1. The Suicidal Patient A Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DFAPA November 20, 2009 1 My aim is to offer practical insights you can put to practical use in your professional life. 2 Please let me know whether I have succeeded on your evaluation form.

2. Why is this important? One percent of Americans will die by suicide. 30,000 people take their own lives each year in the US. Suicide is the 8th leading cause of death in this country. Our suicide rate has averaged 12.5 per 100,000 for the past century. Adolescent rates have tripled over the past 40 years to 13.3 per 100,000 making suicide the 3rd leading cause of death in this age group. 8-10 people attempt suicide for every one who completes it. More than 12,000 children under 13 try to kill themselves each year. If you pursue clinical practice, these people will come to you for help and your reactions will be second guessed. After learning the material in this presentation, you will be able to answer the following questions? –What are some of the demographic risk factors for suicide? –What are the most common methods for committing suicide? –What is the role of mental illness in suicide? –What medical illnesses are associated with increased risk? –What is the relationship between suicide and heredity? –What about antidepressants and suicide? –How can you assess for suicide risk? There is no way to predict suicide with certainty. Involving a mental health professional in the assessment process is the usual way of sharing the professional liability. 1,2 1 Consulting does not entirely relieve the physician of the risk. 2 I once consulted the judge when the local mental health clinic employee disagreed with my assessment of a man I considered homicidal.

3. What are some of the demographic risk factors for suicide? Age –Caucasians aged 75-84 suicide 2 times more than those aged 15-24 –Rates in African Americans highest in males aged 25-34 Race –Whites complete suicide 2 times more often than blacks or Hispanics –American Indians and Alaskan Natives suicide 1.7 times as often as whites Sex –M:F ratio 3:1 to 4:1 –Women make up to 70% of attempts –Attempt : Success is 23:1 1,2 Marital status –Divorced or widowed > single > married –Among women, the more children, the lower the rate 1 Don’t fall into the trap of assuming that these patients are “not serious.” 2 I saw a young woman who took an overdose of ASA to “numb myself up to jump in front of a car.”

4. What are the most common methods for suicide? Men –Firearms –Hanging –Gasses or vapors –Drug ingestion Women –Drug ingestion 1,2 –Firearms –Gasses or vapors –Hanging 1 People on drugs may not realize or remember that they tried to kill themselves. 2 I interviewed a woman who was blacked out when she shot herself with a handgun.

5. What is the role of mental illness in suicide? 95% suffer from mental illness at the time of death Up to 70% are depressed 1,2 Degree of hopelessness is predictive The six months after hospital discharge is a high risk period Major depression (15%) Bipolar disorder (10- 15%) Schizophrenia (10%) Alcohol dependence (2%) Borderline personality (4-9.5%) Antisocial personality (5%) 1 Suicide is a selfish act; their pain blinds them to the impact this will have on others. 2 I treated a man who refused to take antidepressants. I interviewed his wife and children afterwards.

6. What medical illnesses are associated with increased risk? AIDS (Up to 36 times) GI cancers 1,2 Head injury Epilepsy (5 times) Temporal lobe epilepsy (25 times) Peptic ulcer disease Spinal cord injury Multiple sclerosis Porphyria Delirium tremens Cushing’s disease Hemodialysis (5 times) Huntington’s chorea Klinefelter’s syndrome 1 Your glib answers will diminish with age. 2 I was consulted on a patient with inoperable cancer who wanted to spare his family.

7. What about suicide and heredity? Relationship is not entirely clear Incidence 4% in biologic relatives of adoptees who suicide but only 1% in adoptive relatives and in biologic relatives of non suicidal matched controls Monozygotic twins 6 times greater concordance for suicide than in dizygotic twins Difference may represent heritability of mental illness Suicidal persons may copy behavior of a loved one Personally knowing a suicide victim is a risk factor 1 1 Remember Stewart’s “Aircraft Carrier Landing Theory” of impulse control.

8. What about antidepressants and suicide? About 50% of depressed persons feel suicidal, so some persons on antidepressants will suicide. Fluoxetine and other SSRIs do not increase suicide but protect against it. 1,2 There are new warnings about using these drugs in children and adolescents. Lithium is the most effective anti-suicide drug. Lithium and the older antidepressants are the most commonly used drugs in fatal overdoses. 1 A patient threatened to sue me over fluoxetine (Prozac) 2 The way you manage such things is different in a small town.

9. What are some of the essential steps in the evaluation of a suicidal patient? Answer the question, “Why now?” Careful history Mental Status Examination Accurate diagnosis 1 Evaluate social support Develop a plan Arrange for follow up 1 I once evaluated a “suicidal” patient who was obsessed with suicide.

10. How do suicide risk factors rank? 1. Age (45 and older) 2. Alcohol dependence 3. Irritation, rage, violence 4. Prior suicidal behavior 5. Male 6. Unwilling to accept help 7. Longer than usual duration of depression 8. Prior inpatient psychiatric treatment 9. Recent loss or separation 10. Depression 11. Loss of physical health 12. Unemployed or retired 13. Single, widowed or divorced

11. What acronym will help you assess suicide risk? S ad A ge D epression P revious attempts E thanol abuse R ational thinking loss (psychosis) S ocial supports lacking 1,2 O rganized plan N o spouse S ickness 1 The lack of social support can be startling. 2 I once called the mother of a patient who said she had just be raped.

12. The Suicidal Patient A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process Introduce yourself using AIDET 1. Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Ask me directly about suicide and homicide. Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. Review my laboratory data and other available records. Tell me what diagnoses you have made. Carefully assess my suicidal and homicidal risk. Outline your recommended treatment plan while making sure that I understand. If you believe I am at risk, discuss my options without threatening me. Acknowledge that I am ultimately the boss. Explain the transient nature of most suicidal and homicidal impulses. Explain that you will make your best recommendation, but that the disposition of my case may be up to the court. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

13. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000 Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008 1 Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007 2 Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005 Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3 Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007 Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008 Median, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008 Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

14. Where can you find evidence-based information about mental disorders? 1 Explore the site maintained by the organization where evidence-based medicine began at McMaster University, http://hsl.mcmaster.ca/resources/ebpractice.htm. http://hsl.mcmaster.ca/resources/ebpractice.htm Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice at http://www.medscape.com/psychiatry.http://www.medscape.com/psychiatry Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/.http://ebmh.bmj.com/ Search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration at http://ebmh.bmj.com/.http://ebmh.bmj.com/ Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health at http://www.medicine.uiowa.edu/ICMH/evidence/. http://www.medicine.uiowa.edu/ICMH/evidence/ 1 Please visit www.KendallLStewartMD.com to download related White Papers and presentations.

15.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? www.somc.org Jeffrey Hill, DO OUCOM 1987 Justin Greenlee, DO OUCOM 2004