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Learning aboutMood Disorders and Suicide RiskSuzanne Zinck, MD, FRCPC IWK Health CentreDalhousie Department of Psychiatry
Objectives• Understand the basic causes and treatment of mood disorders• Learn to recognize the signs of a mood disorder in your students and how you can help.• Learn about how mood disorders can affect performance and some strategies to assist students with their learning as they recover from a mood disorder• Learn basics of suicide risk assessment
DSM-IV Mood Disorders• Major Depression• Dysthymia• Adjustment disorder with depressed mood• Bipolar I and II disorder• Depression due to a general medical condition• Substance-induced mood disorder
Major Depressive Episode• DSM-IV-TR (2000) criteria requires 5 out of 9 signs or symptoms for a two week period – Sadness or Irritability – Decreased Interest – Increased Guilt and/or Low Self-Esteem – Decreased Energy – Poor Concentration – Low or high appetite with possible weight change – Psychomotor (movement)changes – Poor or increased need for Sleep – Self-harm/suicide
Mood or Mood Disorder?• Mood changes are adaptive and assist us in coping with change and stress• If sustained low or irritable mood with negative thinking that affects functioning socially or in school or work for most of the day every day for two weeks or more, then it may well be a mood disorder.
SIGECAPSS• SIG prescribe• E energy• CAPSS capsules
Bipolar disorder• 0.8% Bipolar I• Up to 2% with inclusion of Bipolar II and 10% of whole spectrum• Increased risk in children and adolescents with psychotic depression or vegetative features (approximately 15-20%)• Early (childhood) onset is controversial – mixed states and rapid-cycling may predominate – may not meet DSM-IV criteria: if not, what is it?• Treatments: – Medication: • Lithium, valproate or combination • Lamotrigine • Atypical antipsychotics • SSRI’s (?switch) – Psychotherapy
Rates of depression in childrenGeneral population: – Pre-schoolers 0.3-0.9%* – School age 1.5-3% (boys > girls) – Adolescence • Early teens 1-6% (girls > boys) • For all syndromes 10% • Late teens (girls>boys) Males 12% Females 21-24%
Duration of depressive disorders• Mean durations: – Major depressive episode (MDE): 8-13 months – Dysthymia: 3 years – Adjustment disorder (<6 months by definition)• 69% will have MDE within 5 years of diagnosis with dysthymia• 30-72% children with MDE will relapse within 5 years. 12
Double Trouble: Comorbidity is common• 50% depressed will have another mental disorder• Anxiety disorders – 34% (> in girls)• Conduct disorder (law breaking) – 40% (> in boys)• Oppositional defiant disorder (rule-breaking)• Eating disorders• Substance use• ADHD ‘Bad’ or ‘Sad’?
Etiology: Causes Aplenty• Interaction likely among genetic risk (heredity), in-born temperament, learned cognitive style, learned behaviours and various forms of stress.• Likely multiple contributors as no single biological factor found in all subgroups of depressed adults or youth• Problems assessing causes versus consequences• Which comes first? Detailed time course can tell.
Development affectssymptom presentation of mood disorders.
Early school-age6-8 years old: 9-12 years old: – Lethargy As for 6-8, but also: – Sleeping problems -Low self-esteem – Irritability -Helplessness – Separation anxiety -Guilt – Prolonged unhappiness -Self-destructive behaviours – Poor school performance -Suicidal ideation – Accident-proneness -Aggression – Phobias - even Psychotic features – Attention-seeking behaviour
Adolescence (13-18 years old)• As with children, plus: • Concern about the future • Pessimism • Worthlessness • Apathy, “bored” • Vegetative signs and psychosis • Self-harm: – Lethal suicide attempts – Substance use – Eating disorders – Antisocial behaviour
Signs of depressed mood in the classroom• Decreased grades• Sad face/tearfulness• Appears tired• Appears overwhelmed• Poor attendance or leaving early• Cranky; giving attitude• Late assignments• Change in quality of work• Social isolation: drops friends and activities• Visible scars of self-harm
Downward spiralDepression affects thinking, action and self-concept. Problems at school can lead to decreased self- esteem and conflict with parents. They can withdraw from activities and see friends less or lose friends. They can become targets of bullying due to sad or reserved behaviour. They may not know what is happening and become hopeless. This may lead to suicidal thoughts and acts of self- harm.
Risks of untreated depression• Safety: self-harm or suicide• Failing a grade• Lose social supports• Drug abuse• Damage to family relationships
Self-harm and suicide• Rare event in the population but not among depressed youth.• 50% of mood disordered youth have ideas/plans• Up to 15% lifetime completion risk depending on co-morbidity.• Youth who talk about it still at risk• Cutting/burning never simply a “gesture”• Asking decreases risk not increases it.• Call parent or GC right away if suspect suicidal.
I think she’s depressed. What now?• Ask student, confidentially, caring.• Explain limits of confidentiality.• Expect stigma and irritability: don’t give up.• Speak to guidance counselor/Teen Health• Let student know about next steps• Call parent: check-in; provide referral info.• Invite parent to school meeting if needed• Consider & discuss adaptations in class• Encourage activities with adaptations
Getting teens to further help• Public & private options: depends on ability to pay or insurance coverage: IWK Central Referral (902) 464-4110 MHMCT (Mobile Crisis Team) (902) 429-8167 Local Mental Health clinics outside HRM Parent can refer to private psychologist or social worker.
Treatments• Pharmacotherapy – SSRIs – SNRIs – SARI ( trazodone ) for sleep – Lithium carbonate and antipsychotics• Psychotherapy – IPT – CBT – Family therapy• Combination therapy• Lifestyle modification
Treatment• Alone or in combination: – Skills-based psychotherapy – Medication (antidepressants) – Parent and teen education – Liaison with teachers, GC and VP of school – School meetings – Increase or resume positive activities – Level of treatment by severity & risk
Assisting in the school• Ensure confidentiality• Longer time for assignments and projects• Deferred or alternate exams• Encouragement• Matter-of-fact acceptance• Classroom education independent of event• Call parents as needed about attendance, performance.• Let therapist or psychiatrist know if permitted
Suicidal ideationVERY COMMON14% boys24% girls50% depressed teens will attempt in lifetime.Suicide attempts peak during teen years, after whichthere is a marked decline in frequency.Completed suicides increase throughout teen years intoadulthood. CDC, 2000 37
Suicide prevalencePre-pubertal children: Very rareAdolescents:Age 5-14: 1.5 per 100,000 (boys) 0.6 per 100, 000 (girls)Age 15-19: 8.2 per 100,000 (total)Ages 19-25: 22.4 per 100, 000 (white males) 4.5 per 100, 000 (white females)
Impact of suicidalityIn 2001:•19% of high school students “seriouslyconsidered attempting suicide”•15% made a specific plan•8.8% made an attempt•2.6% made a medically serious attempt Youth Risk Behavior Survey (YRBS),
Assessment of suicidality• Often time-limited in ER & office• In office, a screen of risk and stratification using knowninformation about your patient and their family is required.Screening assessment can determine whether an ER assessment•or admission is required or whether an office appointment can bemade.• Phone contact may be needed between visits.• Use MHMCT if available (902) 429-8167
Full crisis intervention includes a diagnostic•and a therapeutic interviewAssessment for depression, anxiety and•psychotic and substance abuse disordersOnce diagnoses and stressors understood, the•ER assessor and family doctor can collaborateon a safety plan and protocol on use of officeversus ER.This can treat not just manage patients withrecurrent self-harm.
Risk assessment has a time courseThe psychiatric and gender-specific diagnostic profiles of youthsuicide attempters are quite similar to the profiles of those whocomplete suicide.Complex issue: multiple factors must be assessed to determineriskAcute on chronic risk is assessed because suicide risk is adynamic state.ACUTE = now CHRONIC = baseline riskExample 1: Past attempt increases chronic risk. Current plan increases acute risk.Example 2: SUD increases chronic risk.Intoxication increases acute risk.
Interviewer’s goals• Obtain detailed information• Increase psychological awareness in patient and family ofsituation including thoughts, feelings and events• Family involvement and reactions: what does support or lackof look like in that family?• Assess teen’s developmental stage & decision-making style• Mental Status Examination: Observe affect and reactions ofpatient & family closely! No change means that there may belittle to no change in risk even if teen agrees to outpatientsafety plan (“ contract”).• Make risk assessment and safety plan and dispositiondecision
Exploring suicidal ideas and acts• Ideation frequency• Duration• Content• Preparation & access to lethal means• Rescue potential before, during, after attempts• Understanding of risk of attempts• Intent of attempt• Changes in motivation and intent• New stressors as a result of or during psychiatric illnessand the patient’s understanding of the meaning of theseevents
Risk assessment in mental status examination Affect: closed, angry, tearful, anxious Mood: congruent? Do they know? Sensorium: Intoxication Speech: coherent? Thought content: stressors known? Areproblems seen as solvable? Thought form: flexible? Rigid? Psychotic? Reasoning ability: normal or compromised? Psychomotor: agitated, apathetic and shut-down?
Stressful Life Events•Most common precipitants or interpersonalconflict or loss•Parent-child more common among youngerteens.•Romantic conflict more common among older.•Discord is a risk factor for attempted andcompleted suicide, especially if it is unrelenting.•Legal or disciplinary problems for those withdisruptive behaviour also a risk
Rating Risks•Risk of suicide has both acute and chronic component•Be vigilant of change in acute risk•Examine history for new or worsening life events•Focus on consequences & meaning of an event to youth•Understanding meanings of events will allow points of intervention & alsoaccurate risk assessment•Check on daily activities. Ask about “typical day” and “today”•New self-harm behaviours even very “mild” and medically not seriousincrease risk Worsening frequency or severity of self-harm behaviours in aperson who habitually self-harms is a sign of increased acute risk.•You are never wasting any clinician or family members time by insisting onan ER assessment for intervention and/or possible admission.
Decision-Making in the Office or ER•There is no suicide decision tree for all locales•Risk is a balance of diathesis interacting with life events andother risk factors•Don’t contract if there is missing or vague information•“Ifs” are not part of a workable solution, especially around anissue over which the youth has no control.•Youth must have a supportive environment to return to; familywork in ER may be needed, otherwise as inpatient.•If in doubt, check own reaction and if info or support missing,then refer to ER or admit.•A first admission is always an intense ambivalent experience fora youth & family. Admission can be a new crisis for family thatcan lead to effective crisis intervention.
Resources www.teenmentalhealth.org TASR-A : Tool for assessment of suicide risk Depression assessment guidelines Parent, school and teen handouts on variety ofmental health topics
For Own Study: Risk Factors ReviewThe following slides were not includedin the presentation talk due to timeconsiderations. They provide importantbackground that guides therecommendations in the presentation& are suggested for review on your own.
Psychiatric Diagnosis = Risk90% suicide victims have diagnosis9-fold increased risk if Axis I disorder present80% community & referred cases of suicideattempts have disordersChronicity and severity impose greater risk
Psychiatric diagnosis = RiskBipolar disorder: Greatly increased risk of attempts (50 %) withcompletion (10-25%). Mixed states may be a risk factor for completedsuicideSchizophrenia15% lifetime risk of completed suicide
Age Very rare among prepubertal youth globally Increase at age 12 may be due to: Increase in depression rates Substance use Complex social lives Activation of stress-diathesis
Gender Completed suicide is 5 times more common among males 15-19 years old in NA, Western Europe, Australia and NZ. Rates are equal between sexes in Singapore. More women die by suicide than men in China Substance use and lethal methods are more common in men Ingestion is more common in women (30% women vs. 6.7% men) but in China, ingestion is morelethal so more women die there.While among transgender or gay youth, there is highercompleted suicide rate in studies, this increased incidence ofsuicide is accounted for by whether a psychiatric diagnosis ispresent. Always screen and also ask about intimidation ordiscrimination.
Ethnicity Mixed results by community not ethnicidentification Native Canadians are at highest risk overall Caucasian Canadians have higher rates thanAfrican Canadians but this gap is closingespecially among males (1986-1994).
Psychiatric Diagnosis = Risk Depressive illness 49-64% Increased OR of 11-27 More common among female completedsuicides Substance abuse and conduct disorder are higherrisk comorbidities Decreased judgment Increased impulsivity
Cognitive & Personality Factors Hopelessness or seeing problems as unsolvable Poor interpersonal problem-solving Social skills Aggressive-impulsive behaviours
Suicide genes•Family history of suicidal behaviour greatly increasesrisk of completed suicide: heritability of 43%.•Possible defect in serotonin transporter receptor and5HT1A receptors in pre-frontal cortex and dorsal raphenucleus.•Other correlates:•Decreased CSF 5-H1AA•Distinctive genetic haplotypes among suicide completers andattempters compared to single-gene polymorphisms.
Family Functioning Parental psychopathology Effects of youth’s depression symptoms oncommunication High expressed emotion can worsen symptoms Attachment not studied prospectively Positive relationships and strong cohesion areprotective factors
Socioeconomic Status No differences among completed suicides Attempters are more likely to be poor Youth with few social supports: not in school,no job, few close friends are at higher risk.Routines and positive social contact areprotective.
Child abuse Past history of physical abuse confers riskindependently Mediates risk in cases of interpersonal conflict,social isolation or re-victimization via bullying. Sexual abuse link is much less strong