The Suicidal Patient Peter M Hartmann M D

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 11 th 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 5 HIAA 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 Hopelessness Externalizing behaviors 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 i. POD 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 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 Td. P: 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. Monitor BP & P 2. Baseline EKG if age > 50 or personal/family history of syncope, electrolyte abn. , or CV disease 3. Repeat EKG at steady state 4. Worry if QTc > ½ R-R or > 500 msec 5. Holter if bradycardia 6. 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 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 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?