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 MDDHas 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 maleCaucasianRecently bereavedMajor depressive disorderHas ideation, plan and actionLives aloneNo religious injunctionPositive 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!

EpidemiologySuicide is 11th 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 rateOne of top 3 causes of death in adolescentsIncreased incidence in: 1.early-onset mood disorders2.traumatic brain injury,3.homosexual and bisexual adolescents4.borderline & antisocial personality

disorders5.eating disorder patients

Epidemiology Continued:6. Alcohol/substance abusers7. Sex abuse history8. Caucasian > African-American9. Native American10. Schizophrenia and other

psychoses11. Immigrants

Additional Risk FactorsDivorced, widowed, singleLive aloneUnemployedMood or anxiety disorder (esp. anxious

depression)Bipolar disorderPrior attemptsPositive 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

femaleNo intent, plan or action.Religious prohibitionStrong social supportChild in householdNo personal or family history

Management:Have her commit to safety? No suicide contractInstructions regarding Crisis CenterRemove any guns from houseAntidepressant titrated to full doses (don’t

undertreat)Consider sertraline (worked before)Warn regarding increased suicidal ideation initiallyReturn visit in 1-2 weeksDOCUMENT!!

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

AkathesiaImpulsive-aggressive behavior

Psycho-Social-Spiritual FactorsAnxious +/or

depressed mood

Externalizing behaviors

Recent loss of relationship

No religious prohibition

Hopelessness

Lack of social support

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 iPOD 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 - highSays “maybe” about suicidal

thoughts but has a plan.Adolescent white maleDown, irritable mood that lightened

recently without treatment.AnhedonicGave 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 AntipsychoticLow dose antipsychotic can make

antidepressant more effective (e.g., aripiprazole 5-10 mg hs).

Side effects of antipsychotics are a problem:1.Sedation2.Metabolic Syndrome3.Extrapyramidal 4.Prolongation of QTc

Prolongation of QTcQTc from beginning of QRS to end of T waveHR > 70, normal QT < ½ R-R intervalQT 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 msecFemale < 450 msec

(Worry if > 500 msec)

QRS – T Complex

Prolonged QT Interval

Heart Rate and QT Interval

Risks for PTc ProlongationCertain drugsFemaleOlder ageNighttime (normal increase of 20 msec)Cardiovascular diseaseLow potassium or magnesiumPoor metabolismHypertropic cardiomyopathyCongenital (e.g., Brugada Syndrome)

Psychiatric Drugs at Risk of Causing TdP:ChlorpromazineHaloperidolMesoridazineMethadonePimozideThioridazine

Arizona Center for Education and Research on Therapeutics funded by AHRQ (www.QTdrugs.org)

QTc & Antidepressants or Antipsychotics:1. Monitor BP & P2. Baseline EKG if age > 50 or personal/family

history of syncope, electrolyte abn., or CV disease

3. Repeat EKG at steady state4. Worry if QTc > ½ R-R or > 500 msec5. Holter if bradycardia6. Obtain potassium, magnesium and calcium

levels if on multiple drugs, congential QT prolongation, liver disese, female, long QTc, or bradycardia.

EvaluationSensitive 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!]

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 SurvivorsFeel stigmatizedOften have guiltAbandonment feelingsIncreased psychosomatic complaints &

vulnerable to medical and psychiatric illnesses

Behavioral problems in kidsWant PCP to contact them for supportConsider suicide group for family

PreventionRecognize and fully treat psychiatric illnessTake all comments seriouslyHigh index of suspicion (adolescents often

give away prized possessions before suicide)Assure social supportEducation of public and patientsWatch for suicide clusters in adolescentsSuicide hot lines

Questions?