Suicide disorder

Anxiety disorders and insomnia represent relatively common medical problems within the general population. These problems typically recur over a person s lifetime (3,4). Epidemiological studies in the United States indicate that the lifetime prevalence for significant anxiety disorders is about 15%. Anxiety disorders are serious medical problems affecting not only quaUty of life, but additionally may indirecdy result in considerable morbidity owing to association with depression, cardiovascular disease, suicidal behavior, and substance-related disorders. 

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). 

The antipsychotic dru are used cautiously in patients exposed to extreme heat or phosphorous insecticides and in those with respiratory disorders, glaucoma, prostatic hypertrophy, epilepsy, decreased renal function, lactation, or peptic ulcer. The antipsychotic drags are used cautiously in elderly and debilitated patients because these patients are more sensitive to the antipsychotic dragp. lithium is used cautiously in patients who are in situations in which they may sweat profusely and those who are suicidal, have diarrhea, or who have an infection or fever. 

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. 

Few papers have looked at the economic implications of bipolar affective disorder. Most of the published studies look at direct medical costs over the course of a year. Industry-sponsored studies focus on the benefits of a new treatment over older treatments. However, factors individual to a particular patient are likely to be more important than the average cost of a particular treatment. These include selection of patients who are likely to respond to a particular treatment, and psychoeducation coupled with encouragement during follow-up and carefial monitoring, to avoid such expensive outcomes as ftill-blown relapse, serious toxicity or suicide. 

Psychiatric adverse effects occur frequently and may include irritability, depression, and rarely, suicidal ideation. Individuals with a history of uncontrolled psychiatric disorders must weigh the risk versus benefit of treatment, as interferon may exacerbate or worsen the psychiatric condition. Patients who develop mild to moderate symptoms may require antidepressants or anxiolytics. Those with severe symptoms including suicidal ideation should have the treatment discontinued immediately.43... 

One extremely important outcome in the treatment of major depressive disorder is the prevention of suicidal attempts. 

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. 

Lifetime prevalence rates of psychiatric comorbidity co-existing with bipolar disorder are 42% to 50%.16 Comorbidities, especially substance abuse, make it difficult to establish a definitive diagnosis and complicate treatment. Comorbidities also place the patient at risk for a poorer outcome, high rates of suicidal-ity, and onset of depression.2 Psychiatric comorbidities include ... 

Assess for the safety of others and potential for violence. If accompanied by friends or family with whom the patient is living, ask them to remove from the home all guns, caustic chemicals, medications, and objects the person might use to harm self or others. Risk factors for suicide include severity of depression, feelings of hopelessness, comorbid personality disorder, and a history of a previous suicide attempt.19... 

Psoriasis is a common inflammatory skin disorder which is estimated to affect 1.5% to 3% of the Caucasian population.1,2 It may present at any age.3,4 Ethnic factors influence disease prevalence. In the United States, prevalence among blacks (0.45% to 0.7%) is lower than in the remainder of the United States population (1.4% to 4.6%).1 Between 10% and 30% of patients with psoriasis will also have psoriatic arthritis.5 In 10% to 15% of psoriatic patients with arthritis, joint symptoms actually appear prior to skin involvement.3 Clinical depression is another frequent comorbid illness in these patients. A recent United States survey showed that 8% to 10% of psoriatic patients aged 18 to 54 years old actively contemplated suicide because of their psoriasis.6... 

Kramer, T., Lindy, J., Green, B., Grace, M. and Leonard, A., The lombordity of post traumatic stress disorder and suicidality in Vietnam veterans. Suicide and Life Threatening Behaviors 24(1), 58, 1994. 

Convulsive disorders are still a serious therapeutic problem and new agents are being actively sought. Classical therapy was based upon the barbiturates that are no longer in favor because of their many side effects and their suicide potential. Interestingly, a seemingly minor structural variation of phenobarbital (152, shown as its sodium salt) leads to an anticonvulsant of increased potency and which has less hypnotic activity. In this case, sodium phenobarbital serves as its own base (so the yield is limited to 50%) and reacts readily with... 

G-protein-coupled cyclic AMP signaling in postmortem brain of subjects with mood disorders effects of diagnosis, suicide, and treatment at the time of death. J. Neurochem. 73, 1121-26. 

Schizophrenia is a chronic, complex psychiatric disorder affecting approximately 1% of the population worldwide. The chronic nature of the illness, in addition to the early age of onset, results in direct and indirect health care expenditures in the U.S., which amount to approximately 30 to 64 billion dollars per year [4]. It is perhaps the most devastating of psychiatric disorders, with approximately 10% of patients committing suicide. The dopamine hypothesis of schizophrenia postulates that overactivity at dopaminergic synapses in the central nervous system (CNS), particularly the mesolimbic system, causes the psychotic symptoms (hallucinations and delusions) of schizophrenia. Roth and Meltzer [5] have provided a review of the literature and have concluded a role for serotonin as well in the pathophysiology and treatment of schizophrenia. The basic premise of their work stems from the known interaction between the serotonergic and dopaminergic systems. 

Suicide risk is higher than any other psychiatric disorder... 

The development of lithium-specific electrodes has assisted greatly in monitoring patient compliance. The toxicity profile of lithium carbonate is now well established and the drug is safely administered and well tolerated. It is of limited use in other psychiatric disorders such as pathological aggression, although additional benefit may also include a reduction in actual or attempted suicide. 

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). 

In depressed patients, cortical-hypothalamic-pituitary-adrenal axis hyperactivity can be explained by the hypersecretion of CRF, and secondary pituitary and adrenal gland hypertrophy. Impaired negative feedback at various CNS sites, including the hippocampus and pituitary are also likely to contribute. Downregulation of hippocampal mineralocorticoid receptors and expression is reported in depressed suicides [50]. In bipolar disorder, hyperactivity of the cortical-hypothalamic-pituitary-adrenal axis has been observed [51]. This increase in cortical-hypothalamic-pituitary-adrenal axis activity has also been observed in mixed mood states, mania and in depression in rapidcycling patients. Partial reversal of HPA overactivity is associated with treatment and recovery from depression. 

Chen, Y. W. and Dilsaver, S. C. Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other Axis I disorders. Biol. Psych. 39 896-899,1996. 

McBride, P. A., Brown, R. P, DeMeo, M. et al. The relationship of platelet 5-HT2 receptor indices to major depressive disorder, personality traits, and suicidal behavior. Biol. Psych. 35 295-308,1994. 

---