Depression and Suicide

Jeff Barwick, FALU, FLMI, CLUDirector

September 10, 2018

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Everything in life is totally fixable

Ken Baldwin

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Case studies

Challenges with Underwriting Depression

Major Depression, Bipolar DO, Anxiety

Depression vs anxiety

Suicide

Outline

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Male, age 36, nonsmoker, applying for $100,000

Occupation is OB/GYN

Current labs, build and BP all favorable

Family history grandfather died of asphyxiation (suicide?)

Fifteen years ago sought treatment for depression, wanted to lie in bed, weight loss 10-15 lbs, anhedonia, sadness, wished he would die. Was prescribed Imipramine and was discharged from care. He had a leave from medical school at this time.

Case Study 1

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A married 78-year-old man is brought to the emergency department after ingesting 10 15 mg Temazepam tablets. After he is stabilized medically, he undergoes psychiatric evaluation.

Q. Which one of the following is most important in assessing his risk of suicide?

a. Early morning awakening with decreased appetite

b. Family history of suicide

c. Male gender

d. Marital Status

e. Patients belief that Temazepam would kill him

source: Forums studentdoctornetwork5

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Five years later he had returned during his residency with recurrent symptoms and was prescribed Imipramine again; he was tempted to take phenobarbital but reported he decided against suicide. He look a leave of absence from his residency, tapered off meds within six months and reported doing well.

Two years later his wife phoned his M.D. and said he was in a tailspin; reportedly suicidal. He was prescribed Imipramine and went into remission, after which meds were tapered again.

Five years later he had a mild recurrence of depression that responded to one M.D. visit and a few weeks of meds. This was the last documented occurrence of depression and treatment; no further information on this condition in three years prior to application.

Offer?

Case Study 1 (continued)

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Male, age 48, nonsmoker, applying for $200,000

Occupation is attorney

Current labs, build and BP all favorable

Rare alcohol use, no drug use

Suicide attempt 10 years ago with an aspirin overdose due to marital and job stress; inpatient monitoring for 48 hours and discharged to see a psychiatrist as an outpatient. Psychiatrist saw him and prescribed Paxil 20 mg. He later divorced.

Case Study 2

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Eight years ago during a physical exam he had discontinued Paxil, with history of MVP, WPW – asymptomatic and an echo showed moderate mitral regurgitation.

Seven years ago he had an episode of transient global amnesia while on vacation/honeymoon in Mexico. An MRI of the brain was normal.

Offer?

Case Study 2 (continued)

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Male, age 47, nonsmoker, applying for $1,000,000

Occupation is anesthesiologist

Current labs, build and BP are all favorable

Twelve years ago noted history of daily cocaine and alcohol use but none since then. Psych APS verified this history. He had been followed by psych and maintained on Wellbutrin 150 md qd and Prozac 40 mg qd. Diagnosis was depressed mood without suicidality.

Seven years ago diagnosed with obstructive sleep apnea with RDI of 27, oxygen desaturation to 81%. He uses CPAP regularly and reports no problems.

Offer?

Case Study 3

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Depression is a common but serious mood disorder

It causes severe symptoms that affect how you feel, think, and handle daily activities such as sleeping, eating, or working

To be diagnosed with depression, the symptoms must be present for at least two weeks.

Major Depressive Disorder (MDD)

Depression

MDD is at the severe end of unipolar depressive mood disorder

Represents a change from previous functioning

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Five (5) symptoms must be present during same two-week period Depressed mood

Markedly diminished interest or pleasure in all, or almost all, activities

Significant weight loss or weight gain

Insomnia or hypersomnia

Psychomotor agitation or retardation

Feelings of worthlessness

Diminished ability to think or concentrate

Recurrent thoughts of death

Major Depressive Episode Criteria

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Q. Bipolar I and Bipolar II - What’s the Difference?

BIPOLAR I - Depression + Mania

BIPOLAR II - Depression + Hypomania

Mania is the more intense experience; lasts at least a week- staying up all night, working madly, doing irrational things, having creative spurts, feeling hugely grandiose and full of love, having no social barriers and acting compulsively.

Hypomania is less intense; lasts around 4 days- also shorter in intensity; Impulsivity, confidence and excess energy, are less serious in degree.

https://www.bing.com/videos/search?q=Examples+of+Mania&&view=detail&mid=A954DD2673ABF9CC83B6A954DD2673ABF9CC83B6&FORM=VRDGAR

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Anxiety is characterized by a sense of fear, uneasiness, dread and vulnerability about future events. The worry is often unrealistic or out of proportion for the situation. The attention of anxious people is focused on their future prospects, and the fear that those future prospects will be bad.

Depression sufferers feel sad, blue, unhappy, miserable, or down in the dumps. They are not so preoccupied with worrying about what might happen to them in the future. They think they already know what will happen, and they believe it will be bad.

“I guess I would say it is about equal, both cause a great deal of pain”

Q. What’s Worse - ANXIETY or DEPRESSION?

Mariah Shipp- Certified Clinical Hypnotherapist www.joourneysinwardhypnosis.com

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Q. Depression - What Are The Mortality Risks?

Suicide• Passive suicide?

Accidents• Driving, risk taking behavior, hazardous sports

General health and well-being

Co-morbidities• Other physical impairments• Compliance with care• Attitude and outlook

https://www.bing.com/videos/search?q=anxiety+versus+depression+symptoms&&view=detail&mid=DA3CA1413549D5A708AFDA3CA1413549D5A708AF&&FORM=VDRVRV

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Q. Depression - What Challenges Do We Face as Underwriters?

No specific objective tests to diagnose Depression• No specific biochemical or physiological laboratory tests

Often a constellation of impairments; not just depression

Quality of records• Not always comprehensive• Entries that repeat from visit to visit• Rx history sometimes difficult to decipher

o What’s current and what’s noto Multiple meds with interchangeable labels

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Diagnosis and Severity • Both can be subjective• Stated diagnosis may inconsistent w/clinical notes

Example: 'Major Depression' often implies moderate or /severe depression

• Individual consideration usually plays a big role• We all bring our own “stuff”

• I know what I’d do, but ...• Often multiple decisions can be defended

UW Challenges (continued)

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Restricted/constricted • mild restriction in the range of intensity of display of feelings

Blunted• reduction becomes more severe

Flat• absence of any exhibition of emotions- voice monotone, face expressionless, body

immobile

Labile• emotional instability or dramatic mood swings

Inappropriate • e.g. laughter when describing pain or sadness

AFFECT is the expression of emotion

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Multiple psych medications

Combined with multiple non-psych medications

Deadly Drug Combinations

Excess Alcohol + __________ = Deadly combination

ANTIDEPRESSANTS OPIATES

STIMULANTS BENZODIAZEPINES

Medication - Another Significant Challenge

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Benzodiazepines and Alcohol• Alone, Benzo’s pose little risk of overdose and coma • Both are CNS depressants- combined are potentially lethal- leading to

LOC and coma

Opiates and Alcohol• Combining the two gives greater relief of pain• Alcohol enhances the sedative effects of both • Increased risk of respiratory depression and overdose

Deadly Drug Combinations

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Antidepressants and Alcohol • Impaired thinking, Intensified depression symptoms and death• Dangerously elevated blood pressure• Serotonin syndrome- can be fatal if severe and untreated

Stimulants and Alcohol• Stimulant mask the effects of alcohol• Users may drink more than they intended• Can lead to increased blood pressure and tension• Especially problematic when driving

Drug Combo’s (continued)

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“Insane people do not purchase life insuranceand

sane people do not commit suicide”

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The Suicide Clause

“The benefits payable are limited if the insured commits suicide, while sane or insane, within two years of the issue date”.

Q. SUICIDE- Does a Life Insurance Policy Pay Death Benefits in the Event of Suicide?

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Q. If asked, most people would say that life insurance doesn’t cover death due to suicide.

TRUE or FALSE

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There are limitations

Death by suicide not always clear-cut Cause of death listed on death certificate Reluctance to rule death as suicide Individual state laws

Q. The Suicide Clause - How Much Protection?

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Missouri• Suicide clause limited to 1 year-

o must prove policy was purchased with the intent to commit suicide

• Case Law- Original court case in the 1950’s, upheld in the 1990’s

“Insane people do not purchase life insuranceand sane people do not commit suicide…”

Q. The Suicide Clause - How Much Protection?

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Suicide ranks #10 in leading causes of death in the US

Suicide rates increase with age• Males over age 65 account for about 25% of suicides (that age group only 10% of the population)

Besides depression, cognitive disorders, widowhood, and ill health / physical health were common comorbidities in male suicide victims > age 30

Suicide Epidemiology

According to the National Center for Health Statistics at the CDC

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The vast majority of people with suicidal thoughts do not carry them out to their conclusion

There are about 12 suicide attempts for one completed suicide

In America, there are four male suicides for every female suicide

90-95% of suicides are associated with a mental illness or addictive disorder• 80% of victims suffered from untreated depression

• Alcohol and substance abuse accounts for 33% of the suicides

Comorbidity is present in 75% of suicides

66% of suicide victims communicated suicidal thoughts in advance of the act

50% had seen their PCP within the past month

Suicide Epidemiology

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Prior suicide attempt - the best predictor of suicide *

Family history- Suicide has a moderate tendency to run in families

First few weeks to months after discharge from a psychiatric unit

People who own guns are more likely to complete suicide

Having to appear in court as a defendant

Serious argument with spouse

Psychiatric diagnosis; depression, bipolar disorder, alcoholism, substance abuse

Q. What are Suicide Risk Factors

*Holden, 1992 Suicide / Chapter 10: Development / from Psychology- an Introduction- by Russell A. Dewey, PhD

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BIOMARKERS *• biomarker encoded by a gene called SAT1 can identify people at risk of suicide

Suicide Risk Factors

Alexander Niculescu, psychiatrist at Indiana University in Indianapolis- article published in Molecular Psychiatry

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“The suicide rate among 10 to 14 year-olds doubled between 2007 and 2014,surpassing the death rate in that age group from car crashes.”

“Young students in prior generations left school each afternoon and avoided someone who bullied them until the next day.

Now, social media allows for bullying 24/7.”

In The News

According to the Centers for Disease Control and Prevention

James M. O’Neill, USA Today – July 2017

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Depression can be effectively treated, but many patients do not receive treatment

There is no exact formula to predict who will commit suicide; however, depression, bipolar disorder, alcohol and substance abuse are key suicide risk factors

Comorbidity is common with alcohol and substance abuse and all psychiatric diagnoses

Comorbidity and non-compliance with treatment are often present at the time of suicide

Depression and Suicide - Key Points

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Physicians- Rank #1

with one very notable distinction:

The incidence among males and females is the same

Q. What Occupation Has the Highest Rate of Suicide?

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One more very important fact….

Physicians also live longer and are generally healthier than people in most other professions. Even if we include those who commit suicide or suffer from depression, life expectancy and well-being are still very high amongst doctors.

Suicide By Occupation

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Q. What is the most popular suicide spot in the U.S?

http://www.bestschoolcounselingdegrees.com/10-most-popular-suicide-spots-on-earth/

https://www.bing.com/videos/search?q=Golden+Gate+Jumper+Survivors&&view=detail&mid=94815772FF183F70934E94815772FF183F70934E&&FORM=VDRVRV

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“I still see my hands coming off the railing.

I instantly realized that everything in my life that I’d thought was unfixable

was totally fixable –

except for having jumped”

Ken Baldwin, survivor

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