Suicidal episodes

My brain was so overloaded with chemicals at that time that I experienced three suicidal episodes. The air outside was too toxic for me, the air inside was too toxic, and the inside of my car was toxic. I couldn t think. I didn t know what to do. I could see no reason to live. There was no place to go. 

Depression is a common psychiatric disorder. The lifetime risk of developing a depressive episode is estimated to be as high as 8—12% for men and 20—26% for women (116). Depression, one of the most widespread of all life-threatening disorders, is almost always a factor in the mote than 30,000 suicides that occur annually in the United States alone (117). 

HINT In order to remember the nine diagnostic symptoms for a major depressive episode, learn the following mnemonic Depression = SIG E CAPS (depression, sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide). 

The course of MDD varies markedly from patient to patient. It is not uncommon for a patient to experience only a single major depressive episode, but most patients with MDD will experience multiple episodes. Some patients experience isolated episodes separated by many years, others have clusters of episodes, and still others will suffer more frequent episodes as they age. The number of prior episodes predicts the likelihood of developing subsequent episodes such that by the time a patient experiences a third major depressive episode, there is about a 90% chance that he or she will have a fourth one. MDD is associated with a high mortality rate because about 15% of patients ultimately will commit suicide.3... 

The mean age of onset of bipolar disorder is 20, although onset may occur in early childhood to the mid-40s.1 If the onset of symptoms occurs after 60 years of age, the condition is probably secondary to medical causes. Early onset of bipolar disorder is associated with greater comorbidities, more mood episodes, a greater proportion of days depressed, and greater lifetime risk of suicide attempts, compared to bipolar disorder with a later onset. Substance abuse and anxiety disorders are more common in patients with an early onset. Patients with bipolar disorder also have higher rates of suicidal thinking, suicidal attempts, and completed suicides. 

Patients with bipolar disorder have a high risk of suicide. Factors that increase that risk are early age at disease onset, high number of depressive episodes, comorbid alcohol abuse, personal history of antidepressant-induced mania, and family history of suicidal behavior.15 In those with bipolar disorder, 1 of 5 suicide attempts are lethal, in contrast to 1 of 10 to 1 of 20 in the general population. 

Non-motor signs of the disorder are also treatable with symptomatic medications. The frequent mood disorder can be treated with standard antidepressants, including tricyclics (such as amitryptiline) or serotonin reuptake inhibitors (SSRIs, such as fluoxetine or sertraline). This treatment is not without risks in these patients, as it may trigger manic episodes or may even precipitate suicide. Anxiety responds to benzodiazepines, as well as to effective treatment of depression. Long-acting benzodiazepines are favored over short-acting ones because of the lesser abuse potential. Some of the behavioral abnormalities may respond to treatment with the neuroleptics as well. The use of atypical neuroleptics, such as clozapine is preferred over the typical neuroleptics as they may help to control dyskinesias with relatively few extrapyramidal side-effects (Ch. 54). 

Suicidal ideation or attempts (suicide completion rates with bipolar I disorder are 10-15% suicide attempts are primarily associated with depressive episodes, mixed episodes with severe depression or presence of psychosis)... 

Lithium is effective for acute mania, but it may require 6 to 8 weeks to show antidepressant efficacy. It may be more effective for elated mania and less effective for mania with psychotic features, mixed episodes, rapid cycling, and when alcohol and drug abuse is present. Maintenance therapy is more effective in patients with fewer episodes, good functioning between episodes, and when there is a family history of good response to lithium. It produces a prophylactic response in up to two-thirds of patients and reduces suicide risk by eight- to 10-fold. 

I sometimes give myself permission to have knock-down-drag-out major depressive episodes, with suicidal thoughts and everything, because that s how sad I feel, or how hurt. But I would not take my life. I can t disappoint Jehovah, and I could not do that to my family or friends. I know the depression will pass. 

Lithium is the simplest therapeutic agent for the treatment of depression and has been used for over 100 years—lithium carbonate and citrate were described in the British Pharmacopoeia of 1885. Lithium therapy went through periods when it was in common use, and periods when it was discouraged. Finally, in 1949, J.J.F. Cade reported that lithium carbonate could reverse the symptoms of patients with bipolar disorder (manic-depression), a chronic disorder that affects between 1% and 2% of the population. The disease is characterized by episodic periods of elevated or depressed mood, severely reduces the patients quality of life and dramatically increases their likelihood of committing suicide. Today, it is the standard treatment, often combined with other drugs, for bipolar disorder and is prescribed in over 50% of bipolar disorder patients. It has clearly been shown to reduce the risk of suicide in mood disorder patients, and its socioeconomic impact is considerable—it is estimated to have saved around 9 billion in the USA alone in 1881. 

About one person in 20 will suffer one or more episodes of major depression at some time during their life. Women are afflicted about twice as frequently as men. Major depressive episodes are life threatening. About 20% of victims end their lives by suicide. Susceptibility to major depression is family related. Although the genes that sensitize a person for major depressive illness have not been identified, it is clear that there is a genetic component to this disorder. 

Depressed mood is the hallmark symptom of MDD, but it is neither required nor sufficient for the diagnosis of major depression. In addition to depressed mood, the key symptoms of a major depressive episode include anhedonia, changes in sleep or appetite, psychomotor retardation or agitation, poor concentration or indecisiveness, and recurrent thoughts of death or suicide. The DSM-IV definition of major depression requires that five or more of these symptoms be present for at least 2 weeks in the absence of an identifiable cause such as medication, medical illness, or the death of a loved one. Refer to Table 3.2 for the DSM-IV criteria for MDD. 

Manic, Hypomanic, and Mixed Episodes. The first step in managing an acute episode of BPAD is to choose the appropriate venue for treatment. Even when the patient is not overtly suicidal, the agitation, disinhibition, and impulsivity inherent to a severe manic or mixed episode of the disorder commonly require hospitalization. Hypomania, however, can usually be managed outside the hospital with frequent outpatient visits. This is particularly true if the longitudinal course of the patient s illness indicates that the patient is unlikely to progress to a full-blown manic episode. 

Depressive Episodes. The emphasis of treatment research in bipolar illness has understandably been on the management of manic and hypomanic phases of these disorders. However, there is clearly room for improvement in the treatment of the depressive phase of BPAD as well. Depression accounts for the majority of BPAD episodes in both men and women, especially the latter. Furthermore, bipolar depression is associated with an increased risk of suicide. 

The course of AN is highly variable. Some patients with anorexia experience a single episode of the disorder with full recovery. Others have recurrent exacerbations of AN interspersed with periods of remission during which they return to a normal weight. Finally, some AN patients experience a chronic, deteriorating course that results in frequent hospitalizations for medical stabilization. Of the chronic AN patients who are admitted to academic center hospitals for medical care, 10% ultimately die from AN due to starvation, suicide, or electrolyte imbalance. 

In addition to parkinsonism, another extrapyramidal side effect is the so-called acute dystonic reaction in which muscles (usually of the face or neck) go into an acute spasm. A dystonic reaction is painful and unpleasant, usually occurs early in treatment, and sometimes occurs after the very first dose of an antipsychotic. Another extrapyramidal symptom is akathisia, a restless inability to relax and sit still. Akathisia can range from a mild restlessness to extreme agitation. Rarely, patients have been known to attempt suicide during severe episodes of akathisia. It is easy to overlook akathisia, because it can easily be mistaken for a worsening of psychosis or anxiety. 

The diagnosis of mania is made on the basis of clinical history plus a mental state examination. Key features of mania include elevated, expansive or irritable mood accompanied by hyperactivity, pressure of speech, flight of ideas, grandiosity, hyposomnia and distractibility. Such episodes may alternate with severe depression, hence the term "bipolar illness", which is clinically similar to that seen in patients with "unipolar depression". In such cases, the mood can range from sadness to profound melancholia with feelings of guilt, anxiety, apprehension and suicidal ideation accompanied by anhedonia (lack of interest in work, food, sex, etc.). 

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. 

Panic disorder is comorbid with episodes of depression at some stage in the majority of cases (Stein et al. 1990), with social anxiety disorder and to a lesser extent GAD and PTSD, and with alcohol dependence and personality disorder. Comorbidity results in increased severity and poor response to treatment. Panic disorder is associated with a significantly increased risk of suicide, and this is increased further by the presence of comorbid depression (Lepine et al. 1993). 

The recommendation for maintenance therapy depends on several factors, such as severity of the present depressive episode (e.g., suicidality, psychosis, functional impairment), number and severity of prior depressive episodes, chronicity, comorbid disorders, family psy-... 

Factors associated with increased risk for recurrence in naturalistic studies of depressed children and adolescents may serve as guidance to the clinician to decide who needs maintenance treatment. These factors include history of prior depressive episodes, female sex, late onset, suicidality, double depression, subsyndromal symptoms, poor functioning, personality disorders, exposure to negative events (e.g., abuse, conflicts), and family history of recurrent MDD (<2 episodes) (Birmaher et ah, 1996 a,b Goodyer et ah, 1998 Fewin-sohn et ah, 1999 Rao et ah, 1999 Rueter et al., 1999 Weissman et ah, 1999a, b Klein et ah, 2001). 

It is recommended that adult patients with second episodes of depression and who fulfill the criteria for maintenance therapy noted above be maintained for several years (up to 5 years in adult studies), using the same dosage of the antidepressant used to achieve clinical remission during the acute-treatment phase. Maintenance therapy for patients with three or more episodes of MDD, patients with second episodes associated with psychosis, severe impairment, and severe suicidality, and those who proved very difficult to treat should be considered for longer periods of time, even for the life of the patient (AACAP, 1998). 

Hospitalization for eating disorder depends on the weight status of the patient, the presence of medical complications, and the presence of related psychiatric comorbidities, such as depression, suicidal behavior, and OCD. Hospitalization for AN may be brief or extended. Inpatient brief hospitalization (7-14 days) is for patients who have (1) relapsed from previous treatment or have been ill for less than 6 months (2) a weight loss of 10%-15% from normal weight if they have relapsed, or 16%-20% if this is their first episode (3) hypokalemic alkalosis with serum potassium < 2.5 mEq/L and (4) cardiac arrhythmias. To promote rapid weight gain, patients can be placed on a liquid formula... 

Diagnosing depression is not a simple matter. Everyone experiences sadness once in a while, and in certain situations, such as the loss of a loved one, it is expected. The American Psychiatric Association, a group of professional psychiatrists, publishes the Diagnostic and Statistic Manual of Mental Disorders, a manual that outlines the criteria for diagnosing psychiatric disorders. This widely followed manual is periodically updated, and it is currently in its fourth edition. DSM-IV, as it is often abbreviated, defines a major depressive episode to be when the patient shows a depressed mood or the absence of pleasure for a certain period of time, as well as exhibiting some other symptoms such as loss of sleep, appetite, or recurrent thoughts of suicide. Depression is one of the most common disorders, with millions of cases diagnosed every year in the United States alone. 

Three or more episodes One or two prior severe episodes with Suicidal behavior Treatment refractoriness Psychosis... 

---