DEPRESSION II – severe and Suicide risk; diagnoses and treatment

DEC 17TH, 2019

Agenda TODAY

00:00 Announcements 00:05 Theme specific Poll00:25 Didactics 00:30 Case presentation/ discussion 00:50 Questions00:55 Didactic survey and bye

NEXT SESSION is on 01.28.20 addressing Maternal Depression

POLLING QUESTION

What are suicidal risk factors among the following? check all relevant

❑ Family history of suicide

❑ Chronic PAIN

❑ Minority gender/sexual identity

❑ Previous suicidal attempts

CME/MOC PACKAGE= 60 POINTS▪ Starts February 2020 – ends June 2020, to Board by July 2020.

▪ In January, we will open registration for the 60 point package

▪ In February 2020 there will be one 60 minute session presented, outside of VMAP, to discuss QI/PDSA and setting up your MOC 4 chart review.

▪ In April- May 2020, the VMAP session will be dedicated to presenting our compiled data from intake and discussing barriers to mental health screening.

▪ In June 2020, you will complete attestation and submit points.

Didactics CECILIA MARGRET MD , Asst .Professor, Ch i ld and Adol . Psychiatry, UW -Seatt le

BETH ELLEN DAVIS MD , Professor, Deve lopmental Pediatr ics , UCV - V i rg inia

Objectives At the end of the session providers will be able to list and discuss the following Depression –moderate and severe categories

1. Prevalence

2. Screening and ASSESSMENT

3. Interventions

4. Non suicidal self injury

5. Medication use in severe and refractory depression

PREVALENCE

Major depression; prevalence among youth

Epidemiology Suicide completion rates

Ages 5 to 11: 1 per 1 million Ages 10-14: 1 per 100,000 Ages 15-19: 7-8 per 100,000

Means of completed Suicide

Hanging and Firearms >90% Overdose ~7% Other Means (Cutting) <3%

The gap between M: F is reducing

CDC, Ruch et al 2019:Trends in Suicide Among Youth Aged 10 to 19 Years in the United States, 1975 to 2016

Prevalence

Prevalence rates for suicidal ideation (SI) range between 19.8% and 24.0% among youth.

Girls are more likely than boys to have SI while boys are more likely to attempt suicide and to die by suicide.

Nock, Borges, Bromet, Cha et al., 2008; Youth Suicide Surveillance Summary, 2017

VIRGINIA

•Suicide is the 2nd leading cause of death for ages 10 to 24, both nationwide and in Fairfax County

•57% of these suicides were individuals with a mental health disorder

NIMH at https://www.nimh.nih.gov/health/statistics/suicide.shtml; Youth Suicide Surveillance Summary, 2017 at https://www.fairfaxcounty.gov/health/sites/health/files/assets/documents/pdf/reports/suicide-epi-report-2017.pdf

WASHINGTON

http://depts.washington.edu/hiprc/suicide/youth/

SCREENING

Screeners▪Use a screener for depression and mental health – BROAD AND SPECIFIC

▪Conduct suicide screeners along with mood screeners - they are usually short: • Ask Suicide-Screening Questions (ASQ): https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-

materials/index.shtml

• The Columbia Suicide Severity Rating Scale (C-SSRS) for primary care settings: http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare/#filter=.general-use.english

• The gold standard for assessment of suicidal ideation is the Suicidal Ideation Questionnaire - there is a junior (for younger adolescents) and a senior version (for older adolescents) but it is copyrighted and costly.

▪Hold and reference the screener during conversation if the individual is reluctant to talk

▪Include them in patient’s chart/ record

PAL guide

Brief suicide risk assessment

1.Praise patient 2. Consider measures (PHQ-9, SCARED, CRAFFT 2.0) 3. Interview patient alone & with caregiver(s) 4. Assess protective factors 5. Make a safety plan 6. Determine disposition 7. Provide resources

SAFETY TRUMPS CONFIDENTIALITY

ASQ NIMH toolkit

Suicide Risk Factors

Risk factors: H/O mood disorder, anxiety disorder, substance use, disruptive disorders, LGBTQ identity, abuse/ trauma, male gender, bullying, self-harm, previous attempts, Native American, substance use, family history of completed suicide, familial substance and psychiatric disorders, chronic medical illnesses

Moderation factors: clinical care, access to care, self regulation skills, problem solving skills, relationship skills, lack of substance use , cultural and religious beliefs for self preservation

Duncan 2017, PAL conference, Hilt

Suicide Risk- IS PATH WARM?

• Self harm, no SI, hopeful, social support

Low

• Previous attempt, high intent and lethal plans, bleak future, hopelessness, agitated/impulsive states, regret for life, no social support, poor communication /engagement

High

ER, Safety planning, crisis planning, crisis lines, hospitalization

Therapy, validation, brainstorm, monitor, means reduction, safety planning psychoeducation of family/parent

Ideation • Substance abuse • Purposelessness • Anxiety • Trapped • Hopelessness • Withdrawal • Anger • Recklessness • Mood changes

PAL conference 2016, Weiss PAL con.

WHAT TO DO ?

Components of Suicidal Ideation1) Intent: passing thought or intention to die with date decided

2) Lethality: #1 method of teens is hanging/ strangulation, #2 is firearms – both nationally and in Fairfax Co

3) Degree of Ambivalence: How sure are they that they want to die? To live?

4) Intensity of Suicidal Ideation: scale of 1 to 10

5) Frequency of Suicidal Ideation

6) Availability of Means/ Methods and Rehearsal

7) Suicide Note (often a text or Instagram post)

8) Deterrents: Reasons NOT to consider suicide (Religious beliefs, a sibling, a pet)

For all people identifying SI a thorough assessment reveals all of these components.

NIMH at https://www.nimh.nih.gov/health/statistics/suicide.shtml; Youth Suicide Surveillance Summary, 2017 at https://www.fairfaxcounty.gov/health/sites/health/files/assets/documents/pdf/reports/suicide-epi-report-2017.pdf

INTERVENTIONS

Develop Safety Plan

PAL GUIDE, Weiss PAL conference /MCH CORWAVA WEBSITE This Photo by Unknown Author is licensed under CC BY-SA-NC

Safety Planning InterventionA brief intervention studied by Stanley and Brown

1) Identify Early Warning Signs – Unique to that patient

2) Internal Coping Strategies – what are they already doing

3) Employ Distraction Activities, and Socialization

4) Make use of Social Support contacts who offer help

5) Contact information for Crisis Resources

6) Make environment safe – Ropes/ cords (strangulation), firearms, medications (overdose)- may include monitoring patient closely

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264.

NON SUICIDAL Self injury Non-suicidal self-injury is the intentional destruction of body tissue without suicidal intent

Common forms of NSSI are cutting and burning

Prevalence 15 %

Goals/associated conditions: Affect regulation, abuse, anxiety, SI and self loathing

Reinforcers: punishment, opioids, peer pressure, groupism

TREATMENT : Validation, regulation of emotion, cognitive recognition and skills (sensory JOLT)

Klonsky et al, Croyle et al 2007, Liu 2018, PAL conference, Hilt

PSYCHOTHERAPIES- evidence based

Cognitive Behavioral Therapy- cognitive restructure and behavioral activation

Interpersonal therapy - Adolescents – interpersonal effectiveness

Dialectical behavioral Therapy – balancing acceptance and change

Family therapy – align support, functional roles and improve communication

WHO atlas

MEDICATIONS

MEDICATIONS

➢First line – SSRIs, fluoxetine, sertraline, and citalopram/escitalopram (TADS’ 03)

➢Second line – SNRIs and dual action, venlafaxine, duloxetine, bupropion, mirtazapine, clomipramine (TORDIA)

➢Augmentation – adding a second SSRI, stimulant medication, atypical antipsychotic, thyroid hormone, lithium for SI

➢Sedatives / additives – short term use only (Trazodone, Mirtazapine, clonidine, Melatonin, Seroquel, prazosin for frequent nightmares).

COMMON CROSSROADS- to name a few

How to change one SSRI to another?

How to monitor for SI or activation ?

What can I augment?

When is it time to call a failed trial?

What to do when teen refuses medication?

What if teen wishes to cross SSRI with drug use?

Understanding Suicide risk with medications

1. Check Height and Weight

2. Be Aware of placebo rates (up to 45%)

3. Check irritability and activation, new onset after 2 and 4 weeks of medication initiation

4. Check bruising, at least once after medication initiation

5. Check on new onset suicidal thoughts, after 2 and 4 weeks and around dosage changes

6. Determine response using rating scales, until remission.

7. Titrate dose to optimal dosing, every 4 – 6 weeks

CLINICAL PEARLS

1. Recognize major depression

2. Recognize suicidal ideations, intent, coping, access etc., to understand RISKs

3. Be ready to screen and intervene

4. HAVE A PLAN, RESOURCES and REFERRALS

5. Engage and EMPATHIZE with patient and parents

6. Refer and monitor

7. SELF CARE PLAN

?

Case discussion

17 F with depression and SI

Patient DOBPatient gender FemalePatient race/ethnicity CaucasianPrior medical or mental health

diagnoses and age at diagnosis

Anxiety and depression, age 17 (my first diagnosis and treatment, though she had perhaps been seen elsewhere previously and

mentions long-standing anxiety)

Symptoms (ABC, FINDS) 3/2018: Jr year of high school - feelings of depression and anxiety, pressure to be successful, unhappy with weight (obese), has

tried counseling in past but didn’t help. “Would be easier” if she were dead but has no plans to hurt herself – “Suicide is wrong

and I will go to hell.” Has quit hanging out with friends, quit band and other after school activities. Mom and dad are supportive,

both with h/o major depression. Started celexa 10 mg and recommended counseling, referred to SW in our office. 4 weeks later –

much better, PHQ9 now 2, patient decided she didn’t need counseling, continued on this dose, no SI. October / November 2018-

lumbar disc herniation with significant pain requiring surgery. Was out of school for several weeks, behind in work, no physical

activity. Depression was worse, not sleeping well, having nightmares and attributed this to celexa, wanted to change medications.

Thoughts of “ending it all” but no plan, felt safe at home. Again referred to SW and counseling. Changed to Prozac 10 mg with

plans to increase to 20 mg but 20 made her feel like a “zombie” so stayed at 10 mg. Had increased motivation with this, PHQ9

from 21 to 9. After about a month- came back – “I hate this medicine.” More SI, again no plan. PHQ9 back up to 18, wanted to

try Effexor (father and aunt had success with this). Started 37.5 mg Effexor and able to finish senior year successfully, motivated,

no more SI, got into JMU for college. 7/2019 – last visit before college, nervous but excited, plan to seek counseling once she got

to school. Still not sleeping well. PHQ9 score 9. 11/2019 – came home from school because overwhelmed- now SI with plan “I

would take all of my medicine.” No motivation, difficulties with roommate, weight gain, bad grades. D/w mom who felt she could

keep patient safe. Effexor increased to 75 mg, should NOT go back to school until safety plan in place with school. Home for 2

weeks. SI improved but other symptoms not better after 2 weeks. Referred for rapid intake through community services board.

Other settings (school, day care)

Related ROS/HX Obese, lumbar dis herniation, SUD? Social (residence, foster care,

finances, trauma, ACES)

living with bio family. Junior in school.

Medications H/O Celexa 10 mg ( nightmares), Fluoxetine 10 – 20 ( zombie effect), currently Effexor XR 75mg Exam/labs/tests relevantCONSULT QUESTION

1) What to do when patients refuse counseling?

2) When to increase medication vs change to another medication?

3) When having SI on current medication, should that medication be stopped – ie, how much of “increased risk of SI with

SSRIs” should be attributed to medications vs baseline depression with need to actually increase that medication?

4) How to determine safety? Need for written safety plan (vs verbal)?

5) Obvious psychosocial factors that exacerbated symptoms – should medication be increased during these times of stress?

Post-Session EvaluationAs a result of attending the session, to what extent did your Confidence in the learning objectives change?

Depression and

suicidality

Much more confident

Somewhat more confident

Confidence unchanged

Less confident

Define and discuss EPIDEMIOLOGY

Define and discussSCREENING

Define and discuss INTERVENTIONS

Define and discuss NON SUICIDAL SELF INJURY

Define and discussMEDICATIONS