Magazine article Clinical Psychiatry News

Depression and Suicide

Magazine article Clinical Psychiatry News

Depression and Suicide

Article excerpt

The recent Food and Drug Administration warning about suicidality and selective serotonergic antidepressants brought renewed attention to a broader issue that clinicians ignore at their patients' peril: the association between suicide and depression.

In fact, more than half of suicides occur in the context of depressive disorders, and in a study of 136 patients hospitalized with major depression, 16% reported at least one attempt in the 2 years after discharge (Am. J. Psychiatry 159[10]:1746-51, 2002).

Identifying patients at risk is the first priority. "The best way is to ask forthrightly: 'Have you had thoughts that life is not worth living [or] of taking your life?'" said Dr. Michael Thase, professor of psychiatry at the University of Pittsburgh. "If there's any hesitancy before [the patient says] no, follow up with something like, 'Talk to me about what just went through your mind.'"

Dr. Maria A. Oquendo of the New York State Psychiatric Institute, New York, noted that the past is the most robust predictor of future attempts: "Ask if the patient has ever tried to kill him- or herself before." A family history of completed or attempted suicide is also suggestive.

Collateral sources can yield vital information, said Dr. Jan Fawcett, professor of psychiatry at the University of New Mexico. Albuquerque. People are more likely to reveal suicidal feelings to family members and close friends than to mental health professionals.

Comorbidity--particularly substance abuse, posttraumatic stress disorder, or borderline personality disorder--is also associated with increased risk. So is a bipolar diagnosis, Dr. Oquendo said. Epidemiologic studies suggest nearly twice as high a lifetime history of suicide attempts for patients who have any symptoms consistent with bipolarity.

Protective factors should not be over-looked. "Asking about what keeps the patient from acting on suicidal thoughts is as important as assessing risk factors," she said.

As essential as the evaluation of long-term risk is, an even more crucial concern is acure danger. "Severity and intensity of negative, hopeless feelings are a common element," Dr. Thase said. Stressful life events compound the risk.

Dr. Fawcett considers anxiety to be of underappreciated significance in this regard. "Severe agitation; severe psychic anxiety, usually in the form of all-consuming rumination; paninsomnia--the patient is hardly sleeping at all. I see a lot of that a short time before suicide," he said.

"I ask patients: 'What do you worry about? How frightening are these worries? What part of the day do you have them?' I try to find out how pervasive the symptoms might be," he said.

Although many antidepressants are also effective anxiolytics, Dr. Fawcett prefers to attack anxiety aggressively, without waiting for the antidepressant to kick in. "I let people know that I understand how painful these symptoms are ... [and that] medication can do something about them right away, even if the depression takes longer," he noted.

If the problem is mainly psychic anxiety, he adds clonazepam (Klonopin) to the antidepressant. If the problem is severe agitation, he uses quetiapine (Seroquel) or olanzapine (Zyprexa), beginning with a low dosage (25 mg quetiapine or 2.5 mg olanzapine) and allowing the patient to increase it in small increments if necessary.

"I tell the patient that this is a temporary phase, probably a few days or weeks, and [I] taper very cautiously and gradually once I'm sure the symptoms are under control," he said. …

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