A 68-year-old man with documented alcohol abuse returns to the office because of abdominal pain and bloating. When you meet with him, he appears dejected and his eye contact is poor. Physical examination is normal. Since his last visit, he has moved from the neighborhood where he had lived for 40 years. In addition, he mentions that approximately 6 months ago breast cancer was diagnosed in his wife; she is currently receiving radiation therapy for bony metastases.
The most important next step in management of his symptoms is evaluation for:
Correct Answer E:
Notice in this question that you are being informed of numerous psychosocial stressors for the patient, including growing old, a move from his home of 40 years, and a potentially terminal illness in his wife. A question that enumerates a list of life stressors is most often related to a developing depression and/or suicidal ideation. Suicidal ideation is consistent with the picture of a depressed patient as described in this question, namely “dejected... .poor eye contact... .” A patient who is alcohol-intoxicated is 50 times more likely to commit suicide. The first step in the management of depression is always an assessment for suicidal ideation.
A high risk of suicide is associated with which one of the following factors?
In most countries, women continue to attempt suicide more often, but men tend to complete suicide more often. Although the frequency of suicides for young adults has been increasing in recent years, elderly Caucasian males continue to have the highest suicide rate. Other risk factors for taking one's life include single marital status, unemployment, low income, mental illness, a history of being physically or sexually abused, a personal history of suicidal thoughts, threats or behaviors, or a family history of attempting suicide.
Data regarding mental illnesses as risk factors indicate that depression, manic depression, schizophrenia, substance abuse, eating disorders, and severe anxiety increase the probability of suicide attempts and completions. Nine out of 10 people who commit suicide have a diagnosable mental illness and up to three out of four individuals who take their own life had a physical illness when they committed suicide. Behaviors that tend to be linked with suicide attempts and completions include violence against others and self-mutilation, like slitting one's wrists or other body parts, or burning oneself.
A 53-year-old male presents with a 3-month history of despondency, insomnia, and irritability with family and co workers. During your interview you also discover that he is drinking heavily at times and has several firearms at home. He thinks his life is “useless”, noting that he “would be better off dead”.
What would be the most appropriate action at this time?
Correct Answer B:
More than 50% of suicides are associated with a major depressive episode and 25% are associated with a substance abuse disorder. Suicide rates (number of completed suicides/100,000 population) increase with age and are higher among men. Increased suicide rates also occur in patients with significant medical illnesses. Because discussing suicidal ideation may relieve the patient’s anxiety, the physician should directly ask depressed patients about any suicidal thoughts. There are no known reliable tools for assessing suicide risk, so the assessment is subjective. The initial management of suicidal ideation should establish safety, often by hospitalization. The suicide prevention contract is of unproven clinical and legal usefulness. Antidepressant medication has not been shown to reduce suicide rates, especially on a short-term basis.
Which one of the following is true regarding suicide?
No evidence that has been found to demonstrate that screening for suicide risk reduces suicide attempts or mortality. There is limited evidence regarding the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify those at high risk. In addition, there is insufficient evidence to show that treatment of those at high risk reduces suicide attempts or mortality. Two-third of suicide deaths occur on the first attempt (choice B), with higher completion rates in men than in women (choice C). Although men complete suicide more often than women, women attempt suicide more often than men (choice D). Almost 75% of completed suicides are by white males (choice E), who have a two-fold higher risk for suicide than black males. Adolescents and the elderly are high-risk groups for suicide (choice A).
A 30-year-old man presents with the typical findings of depression and is started on an antidepressant medication. At the time of presentation he was having suicidal thoughts, but he had no plan to act on them and felt hopeful about improving with medication. He sees you in your office for a follow-up visit the following week and reports improvement in appetite, sleep, and concentration. He reports having more energy to get up and go to work in the mornings. He still has suicidal thoughts, but they are much less frequent. He still feels he won’t act on them. One week later the patient commits suicide.
What is the most likely reason that this patient committed suicide after getting treatment?
Correct Answer C:
In a severe depression there is characteristically a loss of drive, concentration, and energy to carry out any plans. As these factors improve, it become possible that the patient will develop and carry out a plan for suicide.
A. This is a misperception because of the effect that they have on improving the patients’ vegetative symptoms.
B. That is not necessarily so, since some patients do better if they are distracted and still involved in their normal activities.
D. Patients frequently report more hope after seeing a psychiatrist, which is part of the placebo response seen in antidepressant medications and therapy.
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