Depression suicide risk

Comorbidity in social phobia is quite common as it may overlap with other anxiety disorders and with depression. Suicide risk is increased, and substance abuse—interpreted by clinicians as an effort to self-medicate—is commonly seen among these patients. 

Depression occurring as part of bipolar disorder may be severe and accompanied by ideas of guilt and hopelessness, an inability to function at work because of poor concentration and psychomotor retardation or agitation, poor judgement and suicidal ideation. The lifelong risk of suicide in people with this condition is as high as 15%. Factors associated with suicide risk include alcohol misuse, marital separation or divorce, living alone and unemployment, and these are all common secondary consequences of the illness. 

The cocaine addict most often presents during withdrawal after a binge of cocaine use. Cocaine withdrawal is not life threatening and does not require medical intervention in the same sense as alcohol or opiate withdrawal. It is, however, associated with a profound depression that can render the addict suicidal for 24-48 hours. The crashing cocaine addict should be assessed for suicide risk and, if indicated, the patient should be monitored in an emergency psychiatric setting or may require a brief 1-2 day inpatient psychiatric admission until the withdrawal resolves and the suicide risk is relieved. 

Suicide The risk of suicide is increased in patients with substance abuse with or without concomitant depression. This risk is not abated by treatment with naltrexone. 

Suicidality in children and adolescents Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of trazodone or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Trazodone not approved for use in pediatric patients (see Clinical worsening and suicide risk and Children sections in Warnings). 

Suicide risk Patients with major depressive disorder, both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality), whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. 

These are usually treated with sedative neuroleptics (as for schizophrenia, above). Treatment must also aim to support the patient socially including for instance advising on legal protection from the financial or other consequences of mania. One of the risks of treatment is the sudden mood swing at the end of the manic episode, with acute depression possibly triggered by the neuroleptics. Because of the concern for the manic episode and symptoms, return to normal is viewed with relief, and the downswing may go un-noticed, with the concomitant suicidal risk. 

Supervise suicidal-risk patient closely during early therapy (as depression lessens, energy level improves, increasing suicidal potential)... 

Rao, U., Weissman, M.M., Martin, J.A., and Hammond, R.W (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study. J Am Acad Child Adolesc Psychiatry 32 21-27. 

There is no empirical evidence available for clinical use in children and adolescents. Yet, Hypericum seems to be used for the treatment of mild to moderate depression in the young (Walter et ah, 2000). St. John s wort should be avoided in young patients with severe depression and bipolar disorder (given the lack of adult data about effectiveness and risk of manic induction, respectively) and in those who have significant suicide risk. Treatments of proven efficacy (e.g., SSRIs, mood stabilisers) should be preferred in these cases. However, St. John s wort may be considered in cases of unipolar depression where conventional treatments have failed and prior to the use of combinations of drugs that have an increased risk of side effects and whose efficacy has not been demonstrated. 

TCAs in more serious forms of depression such as melancholic or psychotic depression. Some studies have suggested that the SSRls do not work as well as the TCAs in melancholic depression (Roose et al. 1994]. Likewise, one study has suggested that venlafaxine, a drug with a mechanism of action similar to that of the TCAs, was superior to fluoxetine in the treatment of inpatients with melancholic depression (Clerc et al. 1994]. Still, other metaanalyses have failed to find a difference in the efficacy of SSRls versus TCAs in serious forms of depression [Nierenberg 1994]. Nonetheless, given that most studies have employed TCAs, and some debate exists about the utility of SSRls in severe subtypes, it may be prudent to start with a TCA in most patients until the debate is further resolved. For patients who present a significant suicide risk or who have not been able to tolerate TCAs, the SSRls in combination with a standard antipsychotic appears an effective option. 

Psychiatr Chn North Am 19 179-200, 1996 Fava M, Rosenbaum JF, McGrath PJ, et al Dthium and tricyclic augmentation of fluoxetine treatment for resistant major depression a double-blind, controlled study. Am J Psychiatry 151 1372-1374, 1994 Fawcett J Suicide risk factors in depressive disorders and panic disorder. J Clin Psychiatry 53 [suppl 3) 9-13, 1992... 

The best-known products come from the amphetamine group (see Table 1.12) Dexedrine1 1 (generic name d-amphetamine) and Pervitin 1 (methamphetamine) were particularly used in the 1950s and 1960s as stimulants and also as appetite suppressants, but today play hardly any role in medical practice. Ritalin (methylphenidate) has some relevance its psychostimulant action is said to be weaker than that of amphetamines and it is apparent ) less abused than the latter. Because methylphenidate also possesses mild antidepressant activity, in some countries it is used to combat not only narcolepsy and ADHD but also mild depressions without suicide risk (Satel and Nelson, 1989). 

Often there is a childhood history of hyperactivity or parental abuse or a family history of depression, suicide, or alcoholism. As with alcohol, other substances can decrease inhibition or markedly impair judgment, turning a gesture into a completed suicide. Clinicians should assume that patients with a history of substance abuse are at a higher risk for impulsive behavior that may place them or others in jeopardy. In obtaining a history, specific questions in addition to suicidal ideation or behavior should include the following ... 

BZDs may exacerbate depression and possibly increase suicide risk. Case reports and clinical trials also indicate that BZD treatment of generalized anxiety and panic may result in emergence of depression (215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225 and 226). In some of these reports, depression is ill-defined, but in others, it met DSM-III criteria for a major depressive disorder, requiring treatment with an antidepressant ( 225, 226). Depression has been reported with a variety of BZDs (alprazolam, bromazepam, clonazepam, diazepam, lorazepam), but there is no evidence that one is more likely than another to cause or aggravate depressive illness. 

Fawcett J. Suicide risk factors in depressive disorders and in panic disorder. J din Psychiatry 1992 5[3, Suppl] 9-13. 

Several studies have discussed the relationship between serum cholesterol and suicide, violence, anxiety disorders, depressive disorders, and schizophrenia [1-3]. Some of these papers suggested that low or lowering cholesterol levels could cause or worsen depressive symptoms and increase the risks of suicide and violence death. There are many reports that discussed the relationships between the lipid profiles, depression, and suicide from the viewpoints of decreased serotonergic transmission on suicide behavior [4, 5], lower serum cholesterol and serotonin levels [6, 7], serum cholesterol levels and polymorphism in the promoter region of the serotonin transporter gene for depression and suicide [8-10], low serum cholesterol and suicide risk [11, 12], and serotonergic receptor function [13, 14]. These studies supported the hypothesis that reduced cholesterol levels resulted in reduced central serotonin transmission. 

Kim YK, Myint AM. Clinical application of low serum cholesterol as an indicator for suicide risk in major depression. J Affect Disord 2004 81 161-166. 

---