardiovascular disease
 Low potassium or magnesium
 Poor metabolism
 Hypertropic cardiomyopathy
 Congenital (e.g., Brugada Syndrome)
Psychiatric Drugs at Risk of Causing
TdP:
 Chlorpromazine
 Haloperidol
 Mesoridazine
 Methadone
 Pimozide
 Thioridazine
Arizona Center for Education and Research on
Therapeutics funded by AHRQ (www.QTdrugs.org)
QTc & Antidepressants or
Antipsychotics:
1.
2.
3.
4.
5.
6.
Monitor BP & P
Baseline EKG if age > 50 or personal/family history of
syncope, electrolyte abn., or CV disease
Repeat EKG at steady state
Worry if QTc > ½ R-R or > 500 msec
Holter if bradycardia
Obtain potassium, magnesium and calcium levels if
on multiple drugs, congential QT prolongation, liver
disese, female, long QTc, or bradycardia.
Evaluation
 Sensitive 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!]
Nature of ideation (active or passive
Plan (if yes, lethal means?)
Chance of rescue
Action taken
Likelihood of acting
Past attempts
Family history
Plans for future
 Psychiatric illness
 Chronic physical illness
(pain or disfiguring)
 Alcohol or other
substance use/abuse
 Presence of guns or pills
 Hx childhood abuse
 Social support
in house
 Willing to commit safety
 Children at home
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 Survivors
 Feel stigmatized
 Often have guilt
 Abandonment feelings
 Increased psychosomatic complaints &
vulnerable to medical and psychiatric illnesses
 Behavioral problems in kids
 Want PCP to contact them for support
 Consider suicide group for family
Prevention
 Recognize and fully treat psychiatric illness
 Take all comments seriously
 High index of suspicion (adolescents often give
away prized possessions before suicide)
 Assure social support
 Education of public and patients
 Watch for suicide clusters in adolescents
 Suicide hot lines
Questions?